in ‘Non-Westernised’ Groups; Africa; Donnison, Burkitt and Trowell (of Burkitt’s Lymphoma and Kwashiorkor respectively)
Civilisation and Western Disease – C.P. Donnison MD MCRP 1938
Donnison, in addition to practicising in the UK spent two and a half years as a doctor in a remote area of Kenya, and was clearly struck as were many of his contemporaries by the lack of non-communicalble diseases of ‘civilisation’ in his patients.
The first two chapters of the book gather data, and discuss it along with his own observations. He may be one of the first on record to describe these as “diseases of civilisation” and recognised that they probably had a common cause, but chose to discuss psycho-somatic rather than dietary influences.
The work is particularly interesting because of the general scarcity of this data in the public domain, and for the table of hospital visit related reported conditions in the 1930s (below).
He questions the observations that Africans were free of dental decay, but acknowledges that great detail as to their individual diets would be revealing. His comment on dental health is just that; the work of Weston Price on dental health in those on non-westernised diets, which included a visit to East Africa (Ch.9. (Isolated and Modernized African Tribes ) was both driven and rigorous. Of Muhima Tribe or Anchola, Uganda. Price observed for example “In a study of 1,040 teeth of thirty-seven individuals, not a single tooth was found with dental caries.” many groups had very low decay, although Price did observe higher decay rates in those living mainly on grain based diets.
The tables of data on disease incidence on pages 11 and 12, and blood pressure on page 16, are thought provoking. Donnison acknowledges and makes the point that the UK mortality figures do not in any way compare to the hospital presentation data, and that they were only included as no other comparator could be found.
Based on hospital data looking and between 283,000 and 831,000 hospital attendance cases in 4 African areas in the first half of the 1930’s, high blood pressure, arteriosclerosis, angina, diabetes, enlarged prostate, gall stones were in single and sometime double figures only.
Donnison makes this observation on atheromas (page 18)
“My own conclusions basal on clinical observations and a series of between twenty and thirty autopsies, without facilities for paraffin sections, are as follows. Atheroma is common, usual in later life, but is usually less in degree than is encountered at a corresponding age in the European. Medial degeneration of any marked degree I have never seen. Clinically in elderly natives it is common to encounter arteries that feel slightly thickened and tortuous, a condition closely comparable with decrescent arteriosclerosis in the European. Markedly thickened and tortuous arteries arc rarely seen. The secondary complications of arterial disease are also rarely seen.”
He includes this table on comparative blood pressure based on 1000 examinations. Two others independently got similar results. (See also Western Diseases, Burkitt and Trowel, Ch.1 page 6)
He also comments on the occurrence and progression of a number of other diseases.
The rest of the book whilst a thought provoking exploration of the connection between disease and mental health / well-being is interesting but not core to the aims of this web site, and scanning is time consuming so at the present time has not been included.
PDF scan of first chapter of Civilisation and Disease
(It is important to at least skim the Introduction and Preface, because it gives an idea of the care that has gone into preparation.
His struggles in trying to work out, and describe, how stress impacts health, and his internal debate as to how much it factored in disease differentials, is of its time, and predated much of what we now know about the impact of nutritional factors. He was however clearly ahead of his time in pondering the issue, and probably was one of the first to define non-communicable Western Diseases, as lifestyle related conditions.
At the beginning of Chapter 1 Donnison very carefully defines what he means by ‘Primitive’, and it is very clear he does not in any way mean it to be rude, he is simply defining that groups of people live in different ways)
(The PDFs are all present but possibly due to demand are taking a while to appear and do so somewhat randomly – so please try the link again if the one you want has not appeared it hopefully will the next time – apologies but this is all done on a shoestring)
Western Disease: Their Emergence and Prevention. Chapter 1 ‘Hypertension, obesity, diabetes mellitus
and coronary heart disease‘
There book contains a wealth of comparative disease occurrence observations and or data. So far as I am aware the book is no longer in print, and second hand copies are getting increasingly expensive. Burkitt certainly had links with and supported the McCarrison society, as likely did Trowell, and on that basis have copied very limited data from their book to make this important information more widely available.
“Significant professional medical presence in East Africa in the 1920. The Kenya Medical Journal was started in 1924.”
Kenya and Uganda lifelong low blood pressure 1929-40
“Kenya, Uganda and Tanzania were among the last African countries to be westernized, for in the days of only sea communications they were more remote from Europe than North, West or South Africa. Intertribal warfare, slave-raiding and roaming nomadic warriors like the Masai had previously been barriers to trade. No railways or permanent roads ran inland from the Indian ocean until the turn of the century. Metal currency came into common use in the Kenya highlands only in the 1920s; then Africans began to open shops. Throughout the Kenya highlands and the whole of Uganda there are few surface deposits of salt (page II).
The sunny equatorial climate of Kenya, modified by altitude, encouraged thousands of British settlers to open farms in the 1920s. Scores of British doctors devotetl their lives to medicine and surgery either in government service, or in missionary hospitals, or in private practice. Never before did, and probably never again will, so many resident doctors observe three million men, women and children, as in Kenya in the 1920s, emerge from preindustrial tribal life and undergo rapid westernization. A comparable numberlived in Uganda wherein African kingdoms had welcomed some elements of westernization at least three decades earlier than occurred in Kenya. Disease patterns shifted earlier in Uganda than in Kenya. Doctors in all East African territories began to record their observations in the Kenya Medical Journal, · founded in 1924, long before comparable medical journals emerged in West _ and Central Africa. Annual conferences of doctors in Kenya reflected their number; for instance 56 doctors attended the 1926 conference in Nairobi; in 1927 the Kenya Medical Association had 100 members with British qualifications. Formal training of Kenyan hospital assistants (bush doctors) started in 1931 at Nairobi. I was responsible for their training from 1933 to 1935, then transferred to teach medicine at Mulago hospital and Makerere University in Kampala, Uganda, until 1958. It became incumbent on all teachers of medicine to collect data concerning the prevalance of the common diseases in Africans. From 1930 until 1935 doctors in Kenya were unanimous that they had never seen essential hypertension in an African and no case was reported either in Kenya and Uganda until 1941.”
Blood pressure data page 7. ‘Kenya and Uganda lifelong low blood pressure’
Coronary Heart Disease – a competition to report the first cases.
A paragraph of a chapter by Trowell taken from ‘Western Disease; their emergence and prevention’, Burkitt and Trowell Ch1, page 26.
PDF copy of Foreword and Chapter 1
Western Disease: Their Emergence and Prevention. Chapter 13 ‘Uganda West Nile district‘
Edward Williams and Peter Williams
Edward Williams and Peter Williams from 1941 and 1948 respectively worked at 108 bed Kuluva Hospital on the northern Uganda border. They treated 150,000 patients over 38 years. In patient and outpatients notes were kept together so providing continuous long term records.
The hospital was quite well equipped portable x-ray, ECG, specialist opthalmological instruments etc, and had an operating theatre.
“Traditional Regional Diet”
The regional diet is set out in paragraph of chapter 13. Significant changes include salt, sim-sim and cotton seed oil of East African manufacture also had come onto the market, as had sugar. In the better off refined sugar intake when available and affordable rivaled that of the west at 100g a day. For salt historically (1902 report) they used burnt reeds and water plants, rich in potassium, but low in sodium. Vegetable oil consumption was also seen in Southern India, and in Indian African populations, who generally exhibited higher incidence of Western Disease, and are a potential factor.
The setting out of disease incidence in this chapter (Western Disease Ch. 13 by E and P Edwards see above) is particularly concise and has been selected as mirroring in very general terms the reports of the increasing incidence of ‘Western Disease’ in populations including western refined foods into their diets. As earlier on the grounds this book is out of print and the information is of considerable public interest given the rising global individual and public health burdens of cardiovascular with related conditions, and diabetes, it is felt there is justification for positing this small section intact as representation of the wider content of the book; the words have much more power in their original form than if paraphrased.
It is clear that the information was based on the observations of highly experienced very professional dedicated doctors, and cannot be dismissed as the flights of fancy of the inexperienced working in an unsophisticated third world environments, which may be the initial reaction of some to the suggestion that western diseases likely have their roots in dietary changes, and were almost never seen in populations on traditional diets free of refined western products. Clearly infectious and other disease, hunger, and general living conditions meant that this was no Shangri-la but notwithstanding western diseases were rare
PDF copy of chapter 13
Western Disease: Their Emergence and Prevention. Chapter 14 ‘Zimbabwe‘
Zimbabwe Africans’ diet and lifestyle
“The country of Rhodesia became Zimbabwe in 1980, but in this chapter the shorter terms Zimbabwe Africans ( or just Africans) and Rhodesian Europeans (or just Europeans) will be used to distinguish the two main ethnic groups before independence came to Zimbabwe. Zimbabwe Africans total at present six and a half million; two million live in the townships, four and a half million in rural areas, and one and a half million live on European farms. Comparatively few of those living in the townships are true urban dwellers, for most of them retire to their rural homes after middle-age; also during their sojourn in the urban areas there is continual movement from town to country and back again. Rhodesian Europeans number at present about half a million. Zimbabwe Africans have accepted many of the material features of Western culture, such as its dress and economic system. Western foods have come into vogue, although in both rural and urban areas traditional foods still predominate: white bread, refined sugar, jam and tea are all popular nowadays and are taken between the two main meals of lunch and dinner. These main meals consist of large portions of stiff porridge, usually made from maize meal, and eaten with a vegetable relish and some meat or fowl occasionally. Breakfast, a modern innovation, eaten even by rural inhabitants, consists largely of tea with milk and sugar and one or two slices of white bread and jam. Salt has been in common use by Africans for a long period of time. It was commonly said that African men and women employed by Europeans, usually as cooks, were liable to indulge in rich dishes, thereby predisposing themselves to certain diseases, such as appendicitis and peptic ulcer. However, after investigating this matter closely, I am unable to prove this association, although the figures definitely showed that urban Africans were more prone to develop both these diseases than rural Africans (Gelfand,1971).
PDF copy of Chapter 14
Western Disease: Their Emergence and Prevention. Chapter 18 ‘South African Black, Indian and Coloured populations’
Alexander Walker “South Africa occupies about 1·5 million square kilometres (0·5 million square miles). Its populations include about 18,25 million Blacks, 0·75 million · Indians, 2·5 million coloureds (Eur-African-Malay), and 4·5 million Whites. The first three populations will be discussed regarding: 1. particulars of origin, numbers, location, occupations; 2. environmental factors: non-dietary and dietary; 3. vital statistics; 4. general characteristics; 5. diseases of deficiency and low privilege; 6. diseases of excess and westernization. After their presentation, there will be a discussion. Understandably, the information presented is by no means exhaustive. The changes in the biological and other variables described are primarily those which the writer, his associates and collaborators have been most involved in seeking to characterize and elucidate.”
PDF copy of chapter 18
Western Disease: Their Emergence and Prevention. Chapter 26 and 27 ‘Contributors’ reports‘
Hugh Trowell and Denis Burkitt
Joint enquiry into Western diseases”
All 34 contributors to this book were sent a 12-page memorandum prepared by the editors concerning a suggested list of Western diseases. In some 22 diseases, or disease groups—cancer being enumerated as a single group-existing evidence was usually consistent and occasionally weighty, as in coronary heart disease. These 22 diseases and disease groups are listed in the Preface. Contributors were asked to present data concerning the hypothesized list of diseases and opposing viewpoints were assured full publication, as occurred in some of the data from Hawaii (Chapter 19), also in multiple sclerosis (Chapter 5). Epidemiologists can justifiably object that there exist valid age and sex group incidence data in only a minority of these diseases, that few of them have been clearly defined by international agreement, also that incidence has not been determined by agreed methods of investigation. These conditions have been fulfilled only for ischaemic heart disease and some varieties of cancer. There are much data concerning dental caries, also obesity and body weight, and increasingly for the different types of diabetes mellitus. Nevertheless it is probably true to state that whenever sophisticated surveys have been conducted to determine the incidence of any Western disease, the data have confirmed opinions held by experienced clinical workers. There is a modern tendency of excessive reluctance to accept evidence of anecdotal and incomplete nature. It is pertinent to remember that a substantial body of such evidence can be of greal value. It was largely such evidence that elucidated the epidemiological and other features of kwashiorkor and Burkitt’s lymphoma in which we were respectively involved. Knowledge concerning the incidence of Western diseases is restricted at present to the commoner medical and surgical diseases of adults and specially of the elderly. Subsequent studies will certainly show that there are paediatric, orthopaedic, gynaecological and obstetrical, neurological, dermatological, ophthalmic and auditory diseases that may be regarded as Western diseases. A few of the possible candidates are mentioned briefly later in Chapter 2″ Continues see PDF below
Western diseases and ageing “Western diseases are predominantly the degenerative diseases of ageing. Before prevention can be discussed one basic criticism of the general hypothesis concerning Western diseases must be met. Many who have never spent much time in developing countries have suggested that the apparent scarcity of Western diseases is explained because young persons do not come to hospital if they have, say, appendicitis, and the elderly languish and die of degenerative diseases at home, and in any case there are very few of them. Many surgeons in these countries can, however, produce lists of their surgical emergencies crowded with strangulated herniae and other acute abdominal conditions, but very few cases of appendicitis. Pathologists also publish papers on the diseases detected in the autopsies of elderly persons. Forty per cent of South African Bantu aged 50 years survive until 70 years of age, but only 33 per cent of 50-year-old South African Caucasians survive to 70; the latter have better medical treatment, but the former have much less degenerative disease (Walker, 1974). In Uganda there are over half a million Ugandans aged 6o years or more; this represents 6 per cent of the total population. Among the 400 autopsies of Ugandans of this age conducted during 1968-72 at Makerere University Medical School, Kampala, less than 5 per cent died of degenerative disease. Only 3 died of coronary heart disease (CHO), and 9 of hypertension. Most died of infective disease. ‘CHO has emerged and can be identified over the age of 60’ but not at an earlier age, according to this pathologist (Drury, 1973). A medical survey of a defined population of 12000 rural Ugandans had their ages assessed by the ‘milestones. of local history’: 729 persons were 50 years or more, 219 persons were over 70 years, but only 4 appeared to be suffering from senile dementia (Bennett, 1971). Little is known about the prevalence of senile dementia in peasant agriculturalists who had low salt intakes for most of their lives”