Global economic development has had major positive impacts on public health in many parts of the world. Improved economic conditions can lift communities up from abject poverty via expanded agriculture, industrial development and improved access to markets. But globalisation has not benefited everyone; economic inequalities between and within countries are actually increasing. Economic development in itself is not enough to improve health and wellbeing for all people. Specific policies and actions to improve living and working conditions have to be properly financed, implemented and organised.
Aims: This paper examines trends in age-specific mortality in a rural South African population from 1992 to 2003, a decade spanning major sociopolitical change and emergence of the HIV/AIDS pandemic. Changing mortality patterns are discussed within a health-transition framework. Methods: Data on population size, structure, and deaths, obtained from the Agincourt health and demographic surveillance system, were used to calculate person-years at risk and death rates. Life tables were computed by age, sex and calendar year. Mortality rates for the early period 1992-93 and a decade later, 2002-03, were compared. Results: Findings demonstrate significant increases in mortality for both sexes since the mid-1990s, with a rapid decline in life expectancy of 12 years in females and 14 years in males. The increases are most prominent in children (0-4) and young adult (20-49) age groups, in which increases of two- and fivefold respectively have been observed in the past decade. Sex differences in mortality patterns are evident with increases more marked in females in most adult age groups. Conclusions: Empirical data demonstrate a marked "counter transition" with mortality increasing in children and young adults, "epidemiologic polarization" with vulnerable subgroups experiencing a higher mortality burden, and a "protracted transition" with simultaneous emergence of HIV/AIDS together with increasing non-communicable disease in older adults. The health transition in rural South Africa is unlikely to predict patterns elsewhere; hence the need to examine trends in as many contexts as have the data to support such analyses.
Much social science research on HIV/AIDS focuses on its impact within affected communities and how people try to cope with its consequences. Based on fieldwork in rural South Africa, this article shows ways in which the inhabitants of a village react to illness, in general, and the role their reactions play in facilitating the spread of communicable diseases such as HIV/AIDS. There is potentially a strong connection between the manner in which people respond to illness in general, and actual transmission of infection. By influencing the way villagers react to episodes of ill health, folk beliefs about illness and illness causation may create avenues for more people to become infected. This suggests that efforts to combat the HIV/AIDS pandemic cannot succeed without tackling the effects of folk beliefs. Therefore, in addressing the problem of HIV/AIDS, experts should focus on more than disseminating information about cause and transmission, and promoting abstinence, safe sex, and other technocratic fixes. Our findings suggest that people need information to facilitate not only decision-making about how to self-protect against infection, but also appropriate responses when infection has already occurred.
Aims: To use a multidisciplinary approach to describe the prevalence, lay beliefs, health impact, and treatment of hypertension in the Agincourt sub-district. Methods: A multidisciplinary team used a range of methods including a cross-sectional random sample survey of vascular risk factors in adults aged 35 years and older, and rapid ethnographic assessment. People who had suffered a stroke were identified by a screening questionnaire followed by a detailed history and examination by a clinician to confirm the likely diagnosis of stroke. Workshops were held for nurses working in the local clinics and an audit of blood pressure measuring devices was carried out. Results: Some 43% of the population 35 and over had hypertension. There was no relationship with gender but a strong positive relationship with age. Illnesses were classified by the population as being either African, with personal or social causes, or White/Western, with physical causes. The causes of hypertension were stated to be both physical and social. Main sources of treatment were the clinics and hospitals but people also sought help from churches and traditional healers. Some 84% of stroke survivors had evidence of hypertension. Few people received treatment for hypertension, although good levels of control were achieved in some. Barriers to providing effective treatment included unreliable drug supply and unreliable equipment to measure blood pressure. Conclusions: Hypertension is a major problem among older people in Agincourt. There is potential for effective secondary prevention. The potential for primary prevention is less clear. Further information on diet is required.
The papers by Posel et al., Schatz, and Wittenberg & Collinson take three very different approaches to uncovering how HIV/AIDS is affecting members of households. Whereas Posel et al. are mainly concerned with local understandings of the disease and death [1], Schatz addresses the role of elderly women in caregiving [2], and Collinson & Wittenberg look at the trends over time in household composition in Agincourt and nationally [3]. Whereas the first two use primarily qualitative data to investigate the impact of HIV/AIDS on local residents, the Collinson & Wittenberg piece triangulates demographic surveillance data with sub-samples of nationally representative surveys to identify changing typologies of households that could be associated with HIV/AIDS mortality and morbidity. The message from all three papers is clear: HIV/AIDS features prominently in the way people think about their lives, in the gender and generational configuration of households, and in the ways in which people organize themselves, made evident by the distribution of household types at the population level. In reading the papers together, certain important connections should be highlighted. In terms of the unit of analysis, the Posel et al. paper focuses on the individual whereas the Schatz paper aggregates to the household level and the Wittenberg & Collinson paper examines the distribution of households at the population level. Indeed, this provides a useful layering of levels of analysis in order to examine HIV/AIDS and households. More substantively, the notion of ‘‘cultural death’’ raised in the Posel et al. paper can be seen in the other two papers, albeit more implicitly. The extensive role of grandmothers in caregiving, described by Schatz, could be seen as a break with traditional norms as can the increasing prevalence of ‘‘complex’’ households in the Wittenberg & Collinson analysis. The three papers present somewhat varying impressions of the extent of social crisis. Whereas Posel et al. and Schatz see the changes evident in Agincourt as generally very detrimental to the wellbeing of the residents, the third paper does not see a crisis situation, at least at this point in time. For example, Wittenberg & Collinson conclude that there is no evidence that individuals are becoming increasingly isolated residentially. Schatz’s data, however, show that elderly women in Agincourt feel financially isolated in the course of caring for children. This also illustrates the different pictures we gain from quantitative and qualitative research, and underscores the need for more integration of design and method. Whereas people may not be living alone in greater numbers, their ability to care for one another has become more limited. The three papers leave a set of issues that require further research. One, what is the role of religion, in particular through the charismatic churches that are proliferating in the area, in both influencing people’s ideas about disease and death as well as providing additional support in caregiving? Two, how do ageand gender-specific perceptions of the disease and death affect caregiving strategies? Three, to what extent do household typologies reflect people’s own constructions of what household means? Four, to what extent do household typologies assist in understanding community/household/individual levels of vulnerability and coping strategies? Five, how do we use these findings in the development of public health programmes in the district and region? Finally, these papers demonstrate a need to develop innovative ways to triangulate qualitative and quantitative data.
The three papers discussed all deal with aspects of the causation of undernutrition in the Agincourt sub-district. Previous work has highlighted kwashiorkor as an important cause of under-5-year-old mortality [1] in a region that has relatively low infant and under-5 mortality rates when compared with other regions in sub-Saharan Africa. In a casecontrol study, Saloojee and colleagues [2] found that many of the usually accepted factors contributing to severe malnutrition in rural communities were also responsible in Agincourt, namely poor weaning practices and higher birth order, as well as HIV. Diversity of food intake and the family being a recipient of a state child support grant proved protective. Of interest is the finding of a high prevalence of stunting (45%) in the control group of children, which is far higher than that found in a national survey (,20%) [3], but similar to that found in another region of Limpopo Province [4]. It is possible that the prevalence found in the Agincourt study does not reflect the actual prevalence in the region as the control children lived in the same villages as the malnourished study children – thus they may not reflect children living throughout the area – but we have no other information on nutritional status among children from this setting. It is clear that child-support grants do make a significant difference to the lives of families living in impoverished circumstances and these, together with pensions that are available to many of the grandparents of children, are often the only income that families in rural areas have to purchase food and other essentials. Despite the importance of these grants to families, Twine and co-researchers [5] document that barriers prevent the poorest families from gaining optimal access (only a third of South African families living in Agincourt in the lowest socioeconomic stratum had applied), while it is the less impoverished families who make better use of such grants. The most important barriers to obtaining grants include the lack of necessary documentation (such as identity documents), the distance to service offices (which reflects the lack of money for transportation), and the educational level of the household head. The study by Madhavan and Townsend [6] deals with the social interactions within and between families that might prevent or contribute to the development of undernutrition in children (v22 years of age). Not surprisingly, undernutrition is associated with the lack of the mother within the house either through death or non-co-residence, and with the lack of financial support from the father. None of the findings from these studies should surprise health workers who have spent time in the impoverished rural areas of South Africa. Subsistence farming, which in many countries provides at least a minimum nutrient intake for members of poor families, occurs to a very limited extent due to the lack of agricultural land and regular and reliable rains. Poor unemployed families in many parts of South Africa depend on food or money being remitted on an irregular basis – by family members often working hundreds of kilometres away – in order to survive. It is clear that the small but regular income derived from the government social security programme is of considerable benefit to poor families in the region but efforts are needed to improve access to these grants. Several questions remain unanswered: what is the true prevalence of undernutrition (and obesity) among the childhood population in the area; what are the most feasible and practical methods with
Aims: Genetic variation at the apolipoprotein E (apoE) locus is an important determinant of plasma lipids. The aim of the present study was to evaluate the association between apolipoprotein E genotype and plasma lipid levels among a rural black population in South Africa. Methods: Lipid levels and apoE genotypes were studied in 505 volunteer subjects (363 women, 142 men) resident in the Dikgale demographic surveillance site. Results: Allele frequencies were found to be 0.190 for ε2, 0.518 for ε3, and 0.293 for ε4, indicating a relatively low frequency of the ε3 allele and a high frequency of the ε4 allele. To determine the effect of apoE polymorphism on lipid levels three groups were formed: namely ε2-, ε3-, and ε4-expressing groups. A significant effect of the apoE genotype on total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C)/Total cholesterol (TC) ratio, and triglycerides was observed. LDL-C was significantly lower and the HDL-C/TC ratio was significantly higher in the ε2 group compared with the ε3 and ε4 groups. Triglyceride levels were significantly higher in the ε2 group than in the ε3 group. Conclusions: With the unfavourable apoE allele distribution, and the lifestyle changes taking place in rural South African populations, preventive strategies need to be developed to limit a potential epidemic of cardiovascular disease in the black population of South Africa.
Aim: To investigate the relationship between children's nutritional status and a series of measures capturing both the current status and the lifetime history of their connection with adult caregivers in the Agincourt sub-district of rural South Africa. Methods: Using data on a sample of 202 children from a recent ethnographic study of children's social connections and well-being, the authors (1) compare height for age and weight for age to an accepted international standard and (2) conduct bivariate analyses of the relationships between selected measures of social connection and extreme deviations below expected weight and expected height. Results: Fitted curves for weight for age and height for age fall between the 5th and 50th percentiles of CDC growth curves. Compromised nutrition, defined as being more than two standard deviations below expected height or weight, is associated with the death or non-co-residence of the mother, and with the absence of financial support from the father. The co-residence of maternal female kin as substitutes for the mother do not fully compensate for her absence. Conclusions: The findings highlight the importance of parental living arrangements, parental financial support, birth order and the composition of sibling sets, and lifetime residential patterns in facilitating access to nutrition.
It is now 13 years since the political liberation of South Africa – a rollercoaster period through which citizens of the ‘‘rainbow nation’’ have struggled to live up, individually and as a people, to the ideals articulated by visionaries that include Nobel laureates Nelson Mandela and Desmond Tutu. The country’s near-miraculous peaceful transition from apartheid rule to genuine democracy inspired the world community, providing a springboard for President Thabo Mbeki to launch continent-wide initiatives, pre-eminently the New Partnership for Africa’s Development (NEPAD). In parallel with such inspirational efforts has been the difficult, down-to-earth business of building a competent system of government and establishing a stable macro-economic and social environment responsive to the nation’s citizenry, especially the poor and vulnerable. The apartheid legacy of inadequate education and high unemployment, poverty and extreme inequality, and exaggerated emphasis on that which divides rather than unites people, is proving deeply embedded in the fabric of modern South Africa – more so perhaps than national leadership appreciated. In such circumstances, there is no substitute for informed leadership and astute decision-making that takes the longas well as short-term view. This in turn depends – as Adetokunbo Lucas put it – on generating the necessary ‘‘intelligence’’: information that is valid, responds to strategic priorities and captures change over time. While progress has been made – with the efforts of the Medical Research Council, Statistics South Africa, Human Sciences Research Council and key university-linked groups standing out – we submit that South Africa today faces a real ‘‘crisis of evidence’’. This is reflected in the limited availability of empirically-derived population-based data, weak investments to support their production, and limited public sector capacity to absorb, sift, interpret and respond to findings. The situation has been fuelled by the counter-scientific stance that, until recently, characterised government’s response to HIV/AIDS. This volume – comprising some 20 peer-reviewed articles and accompanying commentaries – is part of an effort to address this gap in information and understanding. Work demonstrates the unusual utility of health and demographic surveillance when characterising the dramatic transitions underway in South Africa today, and the exceptional R&D platform that such infrastructure can provide. The study site is part of a district barely 25 miles west of the southern Mozambique border, this rendering it part of north-eastern South Africa and integral to a cross-border region of rural Southern Africa – thereby amplifying the relevance and applicability of data and findings.
Background: World population growth will be increasingly concentrated in the urban areas of the developing world; however, some scholars caution against the oversimplification of African urbanization noting that there may be ``counterurbanization'' and a prevailing pattern of circular rural—urban migration. The aim of the paper is to examine the ongoing urban transition in South Africa in the post-apartheid period, and to consider the health and social policy implications of prevailing migration patterns. Methods: Two data sets were analysed, namely the South African national census of 2001 and the Agincourt health and demographic surveillance system. A settlement-type transition matrix was constructed on the national data to show how patterns of settlement have changed in a five-year period. Using the sub-district data, permanent and temporary migration was characterized, providing migration rates by age and sex, and showing the distribution of origins and destinations. Findings: The comparison of national and sub-district data highlight the following features: urban population growth, particularly in metropolitan areas, resulting from permanent and temporary migration; prevailing patterns of temporary, circular migration, and a changing gender balance in this form of migration; stepwise urbanization; and return migration from urban to rural areas. Conclusions: Policy concerns include: rural poverty exacerbated by labour migration; explosive conditions for the transmission of HIV; labour migrants returning to die in rural areas; and the challenges for health information created by chronically ill migrants returning to rural areas to convalesce. Lastly, suggestions are made on how to address the dearth of relevant population information for policy-making in the fields of migration, settlement change and health.
Aims: To utilize the Agincourt health and demographic surveillance system (HDSS) platform to assess the burden of pulmonary tuberculosis (PTB) in a rural South African sub-district. Methods: During 1999, data from three sources were combined to estimate disease prevalence amongst a non-migrant adult population: (1) passive case-finding (PCF) through hospital register data; (2) active case finding (ACF) using a systematic household assessment of chronic coughers; and (3) verbal autopsy (VA) data on cause of death. Results: Of 66,840 residents, 38,251 permanent adult residents were included in the analysis. A total of 102 cases of PTB were detected through PCF. ACF sweep detected 366 chronic coughers with 6 cases of confirmed PTB. Among 28 PTB deaths detected by VA, 13 (46%) were not previously identified by the health service. The total PTB prevalence was 157/100,000; 110/100,000 of prevalent cases were detected by PCF. Among undetected cases, 24/ 100,000 were identified through ACF, while 23/100,000 were detected by the VA process. Conclusions: Amongst prevalent PTB cases in the permanent adult population, 70% were detected by the health service; 15% of cases were undiagnosed in the community, while an equal proportion died of PTB prior to diagnosis. The latter groups contributed disproportionately to infectiousness in the community through prolonged duration of symptoms. As most of these cases presented to the health service on a number of occasions, strengthening early case detection should remain the cornerstone of TB control efforts. Strategies to strengthen the application of health & demographic surveillance systems to disease surveillance are discussed.
Aims: To investigate changes in household structure in rural South Africa over the period 1996—2003, a period marked by politico-structural change and an escalating HIV/AIDS epidemic. In particular, the authors examine whether there is dissolution of extended family living arrangements. Methods: Data from the Agincourt demographic surveillance system, in rural north-eastern South Africa, and the rural sub-samples of selected nationally representative data sets were used to compare changes in the cross-sectional distribution of household types. Surveillance system data were further analysed to estimate the transition probabilities between household types. The latent pressures for change within the Agincourt area were analysed by projecting the household transition probabilities forward and comparing the projected steady-state distributions to the current distributions. Results: The national surveys show dramatic changes in the social structure in rural areas, particularly an increase in the importance of single person households. These trends are not confirmed in the surveillance system data. The national ``changes'' can possibly be ascribed to changes in sampling frames or household definitions. The transition probabilities within the Agincourt area show considerable changes between household types, despite a slower change in the aggregate distributions. The most important projected long-run changes are an increase in the proportion of three-generation linear households. ``Simpler'' household types such as single person households and nuclear households will become relatively less common. Conclusions: The structure of households is evolving under the pressure of social change and increased mortality due to HIV/AIDS. There is no evidence, however, that the social fabric is unravelling or that individuals are becoming increasingly isolated residentially.
AIMS:To analyse trends in fertility rates and net reproduction rates in Agincourt, a rural area of South Africa located in the former homeland of Gazankulu near the Mozambican border. Trends are analysed in the context of widely available modern contraceptive methods and increasing HIV/AIDS.METHODS:A health and demographic surveillance system has been in place since 1992, covering a population of approximately 70,000 persons, with an annual census update and comprehensive recording of births and deaths. It was complemented by a retrospective study of fertility at baseline. Retrospective and prospective data were used to calculate trends in fertility, survival, and net reproduction. When possible, they were compared with data from other censuses and surveys in the same ethnic group.RESULTS:The fertility transition has almost ended over a course of 25 years in Agincourt. The total fertility rate (TFR) averaged 6.0 in 1979 and 2.3 in 2004. Fertility declined in proportionate fashion in all age groups including adolescents in the recent period. The net reproduction rate (NRR) declined from 1.8 to 1.0 during the prospective period (1992-2004). At current rates of change in fertility and mortality, the NRR can be expected to reach 0.63 by the year 2010.CONCLUSIONS:The situation of a below-replacement fertility level is new for rural Africa, and is likely to have many demographic, economic and social implications. The population could decline in the country as a whole, and is nearly static in Agincourt because of negative migration flows balancing the small excess from natural increase.
Aim: To describe household change over a 10-year period of tremendous social, political, economic and health transformation in South Africa using data from the Agincourt health and demographic surveillance system in the rural northeast of South Africa. Methods: Examination of household structure and composition at three points: 1992, 1997, and 2003. These three years loosely represent conditions immediately before the elections (1992), short term post-elections (1997), and longer term (2003), and span a period of notable increase in HIV prevalence. Results: Average household size decreased and the proportion headed by females increased. The within-household dependency ratios for children and elders both decreased, as did the proportion of households containing foster children. The proportion with at least one maternal orphan doubled, but was still relatively small at 5.5%. Conclusions: This analysis is a starting point for future investigations aimed at explaining how HIV/AIDS and other sociocultural changes post-apartheid have impacted on household organization. The analysis shows both consistency and change in measures of household structure and composition between 1992 and 2003. The changes do not include an increase in various types of ``fragile families'', such as child-headed or skipped-generation households that might be expected due to HIV/AIDS.
Background: In April 1998, the South African government introduced the child-support grant as a poverty-alleviation measure to support the income of poor households and enable them to care for the child. Aims: This research aimed to measure equity of access to applications for the child-support grant in an area characterized by poverty. Three questions were addressed: (i) How does socioeconomic status affect the probability of a household applying for a child-care grant? (ii) What household and caregiver characteristics are associated with child-care-grant application? (iii) What barriers to access are experienced by households that do not apply for the child-care grant? Methods: The study population of 6,725 households with at least one age-eligible child was drawn from the Agincourt field site, a rural sub-district of South Africa. Data used were obtained from health and demographic surveillance, a child-grant questionnaire, and a household-asset survey. Descriptive cross-tabulations and multivariate logistic regression were used in the analysis. Results: Although these grants are intended as a pro-poor intervention, the poorest households are less likely to apply for grants than those in higher socioeconomic bands. Households in lower socioeconomic bands experienced barriers in accessing grants; these related to lack of official documentation, education level of the caregiver and household head, and distance from government service offices. Conclusions: Enhancing access will require improved provision of birth certificates and identity documents, efficient coordination and service provision from a range of rural government offices, and creative methods of communication.
AIMS:To quantify the impact of the South African old age (social) pension on outcomes for pensioners and the prime-aged adults and children who live with them, and to examine alternative means by which pensions affect household outcomes.METHODS:We collected socioeconomic data on 290 households in the Agincourt demographic surveillance area (DSA), stratifying our sample on the presence of a household member age-eligible for the old-age pension (women aged 60 and older, men aged 65 and older).RESULTS:The presence of a pensioner significantly reduces household reports that adults and, separately, children missed meals because there was not enough money for food. In addition, girls are significantly more likely to be enrolled in school if they are living with a pensioner, an effect that is driven entirely by living with a female pensioner. Our results are consistent with a model in which pensioners have a greater say in household functioning once they begin to receive their pensions.CONCLUSIONS:We find a program targeted toward the elderly plays a significant role in children's health and development.
AIM:To examine the hypothesis that circular labour migrants who become seriously ill while living away from home return to their rural homes to convalesce and possibly to die.METHODS:Drawing on longitudinal data collected by the Agincourt health and demographic surveillance system in rural northeastern South Africa between 1995 and 2004, discrete time event history analysis is used to estimate the likelihood of dying for residents, short-term returning migrants, and long-term returning migrants controlling for sex, age, and historical period.RESULTS:The annual odds of dying for short-term returning migrants are generally 1.1 to 1.9 times (depending on period, sex, and age) higher than those of residents and long-term returning migrants, and these differences are generally highly statistically significant. Further supporting the hypothesis is the fact that the proportion of HIV/TB deaths among short-term returning migrants increases dramatically as time progresses, and short-term returning migrants account for an increasing proportion of all HIV/TB deaths.CONCLUSIONS:This evidence strongly suggests that increasing numbers of circular labour migrants of prime working age are becoming ill in the urban areas where they work and coming home to be cared for and eventually to die in the rural areas where their families live. This shifts the burden of caring for them in their terminal illness to their families and the rural healthcare system with significant consequences for the distribution and allocation of health care resources.
Aim: This paper examines financial, emotional, and physical responsibilities elderly women are being asked to take on due to the incapacity of their adult children to care for the next generation; such incapacity is likely to increase as the HIV/AIDS epidemic worsens. Methods: This paper combines quantitative and qualitative data. Census data from the Agincourt health and demographic surveillance system (AHDSS) describe the presence of the elderly (specifically women over the age of 60 and men over the age of 65) in households in the Agincourt study site. Semi-structured interviews with 30 female residents aged 60-75 complement the census data by exploring the roles that older women, in particular, are playing in their households. Results: An elderly man and/or woman lives in 27.6% of households; 86% of elders live with non-elders. Households with a woman over the age of 60 resident (as opposed to those without) are twice as likely to have a fostered child living in the household and three times as likely to have an orphaned child in the household. Elderly women face financial, physical, and emotional burdens related to the morbidity and mortality of their adult children, and to caring for grandchildren left behind due to adult children's mortality, migration, (re)marriage, and unemployment. Conclusions: Older women provide crucial financial, physical, and emotional support for ill adult children and fostered and orphaned grandchildren in their households. As more prime-aged adults suffer from HIV/AIDS-related morbidity and mortality, these obligations are likely to increase.
There is currently a lack of research on the association between demographic dynamics and household use of natural resources in rural Africa. Such work is important because in rural Africa natural resources buffer households against shocks, offering both sustenance and income-generating potential. Aims: The article focuses on adult mortality as a household shock, examining use of local environmental resources as related to household dietary needs. Methods: The authors analyze two sources of data collected during May—December 2004 in the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) in rural South Africa. Quantitative analyses use survey data from 240 households, stratified by adult mortality experience. Qualitative data are based on 31 interviews with members of households having recently experienced adult mortality. Results: The interviews provide insight into a variety of household-level mortality impacts and also suggest the importance of proximate resources in the maintenance of food security following the loss of an adult household member. Quantitatively, there are significant differences, both in patterns of usage of the natural environment and in levels of food security, between households that have lost an adult and those that have not. The association between mortality and household use of local environmental resources is further shaped by the gender of the deceased and the time elapsed since the death. Conclusions: Adult mortality, particularly the death of a male wage-earner, affects household food security. Time allocation is affected as resource collection responsibilities shift, and wild foods may substitute for previously purchased goods.
Aims: To examine how a rural community profoundly affected by escalating rates of largely AIDS-related deaths of young and middle-aged people makes sense of this phenomenon and its impact on their everyday lives. Methods: Data were collected in Agincourt subdistrict, Limpopo Province. Twelve focus groups were constituted according to age and gender and met three times (a total of 36 focus-group discussions [FGDs]). The FGDs explored sequentially people's expectations of their lives in the ``new'' South Africa, their interpretations of the acceleration of death amongst the young and middle-aged, and their understandings of HIV/AIDS. Discussions were recorded, fully transcribed, and thematically analysed. Results: Respondents acknowledged escalating death rates in their community, yet few referred directly to HIV/AIDS as the cause. Rather, respondents focused on the social and cultural causes of death, including the erosion of cultural norms and traditions such as cultural taboos on sex. There are many competing versions of what HIV/AIDS is, what causes it and how it is spread, ranging from scientific explanations to conspiracy theories. Findings highlight the relationship between AIDS and other traditional diseases with some respondents suggesting that AIDS is a new form of other longstanding illnesses. Conclusions: This study points to the centrality of cultural explanations in understanding ``bad death'' (AIDS death) in the Agincourt area. Physical illness is understood to be a symptom of ``cultural damage''. Implications of this for public health practice and research are outlined.
