CROSSROADS, South Africa - In this black township just east of Cape Town, no one doubts that AIDS has caused a health crisis. Every weekend, families go to cemeteries to bury victims of the disease.
But at Crossroads Community Health Center, health workers are witnessing the first signs of what might be the nation's next health tragedy: heart disease.
Each month, more men and women line up outside the clinic's iron gates seeking treatment for high blood pressure, one of the major risk factors leading to strokes and heart attacks. South Africa is thus following the experience of many of the world's developing nations, where cardiovascular disease increases as the population migrates from the countryside to the city, health officials say.
"We are going through a rapid economic transition," says Dr. Anthony D. Mbewu, executive director of research at the Medical Research Council of South Africa. "The risk factors [for heart disease] are increasing."
Since the end of apartheid in 1994, millions of black South Africans have moved from the rural "homelands" created by the white-ruled government into Cape Town, Johannesburg and other cities in search of a better life.
The move often includes a radical lifestyle change. City dwellers have better access to desk jobs with fewer physical demands than the hard labor of the countryside. The urban newcomers drop their rural diets in favor of fatty Western fast foods, widely available in supermarkets and on street corners. Instead of walking, they commute by taxi and buses. And at night, many of these new urban residents relax in front of a television.
Health officials warn that as these new habits take hold, heart disease will grow among the South African black population and place new burdens on a taxed health system. Also, they wonder whether the government will be ready to meet the challenge.
"Policymakers are so fully preoccupied with AIDS that heart disease is like a distraction," says Mbewu. "They should deal with the No. 1 health crisis, but they should not forget the No. 2 health crisis."
In the United States and other developed countries, the risks of heart disease have long been known and publicized. In South Africa, much of the nation is awakening to the problem.
Most people here are so unfamiliar with heart disease that if a black South African man age 45, appearing to be in perfect health, died suddenly, a heart attack would not immediately be considered a possible cause of death, Mbewu says.
Health officials are only beginning to understand the scale of the problem. Under apartheid, the white-controlled government paid scant attention to the health needs of the black population. But since 1994, when the first democratic elections were held, the government has tried to make the distribution of health care less unequal.
In 1998, the Medical Research Council found in the first national health survey that more than 25 percent of South Africans 15 or older have high blood pressure. It also found that obesity, drinking and smoking were prevalent among men and women with high blood pressure.
High blood pressure was slightly more prevalent among whites, but because whites have had better access to medical care, they also had the highest rate of treatment. Blacks, who make up 75 percent of the population, had the lowest rate of high blood pressure awareness and treatment. Health officials say that with nearly half the black population rural, the prevalence of high blood pressure and heart disease will increase.
They point to the United States, where high blood pressure, heart disease and stroke disproportionately affect African-Americans. Officials fear the same trend might occur here.
According to the latest statistics, about 10 percent of South Africans die from cardiovascular disease every year. But the figure might be as high as 25 percent because of the underreporting of death statistics in black communities, Mbewu says.
At the heath center in Crossroads on a recent morning, registered nurse Zodwa Maxhama looks out over a crowded room of patients with high blood pressure. She rattles off the challenges to high blood pressure control in this community: poor diet, little exercise, obesity and an environment in which crime, AIDS and poverty are part of everyday life.
"They need to alleviate more of the stresses of life. They need counseling," Maxhama says.
The demands placed on South Africa's health care system make such individual counseling almost impossible. Because of limited medical facilities in townships, patients often stand in line for hours to see a doctor and are reluctant to make follow-up visits. Patients are seldom urged to take their blood pressure pills regularly or to maintain healthy diets.