By visiting 177 random households in a Cameroonian town, we traced and treated 35 people with undiagnosed disease threatening individual health and in many cases also public health. The importance of tuberculosis and malnutrition is demonstrated, as well as malaria and cases of HIV infection. We showed that poverty affects children's health. An encouraging sign is that smoking is little prevalent, but we found a relationship between coughing in children and smoking in the household. Lack of therapy for congenital orthopaedic and neurological disease was demonstrated. Cripples observed in the streets indicate that this is a general phenomenon, resulting in far more disability than necessary.
Lack of population registers and city plans makes formal randomisation of households impossible, and we cannot claim that our study is representative for the town of Ngaoundere. Nevertheless, we think that our approach was sufficiently scattered and haphazard to give a good impression of health problems. Sex and age distribution is as expected. The relatively low number of young adults probably reflect that young men leave their homes and are geographically mobile for a good decade before marrying, with implications for their sexual life and HIV prevention possibilities. The low number of old persons corresponds with life expectation figures.
The data are partly based on observations, partly on answers to questions. In most cases several members of the household were present and helped each other with the answers. It happened that someone told she or he did not smoke, but admitted it when laughingly corrected by other people present. The low number of smokers is in accordance with our observation that we rarely see people smoking in Ngaoundere, even in bars. We had no impression that any woman tried to exaggerate her schooling.
Different diseases, different requirements
In Africa, common illnesses seen in Western countries are modified in incidence and disease manifestations by poverty and illiteracy. Some more special diseases are serious, long-lasting and often difficult and expensive to cure. On average, each of our hospitalised patients cost seven times more than one patient treated without hospitalisation. For less serious disease, much could be done in terms of both prevention and cure. Prices for laboratory tests and medication at this hospital are modest and mostly cover expenses. The consultation with a nurse costs 0.7 USD, plus 1.4 USD more if the patient is subsequently seen by a doctor. If the doctor is seen directly the price is 4 USD. Hospitalisation costs 3.5 USD regardless of length of stay. Investigations and therapeutic procedures as well as more long-lasting and expensive medication add to hospital bills. Few families have an income exceeding 150 USD per month. An ox could be sold for 200 USD and a merchant at the market may earn 300–350 USD per month, but a nurse would earn 120 USD, a salaried secretary about 70 USD. A maid or a woman selling her self-cultivated vegetables at the market often must do with 20–30 USD a month. Thus, many people live with less than the World Bank global reference lines for poverty set at 1 USD and 2 USD per day in 1993 purchasing power parity . Many people can afford an outpatient illness episode, but a hospitalisation is beyond their means for most people.
Three of the hospitalised patients had sputum positive tuberculosis. Cameroon does not have a system of free treatment for tuberculosis, which is the case for some other African countries with organised national Tb programmes. Minimum cost for a Tuberculosis cure in Ngaoundere is 100 USD. While infectious disease was the cause of death in 1,2% of deaths in the Western world in 1996, this percentage was 43% in developing countries . The AIDS-sick, motherless infant is represented in our sample. For serious diseases with great implications for public health it is difficult for an African country to act alone. Special programs and foreign aid is needed, but the responsibility for taking initiatives, organising and administering should clearly be national and local.
A serious but curable disease like malaria requires competent local personnel. Malaria was less prevalent than expected in our study, but seriously ill and deeply anaemic children with malaria are seen every week in the hospital. A high level of clinical suspicion must be maintained. We believe our findings show the advisability of extensive and decentralised use of combined clinical and laboratory diagnostics when malaria is suspected. Campaigns and sewage measures to eliminate stagnant water may reduce the malaria incidence during the dry season.
Prevention possibilities: poverty and smoking
African children, after weaning, on average follow a slacker growth curve than European children. The borderline towards malnutrition, anaemia and an increased vulnerability in relation to disease is not clear, but it is telling that the great majority of our referred children were low on the percentile curve. The tendency for sick children in our study to come from poor families supports the banal truth that preventing poverty is an effective way to improve health in a population. Poverty measures are commonly based on income or consumption. For an average citizen, Cameroon is just below the World Bank limit of 2 USD a day with 600 USD in Gross National Product per capita in 1999 . In Cameroon in 1996, the consumption poverty line with regards to a minimum diet and other basic necessities, was estimated at F CFA 148 000, or a little less than 200 USD . However, the World Bank Report  emphasises the need to study non-income dimensions of poverty as well. Our criteria education, shelter and access to sanitation are among the most important criteria suggested. Lacking a universal validated poverty measure, we believe our index discriminated well between rich and poor in the local setting and could do so in other localities as well. We did not include access to safe water because almost everybody in Ngaoundere has got such access, but it probably should be included as a criterion in communities where this is a problem.
It is important to emphasise what is good or promising in a community. Smoking is in many regions a much less widespread habit than in Europe, although national official smoking prevalence among adults in Cameroon was 35,7% in 1994 . It is encouraging that poverty showed no relationship with smoking and seems to be little prevalent among village people who recently moved to town. Smoking, although cheap by western standards, is sufficiently expensive to require a certain level of income. However, this state of affairs could turn out to be fragile if economic conditions improve. The statistical association between coughing children and living in a household with at least one smoker is important because in vulnerable children common infectious diseases more easily develop into serious disease. The connection between passive smoking and coughing is in accordance with studies from Hong Kong [8, 9]. Knowing what smoking means in terms of wasted health and expenses for a country, anti-smoking measures deserve high priority, even if not usually considered an urgent third world health problem.
Three conditions for improved health care: organisation of health care, generic drugs, education
Simple examinations are often the most important for diagnosis. In the present study, a good clinical examination and access to a few basic x-ray and laboratory examinations was crucial and sufficient in many cases. The cost gap between hospitalised and ambulant patients suggests that a better distribution of tasks between primary and secondary care could make health care more efficient. A national program for tuberculosis with free examination and treatment is urgently needed. A national hiv/aids program including antiretroviral therapy is in the process of being established with drug prices negociated down to 30 USD per month, still a high price in relation to income even if it increases hope for many people. Co-operation, supervision and a system for necessary transport are preconditions for health care on all levels.
Secondly, cheap and efficient drugs must be available, a goal which necessitates co-operation between international institutions and an ethics-considering pharmaceutical industry. Such considerations are important not only for HIV drugs; trade agreements must include obligations to make good generic drugs available. Globalisation must imply an effort to improve conditions globally. The most expensive treatment in our study was the osteomyelitis treatment in a six years old boy. The drug used was made in India, and the original brand drug costs about four times as much in a European pharmacy. The price of his antibiotic treatment, approximately 110 USD, is beyond the means of most families in light of the income examples given.
The third requirement is a large effort to increase education on all levels, and a fair geographic distribution of health personnel. Our study showed a frightening high level of illiteracy among mothers. This is unacceptable, both for the country and for the international community. Basic schooling allows improved understanding about child care and increases the possibility to rise from the most extreme poverty. The relationship we found between low female education and many children supports the assumption that education also promotes family planning. Higher education is equally important. Large numbers of physicians, nurses, physiotherapists and other groups of key personnel are needed. Practice periods should take place in rural communities to increase interest in future work in peripheral areas.