the changing age structure and the relative success of improvements in child health and reductions in child mortality.

Without HIV/AIDS, 19 percent more deaths are expected to occur during 2010-2015 compared with 1985-1990, with the entire increase occurring in the adult population (Heligman et al., 1993). However, high levels of HIV/AIDS characterize much of sub-Saharan Africa, including South Africa, and are altering the expected age distribution of these populations as a result of dramatically increasing mortality in the young and middle adult age groups (Dorrington, Bourne, Bradshaw, Laubsher, and Timaeus, 2001; Heligman et al., 1993; Joint United Nations Programme on HIV/ AIDS, 2002; Timaeus, 1998), together with decreasing fertility (Gregson, 1994; Gregson, Zaba, and Garnett, 1999).

Almost half the South African population resides in rural and semirural settings, comprising the majority of the country’s poor. The past decade has been one of momentous sociopolitical change in South Africa, with the population undergoing dramatic changes in patterns of health and disease. Yet the evidence base on which to premise interventions in support of rural health and development remains deeply inadequate. Characterizing and understanding the transitional process, let alone managing it effectively, are difficult tasks. This is apparent in the mixed results from policies to date, the concerns of leaders in the public sector, and a renewed government initiative to launch an integrated rural development strategy.

An overarching concern in the country, mirrored in many other settings, focuses on how best to apply society’s limited resources to a rapidly unfolding health and social transition in the face of escalating HIV/AIDS and continuing high levels of violence and injury. To do this, knowledge is needed about trends in rural health status and population dynamics, insight into the complex interplay between poverty-related diseases and emerging “chronic diseases of lifestyle,” understanding of the socioeconomic pressures imposed on households by severe illness and death, and evidence for medical, health, and social interventions that can enhance individual and household resilience.

Such understanding is vital to effective decision making at different levels of the health service. Understanding of changing mortality patterns is of real consequence for intervention programs, development of “essential packages” of care and the impact that can be expected, and resource allocation and human resource development. As reflected in the report of the Commission on Health Research for Development, drafted more than a decade ago, research on the problems of rural health and development remains essential to an effective societal response and may well prove the “essential link to equity in development” (Commission on Health Research for Development, 1990).

This paper is divided into three parts. First, we review the theory of



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