A distinctive gastritis precedes the development of cancer distal to the cardia. Helicobacter pylori infection and the use of pickled foods as substitutes for fresh fruits and vegetables constitute the most important environmental factors that generate this gastritis. This review describes the anatomical changes that characterise the step-by-step evolution of a process that begins in childhood and culminates in invasive cancer in middle and old age. Progression of the gastritis can be followed by measuring the host antibody response to the H. pylori infection and by serum assays that indicate loss of parietal cell mass. Cancer of the distal stomach will disappear if adequate, sanitary housing and year-round fresh vegetables are made available to all economic levels of society. Programmes that offer these reforms must be sustained over several generations, since the anatomical changes that precede gastric cancer are probably not reversible and begin early in life. In the absence of these reforms, death from gastric cancer may be prevented if patients with asymptomatic, early cancers are identified. High H. pylori antibody levels and serum pepsinogen assays may be used to identify persons with the extensive gastritis that favours the presence of such early cancers.