Shifting Patterns of Morbidity
and Mortality in the
Developing World
Calvin L. Wilson MD
Director – Center for Global Health
University of Colorado Denver
Presenter Disclosures
Calvin L. Wilson MD
The following personal financial relationships
with commercial interests relevant to this
presentation existed during the past 12 months:
No relationships to disclose
Objectives



Understand past and current
patterns of morbidity and mortality
around the world
Discuss the epidemiologic and
demographic transitions taking place,
and propose some possible
determinants of this change
Review potential health system
strategies needed to deal with this
challenge
Definitions

Levels of development traditionally
expressed in economic terms (World
Bank), rather than human or system
development
• Developing countries (“majority world”) – GNI
< $4000 (Low Income – GNI < $975)
• Developed countries (“Western/Industrialized
world”) – GNI > $12,000
• “Upper Middle Income” countries – GNI $4000
- $12,000
Mortality – Global Picture
Cause of Death
Cardiovascular
Disease
Cancer
Chronic Resp. Disease
Diabetes
Other Chronic
Diseases
Communicable,
Preventable
Injuries
WHO
USA
(2002)
Jordan
(2002)
Kazakhstan
(2002)
Nepal
(2002)
Nigeria
(2005)
38%
32%
53%
21%
11%
23%
8%
3%
14%
3%
1%
13%
4%
1%
7%
5%
2%
4%
3%
1%
16%
15%
8%
7%
5%
6%
19%
8%
49%
69%
6%
16%
13%
9%
7%
Mortality – Global Picture
Cause of Death
High Income (2005)
Cardiovascular
38%
Disease
Cancer
26%
Chronic Resp. Disease
6%
Diabetes
3%
Other Chronic
14%
Diseases
Communicable,
7%
Preventable
Injuries
6%
WHO
Low Income (2003)
23%
7%
5%
1%
7%
48%
9%
Life Expectancy
80
74
65
70
60
50
45
50
50
55
65
55
Developing
Developed
40
30
20
10
0
1945
1960
1980
1995
LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/
Life Expectancy
Example - Egypt
20
Years
80
75
70
65
60
55
50
45
40
5
Years
US
Egypt
1945
1975
1995
LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/
Epidemiologic Transition


Shift from one pattern of morbidity and
mortality to another
Transition from diseases of “Developing”
world to those “Developed” world
• Most clearly seen in shift from Infectious
Diseases to Chronic Diseases (“NCD”)

Has been occurring for past 200-300 years
(Abdel Omran), but at different rates and
different dynamics across the world
Epidemiologic Transition
Infectious Diseases
Mortality Rates
NCD
Epidemiologic Transition
LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/
Primary Chronic Diseases
(NCD)





Heart Disease
Stroke
Cancer
Chronic Respiratory Disease
Diabetes
Epidemiologic Transition
LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/
Infectious vs. Heart Disease
Deaths (in Thousands) due to Cardiovascular Diseases (CVD) and
Infectious and Parasitic Diseases (IPD) in 30-69 year olds in 1990
Men
Region
Women
CVD
IPD
CVD
IPD
Established Market Economies
483
42
227
12
Former Socialist Republics
416
20
253
6
India
611
429
481
240
China
576
158
439
89
Other Asia & Pacific
289
147
226
140
Sub-Saharan Africa
183
215
211
228
Latin America/Caribbean
186
62
147
48
Middle East Crescent
285
56
215
35
3,028
1,128
2,201
798
Worldwide
WHO
Epidemiologic Transition - NCD
Dodani, Sunita, “Health Transition and Emerging CVD in Developing Countries”,
www.bibalex.org/supercourse/
Heart Disease Mortality Projections
Heart Disease Mortality (Thousands)
Women
1990 2020
Men
% Increase
1990
2020
% Increase
Established Market
Economies
Former Socialist
Republics
India
838
1107
32%
829
1209
46%
559
702
26%
468
712
52%
556
1197
115%
619
1405
127%
China
377
684
81%
386
811
110%
Other Asia & Pacific
227
552
143%
233
581
149%
Sub-Saharan Africa
117
263
125%
92
222
141%
Latin America/Caribbean 169
412
144%
179
444
148%
Middle East Crescent
717
146%
319
874
174%
291
Heart Disease Mortality Projections
Summary
Heart Disease Mortality (Thousands)
Women
Men
1990
2020
% Increase
1990
2020 % Increase
Total developed
countries
1397
1809
29%
1297
1921
48%
Total developing
countries
1737
3825
120%
1828
4337
137%
Worldwide
3134
5634
80%
3125
6258
100%
Cancer Mortality by Income Level
Source: The Lancet 2010; 376:1186-1193 (DOI:10.1016/S0140-6736(10)61152-X)
Terms and Conditions
Epidemiologic Transition

Observed elements of transition
• Transition more bimodal in developed
world, but overlapping in developing
world (resulting in “double burden of
disease”)
• Transition much more rapid in
developing world – 2-3 generations vs.
6-7 generations in developed world
• Dynamics of transition different between
developing and developed world
Possible Determinants of
Epidemiologic Transition









Globalization
Urbanization
Decreased fertility and birth rate
Increasing life span, population, and percentage
of elderly
Decreased infant mortality
Dietary changes ( fats, fruits and vegetables)
Public health advances
Increased use of tobacco products
Environmental and climate changes
Associated Changes in
Demography
LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/
Determinants and Dynamics of
Epidemiologic Transition
Dodani, Sunita, “Health Transition and Emerging CVD in Developing Countries”,
www.bibalex.org/supercourse/
Different Dynamics – Developing
vs. Developed Countries

Determinants similar, but dynamics of
change are different
• Compressed time of transition imposes “double
burden” of diseases, with increased stress on
public health system
• Increasing urbanization occurs in context of
poverty and international debt, which restricts
public health response
• Prevention efforts in developed countries
occurred at peak of NCD epidemic, while NCD
are currently on initial rise in developing
countries
Different Dynamics – Developing
vs. Developed Countries
• Urban populations (increasing rapidly in
developing countries) have higher CVD risks
due to obesity, diet, decreased physical
activity
• Tobacco consumption decreasing in developed
world, but increasing markedly in developing
world
• Treatment of CVD much more expensive than
that of infectious disease, which decreases
access by the poor, especially rural poor; and
depletes available resources
Costs of Care – Infectious vs. NonCommunicable Disease
Infectious Disease
Disease
Treatment/
month
Cost
Chronic Disease (NCD)
Disease
Treatment/
month
Cost
Malaria
3 day med
$2.00
CHD
Meds, stent
$35+
Diarrhea
ORS
$0.25
Renal
Dialysis
$1200
Measles
Immunization
$0.25
CVD
Rehab.
???
Pneumon 5-7 day med
$0.50
Diabetes
Meds, Insulin
$60+
Strep
$1.00
RHD
Meds, valve
$35+
10 day med
Management of Shifting
Epidemiology in Developing World

Principles of Management
1. Must simultaneously deal with ongoing
infectious diseases, and an effective response
to emerging chronic diseases
2. Because treatment so expensive, best
approach is PREVENTION of chronic diseases
3. Approach must deal with as many as possible
of underlying determinants of epidemiologic
changes
4. Globalization may be major factor in increase
in chronic diseases, but also offers proven
and effective principles of management
Basic Principles of Chronic Disease
in Developing World (WHO)
1. Chronic diseases are major source of
DALYs lost and early mortality, and
steadily increasing in developing world
2. Must deal simultaneously with acute
infectious and chronic disease
3. Chronic disease affects young and
middle-aged individuals – 25% of all
deaths <60
4. Chronic disease affects men and women
equally (47% women; 53% men)
Basic Principles of Chronic Disease
in Developing World (WHO)
5. Poverty reduces options for healthy
lifestyles
6. Risk factor reduction can lead to
significant reduction in chronic disease
morbidity and mortality
7. Effective preventive measures can be
inexpensive and have been successfully
implemented
8. Effective preventive strategies can
significantly reduce DALYs lost to chronic
disease
Risk Factors for Infectious &
Chronic Disease







Poverty
Poor access to health care
High birth rates and population density
Poor food access and security - chronic
malnutrition
Inadequate and unclean water
Poor sanitation
Institutionalized inequities
Modifiable Risk Factors for
Chronic Disease







Tobacco Use
Obesity
Atherogenic diet (few vegetables & fruits)
Environmental pollution – especially
indoor
Physical inactivity
Hypertension
Elevated blood lipids
Effective Interventions in Chronic
Disease - Examples

Tobacco control
• Bhutan, Cuba, India, Ireland, Chile, Tonga,
Thailand, Rwanda

Increased physical activity
• China, Brazil

Workplace programs
• activity, education, BP and diabetes screening

Screening programs
• Cancer of cervix – Costa Rica
• BP and diabetes diagnosis – many countries
Effective Interventions in Chronic
Disease - Example

Ventilated cook-stove development
• Central/Latin America, India

Chronic disease case management
• “Adult care” – Peru
• Family Medicine program – South Africa

Self-management programs
• Diabetes education & self-management-Mexico
• China – educational programs

Community-based rehabilitation of stroke
• Over 90 developing countries implementing
Summary


Morbidity and mortality shifting from
infectious to chronic diseases across the
world.
Chronic diseases will be most common
cause of death within 25 years in all
countries of the world
•
•
•
•
•
Heart Disease
Stroke
Cancer
Chronic Respiratory Disease
Diabetes
Summary



Globalization, urbanization, population
growth, and aging population are major
contributors to rise of chronic disease
Poverty and established inequities are a
major impediment to effective
management of shifting epidemiology
Proven, effective, and inexpensive
strategies for prevention of chronic
disease are globally available for
addressing this issue.