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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.

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shifting patterns of morbidity and mortality in the developing world

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
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
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
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
life expectancy
Life Expectancy

LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/

life expectancy example egypt
Life ExpectancyExample - Egypt

5

Years

20

Years

LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/

epidemiologic transition
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 transition10

Infectious Diseases

Epidemiologic Transition

NCD

Mortality Rates

Epidemiologic Transition

LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/

primary chronic diseases ncd
Primary Chronic Diseases (NCD)

Heart Disease

Stroke

Cancer

Chronic Respiratory Disease

Diabetes

epidemiologic transition12
Epidemiologic Transition

LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/

infectious vs heart disease
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

WHO

epidemiologic transition ncd
Epidemiologic Transition - NCD

Dodani, Sunita, “Health Transition and Emerging CVD in Developing Countries”,

www.bibalex.org/supercourse/

heart disease mortality projections
Heart Disease Mortality Projections

Heart Disease Mortality (Thousands)

heart disease mortality projections summary
Heart Disease Mortality ProjectionsSummary

Heart Disease Mortality (Thousands)

cancer mortality by income level
Cancer Mortality by Income Level

Source: The Lancet 2010; 376:1186-1193 (DOI:10.1016/S0140-6736(10)61152-X)

Terms and Conditions

epidemiologic transition18
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
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
Associated Changes in Demography

LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/

determinants and dynamics of epidemiologic transition
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
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 countries23
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
management of shifting epidemiology in developing world
Management of Shifting Epidemiology in Developing World
  • Principles of Management
    • Must simultaneously deal with ongoing infectious diseases, and an effective response to emerging chronic diseases
    • Because treatment so expensive, best approach is PREVENTION of chronic diseases
    • Approach must deal with as many as possible of underlying determinants of epidemiologic changes
    • 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
Basic Principles of Chronic Disease in Developing World (WHO)

Chronic diseases are major source of DALYs lost and early mortality, and steadily increasing in developing world

Must deal simultaneously with acute infectious and chronic disease

Chronic disease affects young and middle-aged individuals – 25% of all deaths <60

Chronic disease affects men and women equally (47% women; 53% men)

basic principles of chronic disease in developing world who27
Basic Principles of Chronic Disease in Developing World (WHO)

Poverty reduces options for healthy lifestyles

Risk factor reduction can lead to significant reduction in chronic disease morbidity and mortality

Effective preventive measures can be inexpensive and have been successfully implemented

Effective preventive strategies can significantly reduce DALYs lost to chronic disease

risk factors for infectious 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
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
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 exampl e
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
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
summary33
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.