Shifting Patterns of Morbidity and Mortality in the Developing World

1. Shifting Patterns of Morbidity and Mortality in the Developing World Calvin L. Wilson MD Director – Center for Global Health University of Colorado Denver

2. 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

3. 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

4. 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

5. Mortality – Global Picture WHO

6. Mortality – Global Picture WHO

7. Life Expectancy LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/

8. Life ExpectancyExample - Egypt 5 Years 20 Years LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/

9. 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

10. Infectious Diseases Epidemiologic Transition NCD Mortality Rates Epidemiologic Transition LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/

11. Primary Chronic Diseases (NCD) Heart Disease Stroke Cancer Chronic Respiratory Disease Diabetes

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

13. 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

14. Epidemiologic Transition - NCD Dodani, Sunita, “Health Transition and Emerging CVD in Developing Countries”, www.bibalex.org/supercourse/

15. Heart Disease Mortality Projections Heart Disease Mortality (Thousands)

16. Heart Disease Mortality ProjectionsSummary Heart Disease Mortality (Thousands)

17. Cancer Mortality by Income Level Source: The Lancet 2010; 376:1186-1193 (DOI:10.1016/S0140-6736(10)61152-X) Terms and Conditions

18. 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

19. 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

20. Associated Changes in Demography LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/

21. Determinants and Dynamics of Epidemiologic Transition Dodani, Sunita, “Health Transition and Emerging CVD in Developing Countries”, www.bibalex.org/supercourse/

22. 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

23. 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

24. Costs of Care – Infectious vs. Non-Communicable Disease

25. 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

26. 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)

27. 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

28. 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

29. Modifiable Risk Factors for Chronic Disease Tobacco Use Obesity Atherogenic diet (few vegetables & fruits) Environmental pollution – especially indoor Physical inactivity Hypertension Elevated blood lipids

30. 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

31. 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

32. 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

33. 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.