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 The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Calvin L. Wilson MD No relationships to disclose

3. Objectives Understand past and current patterns of morbidity and mortality around the world 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 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 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 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)Developing countries (“majority world”) – GNI < $4000 (Low Income – GNI < $975) Developed countries (“Western/Industrialized world”) – GNI > $12,000Developed countries (“Western/Industrialized world”) – GNI > $12,000 “Upper Middle Income” countries – GNI $4000 - $12,000“Upper Middle Income” countries – GNI $4000 - $12,000

5. Mortality – Global Picture Cause of Death USA (2002) Jordan (2002) Kazakhstan (2002) Nepal (2002) Nigeria (2005) Cardiovascular Disease 38%32%53%21%11% Cancer23%14%13%7%4% Chronic Resp. Disease8%3%4%5%3% Diabetes3%1% 2%1% Other Chronic Diseases 16%15%8%7%5% Communicable, Preventable 6%19%8%49%69% Injuries6%16%13%9%7% WHO

6. Mortality – Global Picture Cause of DeathHigh Income (2005)Low Income (2003) Cardiovascular Disease 38%23% Cancer26%7% Chronic Resp. Disease6%5% Diabetes3%1% Other Chronic Diseases 14%7% Communicable, Preventable 7%48% Injuries6%9% WHO

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

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

9. Epidemiologic Transition Shift from one pattern of morbidity and mortality to another Shift from one pattern of morbidity and mortality to another Transition from diseases of “Developing” world to those “Developed” world Transition from diseases of “Developing” world to those “Developed” world Most clearly seen in shift from Infectious Diseases to Chronic Diseases (“NCD”)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 Has been occurring for past 200-300 years (Abdel Omran), but at different rates and different dynamics across the world

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

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

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

13. Infectious vs. Heart Disease MenWomen RegionCVDIPDCVDIPD Established Market Economies4834222712 Former Socialist Republics416202536 India611429481240 China57615843989 Other Asia & Pacific289147226140 Sub-Saharan Africa183215211228 Latin America/Caribbean1866214748 Middle East Crescent2855621535 Worldwide3,0281,1282,201798 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 WomenMen 19902020 % Increase 19902020 % Increase Established Market Economies 838110732%829120946% Former Socialist Republics 55970226%46871252% India5561197115%6191405127% China37768481%386811110% Other Asia & Pacific227552143%233581149% Sub-Saharan Africa117263125%92222141% Latin America/Caribbean169412144%179444148% Middle East Crescent291717146%319874174% Heart Disease Mortality (Thousands)

16. Heart Disease Mortality Projections Summary WomenMen 19902020% Increase19902020% Increase Total developed countries 1397180929%1297192148% Total developing countries 17373825120%18284337137% Worldwide3134563480%31256258100% Heart Disease Mortality (Thousands)

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

18. Epidemiologic Transition Observed elements of transition Observed elements of transition Transition more bimodal in developed world, but overlapping in developing world (resulting in “double burden of disease”)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 worldTransition much more rapid in developing world – 2-3 generations vs. 6-7 generations in developed world Dynamics of transition different between developing and developed worldDynamics of transition different between developing and developed world

19. Possible Determinants of Epidemiologic Transition Globalization Globalization Urbanization Urbanization Decreased fertility and birth rate Decreased fertility and birth rate Increasing life span, population, and percentage of elderly Increasing life span, population, and percentage of elderly Decreased infant mortality Decreased infant mortality Dietary changes ( fats, fruits and vegetables) Dietary changes ( fats, fruits and vegetables) Public health advances Public health advances Increased use of tobacco products Increased use of tobacco products Environmental and climate changes 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 Determinants similar, but dynamics of change are different Compressed time of transition imposes “double burden” of diseases, with increased stress on public health systemCompressed 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 responseIncreasing 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 countriesPrevention 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 activityUrban 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 worldTobacco 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 resourcesTreatment 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 Infectious DiseaseChronic Disease (NCD) DiseaseTreatment/ month CostDiseaseTreatment/ month Cost Malaria3 day med$2.00CHDMeds, stent$35+ DiarrheaORS$0.25RenalDialysis$1200 MeaslesImmunization$0.25CVDRehab.??? Pneumon5-7 day med$0.50DiabetesMeds, Insulin$60+ Strep10 day med$1.00RHDMeds, valve$35+

25. Management of Shifting Epidemiology in Developing World Principles of Management 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

26. 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)

27. 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

28. Risk Factors for Infectious & Chronic Disease Poverty Poverty Poor access to health care Poor access to health care High birth rates and population density High birth rates and population density Poor food access and security - chronic malnutrition Poor food access and security - chronic malnutrition Inadequate and unclean water Inadequate and unclean water Poor sanitation Poor sanitation Institutionalized inequities Institutionalized inequities

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

30. Effective Interventions in Chronic Disease - Examples Tobacco control Tobacco control Bhutan, Cuba, India, Ireland, Chile, Tonga, Thailand, RwandaBhutan, Cuba, India, Ireland, Chile, Tonga, Thailand, Rwanda Increased physical activity Increased physical activity China, BrazilChina, Brazil Workplace programs Workplace programs activity, education, BP and diabetes screeningactivity, education, BP and diabetes screening Screening programs Screening programs Cancer of cervix – Costa RicaCancer of cervix – Costa Rica BP and diabetes diagnosis – many countriesBP and diabetes diagnosis – many countries

31. Effective Interventions in Chronic Disease - Exampl e Ventilated cook-stove development Ventilated cook-stove development Central/Latin America, IndiaCentral/Latin America, India Chronic disease case management Chronic disease case management “Adult care” – Peru“Adult care” – Peru Family Medicine program – South AfricaFamily Medicine program – South Africa Self-management programs Self-management programs Diabetes education & self-management-MexicoDiabetes education & self-management-Mexico China – educational programsChina – educational programs Community-based rehabilitation of stroke Community-based rehabilitation of stroke Over 90 developing countries implementingOver 90 developing countries implementing

32. Summary Morbidity and mortality shifting from infectious to chronic diseases across the world. 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 Chronic diseases will be most common cause of death within 25 years in all countries of the world Heart DiseaseHeart Disease StrokeStroke CancerCancer Chronic Respiratory DiseaseChronic Respiratory Disease DiabetesDiabetes

33. Summary Globalization, urbanization, population growth, and aging population are major contributors to rise of chronic disease 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 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. Proven, effective, and inexpensive strategies for prevention of chronic disease are globally available for addressing this issue.