shifting patterns of morbidity and mortality in the developing world calvin l. wilson md director...
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Shifting Patterns of Morbidity Shifting Patterns of Morbidity and Mortality in the and Mortality in the Developing WorldDeveloping World
Calvin L. Wilson MDCalvin L. Wilson MD
Director – Center for Global HealthDirector – Center for Global Health
University of Colorado DenverUniversity of Colorado Denver
Presenter DisclosuresPresenter Disclosures
The following personal financial relationships with The following personal financial relationships with commercial interests relevant to this presentation commercial interests relevant to this presentation existed during the past 12 months:existed during the past 12 months:
Calvin L. Wilson MD
No relationships to disclose
ObjectivesObjectives Understand past and current Understand past and current
patterns of morbidity and mortality patterns of morbidity and mortality around the worldaround the world
Discuss the epidemiologic and Discuss the epidemiologic and demographic transitions taking demographic transitions taking place, and propose some possible place, and propose some possible determinants of this changedeterminants of this change
Review potential health system Review potential health system strategies needed to deal with this strategies needed to deal with this challengechallenge
DefinitionsDefinitions
Levels of development traditionally Levels of development traditionally expressed in economic terms (World expressed in economic terms (World Bank), rather than human or system Bank), rather than human or system developmentdevelopment• Developing countries (“majority world”) – GNI Developing countries (“majority world”) – GNI
< $4000 (Low Income – GNI < $975)< $4000 (Low Income – GNI < $975)• Developed countries (“Western/Industrialized Developed countries (“Western/Industrialized
world”) – GNI > $12,000world”) – GNI > $12,000• ““Upper Middle Income” countries – GNI $4000 - Upper Middle Income” countries – GNI $4000 -
$12,000$12,000
Mortality – Global PictureMortality – Global Picture
Cause of DeathUSA
(2002)Jordan (2002)
Kazakhstan (2002)
Nepal (2002)
Nigeria (2005)
Cardiovascular Disease 38% 32% 53% 21% 11%
Cancer 23% 14% 13% 7% 4%Chronic Resp. Disease 8% 3% 4% 5% 3%Diabetes 3% 1% 1% 2% 1%Other Chronic Diseases 16% 15% 8% 7% 5%
Communicable, Preventable 6% 19% 8% 49% 69%
Injuries 6% 16% 13% 9% 7%
WHO
Mortality – Global PictureMortality – Global Picture
Cause of Death High Income (2005) Low Income (2003)Cardiovascular Disease 38% 23%
Cancer 26% 7%Chronic Resp. Disease 6% 5%Diabetes 3% 1%Other Chronic Diseases 14% 7%
Communicable, Preventable 7% 48%
Injuries 6% 9%
WHO
Life ExpectancyLife Expectancy
4550
55
65
5055
65
74
0
10
20
30
40
50
60
70
80
1945 1960 1980 1995
Developing
Developed
LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/
Life ExpectancyLife ExpectancyExample - EgyptExample - Egypt
40
45
50
55
60
65
70
75
80
1945 1975 1995
USEgypt
20Years
5Years
LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/
Epidemiologic TransitionEpidemiologic Transition
Shift from one pattern of morbidity and Shift from one pattern of morbidity and mortality to anothermortality to another
Transition from diseases of “Developing” Transition from diseases of “Developing” world to those “Developed” worldworld to those “Developed” world• Most clearly seen in shift from Infectious Most clearly seen in shift from Infectious
Diseases to Chronic Diseases (“NCD”)Diseases to Chronic Diseases (“NCD”) Has been occurring for past 200-300 years Has been occurring for past 200-300 years
(Abdel Omran), but at different rates and (Abdel Omran), but at different rates and different dynamics across the worlddifferent dynamics across the world
Epidemiologic Transition
Mor
talit
y R
ates
Infectious Diseases
NCD
Epidemiologic TransitionEpidemiologic Transition
LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/
Primary Chronic Diseases Primary Chronic Diseases (NCD)(NCD)
Heart DiseaseHeart Disease StrokeStroke CancerCancer Chronic Respiratory DiseaseChronic Respiratory Disease DiabetesDiabetes
Epidemiologic TransitionEpidemiologic Transition
LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/
Infectious vs. Heart DiseaseInfectious vs. Heart Disease
Men Women
Region CVD IPD CVD IPD
Established Market Economies 483 42 227 12Former Socialist Republics 416 20 253 6India 611 429 481 240
China 576 158 439 89Other Asia & Pacific 289 147 226 140
Sub-Saharan Africa 183 215 211 228Latin America/Caribbean 186 62 147 48Middle East Crescent 285 56 215 35
Worldwide 3,028 1,128 2,201 798
Deaths (in Thousands) due to Cardiovascular Diseases (CVD) andInfectious and Parasitic Diseases (IPD) in 30-69 year olds in 1990
WHO
Epidemiologic Transition - NCDEpidemiologic Transition - NCD
Dodani, Sunita, “Health Transition and Emerging CVD in Developing Countries”, www.bibalex.org/supercourse/
Heart Disease Mortality ProjectionsHeart Disease Mortality Projections
Women Men1990 2020 % Increase 1990 2020 % Increase
Established Market Economies
838 1107 32% 829 1209 46%
Former Socialist Republics
559 702 26% 468 712 52%
India 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 291 717 146% 319 874 174%
Heart Disease Mortality (Thousands)
Heart Disease Mortality ProjectionsHeart Disease Mortality ProjectionsSummarySummary
Women Men1990 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%
Heart Disease Mortality (Thousands)
Source: The Lancet 2010; 376:1186-1193 (DOI:10.1016/S0140-6736(10)61152-X)
Terms and Conditions
Cancer Mortality by Income LevelCancer Mortality by Income Level
Epidemiologic TransitionEpidemiologic Transition
Observed elements of transitionObserved elements of transition• Transition more bimodal in developed Transition more bimodal in developed
world, but overlapping in developing world, but overlapping in developing world (resulting in “double burden of world (resulting in “double burden of disease”)disease”)
• Transition much more rapid in Transition much more rapid in developing world – 2-3 generations vs. developing world – 2-3 generations vs. 6-7 generations in developed world6-7 generations in developed world
• Dynamics of transition different between Dynamics of transition different between developing and developed worlddeveloping and developed world
Possible Determinants of Possible Determinants of Epidemiologic TransitionEpidemiologic Transition
GlobalizationGlobalization UrbanizationUrbanization Decreased fertility and birth rateDecreased fertility and birth rate Increasing life span, population, and percentage Increasing life span, population, and percentage
of elderlyof elderly Decreased infant mortalityDecreased infant mortality Dietary changes ( fats, fruits and vegetables)Dietary changes ( fats, fruits and vegetables) Public health advancesPublic health advances Increased use of tobacco productsIncreased use of tobacco products Environmental and climate changesEnvironmental and climate changes
Associated Changes in Associated Changes in DemographyDemography
LaPorte, Ronald, Epidemiologic Transition, www.bibalex.org/supercourse/
Determinants and Dynamics of Determinants and Dynamics of Epidemiologic TransitionEpidemiologic Transition
Dodani, Sunita, “Health Transition and Emerging CVD in Developing Countries”, www.bibalex.org/supercourse/
Different Dynamics – Developing Different Dynamics – Developing vs. Developed Countriesvs. Developed Countries
Determinants similar, but dynamics of Determinants similar, but dynamics of change are differentchange are different• Compressed time of transition imposes “double Compressed time of transition imposes “double
burden” of diseases, with increased stress on burden” of diseases, with increased stress on public health systempublic health system
• Increasing urbanization occurs in context of Increasing urbanization occurs in context of poverty and international debt, which restricts poverty and international debt, which restricts public health responsepublic health response
• Prevention efforts in developed countries Prevention efforts in developed countries occurred at peak of NCD epidemic, while NCD occurred at peak of NCD epidemic, while NCD are currently on initial rise in developing are currently on initial rise in developing countriescountries
Different Dynamics – Developing Different Dynamics – Developing vs. Developed Countriesvs. Developed Countries
• Urban populations (increasing rapidly in Urban populations (increasing rapidly in developing countries) have higher CVD risks developing countries) have higher CVD risks due to obesity, diet, decreased physical due to obesity, diet, decreased physical activityactivity
• Tobacco consumption decreasing in developed Tobacco consumption decreasing in developed world, but increasing markedly in developing world, but increasing markedly in developing worldworld
• Treatment of CVD much more expensive than Treatment of CVD much more expensive than that of infectious disease, which decreases that of infectious disease, which decreases access by the poor, especially rural poor; and access by the poor, especially rural poor; and depletes available resourcesdepletes available resources
Costs of Care – Infectious vs. Non-Costs of Care – Infectious vs. Non-Communicable DiseaseCommunicable Disease
Infectious Disease Chronic Disease (NCD)Disease Treatment/
monthCost Disease Treatment/
monthCost
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 10 day med $1.00 RHD Meds, valve $35+
Management of Shifting Management of Shifting Epidemiology in Developing WorldEpidemiology in Developing World
Principles of ManagementPrinciples of Management1.1. Must simultaneously deal with ongoing Must simultaneously deal with ongoing
infectious diseases, and an effective response infectious diseases, and an effective response to emerging chronic diseasesto emerging chronic diseases
2.2. Because treatment so expensive, best Because treatment so expensive, best approach is PREVENTION of chronic diseasesapproach is PREVENTION of chronic diseases
3.3. Approach must deal with as many as possible Approach must deal with as many as possible of underlying determinants of epidemiologic of underlying determinants of epidemiologic changeschanges
4.4. Globalization may be major factor in increase Globalization may be major factor in increase in chronic diseases, but also offers proven and in chronic diseases, but also offers proven and effective principles of managementeffective principles of management
Basic Principles of Chronic Disease Basic Principles of Chronic Disease in Developing World (WHO)in Developing World (WHO)
1.1. Chronic diseases are major source of Chronic diseases are major source of DALYs lost and early mortality, and DALYs lost and early mortality, and steadily increasing in developing worldsteadily increasing in developing world
2.2. Must deal simultaneously with acute Must deal simultaneously with acute infectious and chronic diseaseinfectious and chronic disease
3.3. Chronic disease affects young and Chronic disease affects young and middle-aged individuals – 25% of all middle-aged individuals – 25% of all deaths <60deaths <60
4.4. Chronic disease affects men and women Chronic disease affects men and women equally (47% women; 53% men)equally (47% women; 53% men)
Basic Principles of Chronic Disease Basic Principles of Chronic Disease in Developing World (WHO)in Developing World (WHO)
5.5. Poverty reduces options for healthy lifestylesPoverty reduces options for healthy lifestyles
6.6. Risk factor reduction can lead to significant Risk factor reduction can lead to significant reduction in chronic disease morbidity and reduction in chronic disease morbidity and mortalitymortality
7.7. Effective preventive measures can be Effective preventive measures can be inexpensive and have been successfully inexpensive and have been successfully implementedimplemented
8.8. Effective preventive strategies can Effective preventive strategies can significantly reduce DALYs lost to chronic significantly reduce DALYs lost to chronic diseasedisease
Risk Factors for Infectious & Risk Factors for Infectious & Chronic DiseaseChronic Disease
PovertyPoverty Poor access to health carePoor access to health care High birth rates and population densityHigh birth rates and population density Poor food access and security - chronic Poor food access and security - chronic
malnutritionmalnutrition Inadequate and unclean waterInadequate and unclean water Poor sanitationPoor sanitation Institutionalized inequitiesInstitutionalized inequities
Modifiable Risk Factors for Modifiable Risk Factors for Chronic DiseaseChronic Disease
Tobacco UseTobacco Use ObesityObesity Atherogenic diet (few vegetables & fruits)Atherogenic diet (few vegetables & fruits) Environmental pollution – especially indoorEnvironmental pollution – especially indoor Physical inactivityPhysical inactivity HypertensionHypertension Elevated blood lipidsElevated blood lipids
Effective Interventions in Chronic Effective Interventions in Chronic Disease - ExamplesDisease - Examples
Tobacco controlTobacco control• Bhutan, Cuba, India, Ireland, Chile, Tonga, Bhutan, Cuba, India, Ireland, Chile, Tonga,
Thailand, RwandaThailand, Rwanda Increased physical activityIncreased physical activity
• China, BrazilChina, Brazil Workplace programs Workplace programs
• activity, education, BP and diabetes screeningactivity, education, BP and diabetes screening Screening programsScreening programs
• Cancer of cervix – Costa RicaCancer of cervix – Costa Rica• BP and diabetes diagnosis – many countriesBP and diabetes diagnosis – many countries
Effective Interventions in Chronic Effective Interventions in Chronic Disease - ExamplDisease - Examplee
Ventilated cook-stove developmentVentilated cook-stove development• Central/Latin America, IndiaCentral/Latin America, India
Chronic disease case managementChronic disease case management• ““Adult care” – PeruAdult care” – Peru• Family Medicine program – South AfricaFamily Medicine program – South Africa
Self-management programsSelf-management programs• Diabetes education & self-management-MexicoDiabetes education & self-management-Mexico• China – educational programsChina – educational programs
Community-based rehabilitation of strokeCommunity-based rehabilitation of stroke• Over 90 developing countries implementingOver 90 developing countries implementing
SummarySummary
Morbidity and mortality shifting from Morbidity and mortality shifting from infectious to chronic diseases across the infectious to chronic diseases across the world.world.
Chronic diseases will be most common cause Chronic diseases will be most common cause of death within 25 years in all countries of the of death within 25 years in all countries of the worldworld• Heart DiseaseHeart Disease• StrokeStroke• CancerCancer• Chronic Respiratory DiseaseChronic Respiratory Disease• DiabetesDiabetes
SummarySummary
Globalization, urbanization, population Globalization, urbanization, population growth, and aging population are major growth, and aging population are major contributors to rise of chronic diseasecontributors to rise of chronic disease
Poverty and established inequities are a Poverty and established inequities are a major impediment to effective major impediment to effective management of shifting epidemiologymanagement of shifting epidemiology
Proven, effective, and inexpensive Proven, effective, and inexpensive strategies for prevention of chronic strategies for prevention of chronic disease are globally available for disease are globally available for addressing this issue.addressing this issue.