Demographic Trends in the Developing World: a focus on mortality and morbidity Professor Hazel...

Demographic Trends in the Developing World: a focus on mortality and morbidity

Professor Hazel Barrett

Acting Associate Dean (Research)

Faculty of Business, Environment and Society,

Coventry University, CV1 5FB.

[email protected]

Lecture to Bristol GA

21st September 2010

Introduction

In October 1999 the world’s population reached 6 billion.

World Population has doubled in last 40 years.

Latest one billion added in only 12 years.

2005 world population = 6.5 billion

World Population

Year Period (in years) for addition of one billion people

1 billion 1804

2 billion 1927 123

3 billion 1960 33

4 billion 1974 14

5 billion 1987 13

6 billion 1999 12

Introduction

But… Annual population growth rates have halved since

1960. Now stands at 1.4%. Annual additions of people have dropped from 130m

in late 1980s to 78m in 1999. UN has revised downwards its medium variant

population projection. Global population predicted to stabilise in 2050 at 9 billion (a revision down of 2.5 billion since 1990).

So what is happening…?

Global Fertility

All global regions are now experiencing a fertility transition. (see table)

Only since 1975 that the developing world has experienced significant and sustained declines in fertility.

Sub-Saharan Africa is the last global region to begin the fertility transition.

Global fertility statisticsCBR per 1000 pop

CBR per 1000 pop

CBR per 1000 pop

TFR TFR TFR TFR TFR Pop annual growth rate %

Pop annual growth rate %

Pop annual growth rate %

1970 1998 2003 1960 1975 1990 1998 2005 1980-90

1990-98

2000-05

SSA 48 41 40 6.7 6.7 6.2 5.5 5.5 5.0 2.6 2.3

Mid East & N Africa

45 28 27 7.1 6.4 4.9 3.8 3.4 5.0 2.3 1.9

S Asia 41 27 26 6.1 5.4 4.1 3.4 3.6 3.7 1.9 1.7

E Asia & Pacific

35 18 16 5.8 3.9 2.5 2.0 1.9 2.6 1.2 0.9

Lam & Carrib

37 23 22 6.1 4.7 3.2 2.7 2.5 3.3 1.7 1.4

E Eur & former USSR

20 14 13 3.1 2.4 2.3 1.8 1.5 1.1 0.3 0.0

Developing c’s

38 25 24 6.0 5.0 3.5 3.0 2.9 3.2 1.7 1.9

Industrialised c’s

17 12 12 2.8 1.9 1.7 1.6 1.7 1.2 0.6 0.7

World 33 22 21 5.1 4.1 3.1 2.7 2.6 2.9 1.4 1.2

Global Fertility

Factors responsible for fertility change

Infant & child mortality

Use of modern Contraception FERTILITY CHANGE

Level of female education

Global Fertility

The Synergistic Effect of Female Education

See diagram. Plays a major role in decreasing infant and child

mortality. Educated women are more likely to use modern

contraception. The benefits accrue from generation to generation. Educated women are more likely to understand health

issues and be empowered within the family.

Global Mortality

Since 1960 there have been substantial declines in mortality in all global regions except sub-Saharan Africa. (see table)

Sub-Saharan Africa stands out as having the poorest mortality situation, mainly because of the HIV/AIDS epidemic.

Life expectancy has increased in all global regions, with sub-Saharan Africa recording declines in many countries, again as a result of HIV/AIDS.

Global mortality statisticsCDR per 1000 pop

CDR per 1000 pop

CDR per 1000 pop

IMR IMR IMR U5MR U5MR U5MR

Life expectancy

Life expectancy

Life expectancy

1970 1998 2003 1960 2000 2003 1960 2000 2005 1970 2000 2003

SSA 21 16 18 156 107 104 261 174 163 44 49 46

Mid East & N Africa

17 7 6 153 47 45 241 52 56 52 67 67

S Asia 18 9 8 146 68 67 239 83 92 48 63 63

E Asia & Pacific

10 7 7 133 33 31 201 33 40 58 70 69

Lam & Carrib

10 6 6 102 30 27 154 31 32 60 70 70

E Eur & former USSR

9 11 11 76 20 34 101 33 41 66 69 70

Developing c’s

14 9 9 138 61 60 216 115 87 53 65 62

Industrialised c’s

10 9 9 31 6 5 37 7 6 72 78 78

World 12 9 9 124 56 54 193 75 80 56 67 63

Global Mortality

Although IMR and U5MR have declined in all global regions, the developing world lags some way behind the industrial regions.

Global Mortality

Factors contributing to changes in life expectancy

LIVING STANDARDS HEALTHCARE STANDARDS DISEASE PATTERNS

i. Access to safe water i. Advances in healthcare i. Changing disease

and sanitation severity

ii. Adequate diet/nutrition ii. Levels of immunisation ii. Emerging and

re-emerging diseases

iii. Living conditions iii. Safe motherhood

iv. Access to healthcare

LIFE EXPECTANCY

WHO Classification of Countries according to mortality stratum 2006

The Global Health Transition:WHO Three-fold classification of disease

Group 1: infectious/communicable diseases Infectious and parasitic diseases grouped with

maternal, perinatal and nutritional conditions.

Group 2: non-communicable diseases (NCD) Non-communicable diseases include cardiovascular

diseases, diabetes, cancers, chronic respiratory disease, neuro-psychiatric conditions and musculoskeletal disorders.

Group 3: injury related Injuries, and includes intentional as well as

unintentional injuries.

The Health Transition

Work undertaken since Omran published his Epidemiological Transition suggest the situation is a complex one, with the transition in health comprising three key elements:1. An epidemiological transition from infectious diseases to non-communicable conditions.2. A medical and healthcare revolution which has tackled infectious diseases.3. Changes in socio-economic development which have favoured the control of infectious diseases.


Based on three assumptions:1. Long term changes in the health conditions of a society are associated with socio-economic and human development. These impact on patterns of disease, disability and death.

2. Socio-economic and human development results in changes in the medical and social responses to health conditions.

3. Level of development will determine the health conditions of a society and its ability to respond.


It is a complex relationship between these three factors as shown on the diagram.

This interaction helps explain why within a country the Health Transition can be at different stages.

Global Health Transition:1990-2002

Group 1 Responsible for 32% of global deaths in 2002, with

AIDS, TB and malaria accounting for 10%. Deaths from HIV/AIDS increased from 2-14%,

whereas deaths from other infectious diseases declined. If HIV/AIDS is excluded then deaths would have declined from 33% to less than 20% of all global deaths, although deaths from malaria and TB showed no signs of declining.

Disease burden saw a 20% reduction, would have been closer to 30% without HIV/AIDS.



Group 2 Responsible for 59% of all global deaths, with 80%

of deaths occurring in low and middle income countries.

In 2005 NCD killed more people than AIDS, TB and malaria combined.

Cardiovascular diseases, diabetes, cancers and chronic respiratory disease account for 50% of global mortality.

Burden of disease increased by 10%. The burden of disease from NCD is increasing

globally.


Group 2NCD is increasing and now accounts for

nearly half the global burden of disease.In low mortality developing countries

NCD accounts for 70% of the adult disease burden, in the high mortality developing countries almost 50% of the disease burden is NCD.


Group 3Remained static.Responsible for 9% of global deaths.Injuries primarily affect young adults and

account for 14% of adult disease burden.


Evidence that most global regions are experiencing a Health transition.

Group 1 diseases being replaced by Group 2 diseases as the main causes of death, disease and disability.

Only in sub-Saharan Africa is the Health Transition making little progress, with Group 1 diseases being responsible for almost 80% of the disease burden.


Health Transition will continue, with a dramatic shift from Group 1 to Group 2 causes of death, disease and disability.

Fig 3.8


By 2030 all global regions, including sub-Saharan Africa, will be experiencing a Health Transition with Group 2 diseases being much more important than Group 1 conditions.

This has serious implications for health policy.

The Nutrition Transition

Since 2000, a global Nutrition Transition has been identified by Popkin.

This is based on the Health Transition suggesting that changes in nutritional status relate to the complex interaction of changes between socio-economic factors, including patterns of diet and physical activity.

Result is rapid onset of obesity in developing countries and the consequent rise in nutrition-related non-communicable diseases (NR-NCD).


Many societies in the developing world appear to be converging on a diet high in saturated fats, calorific sweetners, animal food products and refined foods which is low in fibre, often termed the ‘Western Diet’. There has been a fall in total cereal and fibre intake.

At the same time lifestyles in these countries are characterised by lower levels of physical activity, as a result of technological progress and changes in life styles (Popkin, 2003).


Popkin (2006) presents five stages in the Nutrition Transition.

The first stage is linked to hunter-gather societies, a period when the diet was very healthy, but infectious disease and natural hazards resulted in short life expectancies.

The second stage is the period when modern agriculture developed and with it famine. It is a period of poor nutritional status, but strenuous physical activity.

In stage three famine begins to recede as income rises. Infectious diseases begin to be replaced by degenerative diseases as people live longer. The introduction of labour saving devices means that people live more sedentary lives.


By stage 4 people are consuming more fat and have a poor diet producing problems of NR-NCD such as cardiovascular disease and diabetes. People live longer, but have a longer period of disability. Technological developments re-enforce life styles of inactivity, both in the work-place and in leisure time.

Stage five is the stage where people begin to change their diet to make it more healthy, and engage in active leisure pursuits. This results in longer healthier lives.


Today many countries in the developing world are moving from stage 3 to stage 4 of the Nutrition Transition.

This transition has been most rapid in low and middle income countries. Countries such as China, Mexico, Egypt and South Africa have high levels of obesity. Some developing countries have in excess of 20% of the adult population classified as obese. In Egypt over 70% of urban women have a BMI over 25%. Mexico, Jordan, Guatemala, Turkey, South Africa and Peru all record that over 60% of women living in urban areas are overweight.


In China, Indonesia, Mexico and Thailand, annual increases in obesity are some of the highest in the world (only UK and Australia is higher) with annual increases of over 1% a year (Popkin, 2006). Between 1997-2000 the increase in overweight women in China was almost 2% a year (Popkin, 2006).


A study of 36 developing countries undertaken using data between 1992-2000, showed that the numbers of overweight and obese people far exceeded those who are underweight (Popkin, 2006).

As Popkin states ‘there are more overweight or obese than underweight or malnourished persons in the world; this disparity is growing rapidly’. (Popkin, 2006, 296).

Yet little research is currently undertaken on the topic of obesity and NR-NCDs in the developing world and few countries are prepared for the high level of NR-NCDs that will occur in the next decade or so (Popkin, 2004).

Prospects for the 21st Century

WHAT IS CERTAIN IS THAT..

Global population will increase well into the middle of this century.

Most of this increase will take place in the developing world.

More people will be entering their childbearing and working years than ever before.

As people live longer a greater proportion of the world’s population will consist of older people.

Prospects for the 21st Century

The challenge is how to best to provide for these ‘new generations’.

‘Our future will be shaped by how well families and societies meet the needs of these growing ‘new generations’: education and health – for the young, and social, medical and financial support for the elderly.’ (UNFPA, 1998, ii)

Health and Development: a rethink?

Group 1 conditions attract much attention and aid, but WHO currently spends less than 5% of its budget on NCD.

Calls for NCD to be included in the MDGs. ‘the majority of developing countries are facing

a double burden from both communicable and noncommunicable disease.’ (WHO, 2003, 27).

The Nutrition Transition reminds us that development can have negative affects on health.

Reference List

Barrett, H.R., 2000, Six billion and still counting: trends and prospects for global population at the beginning of the Twenty-First Century. Geography, 85 (2), 107-120.

Barrett, H.R., 2007, Too little, too late: responses to the HIV/AIDS epidemics in sub-Saharan Africa. Geography, 92 (2), 87-96.

Dodd, R & Cassels, A, 2006, Health, development and the Millennium Development Goals. Annals of Tropical Medicine and Parasitology, 100 (5 & 6), 379-387.

Lopez, A.D. & Mathers, C.D, 2006, Measuring the global burden of disease and epidemiological transitions. Annals of Tropical Medicine & Parasitology, 100 (5 & 6), 481-500.

Mathers, C.D & Loncar, D, 2005, Updated projections of global mortality and burden of disease, 2002-2030: data sources, methods and results. WHO, Geneva.

Meade, M.S & Earickson, R.J., 2000, Medical Geography. The Guildford Press, London.

Health and Development: a rethink?

Perhaps it is time for a rethink, with NCD given the priority in health policy that have been responsible for declines in infectious diseases.

If we don’t prioritise NCD then it is likely that development will be compromised in the next 20 years.

Reference List

Murray, C.J.L. & Lopez, A.D, 1996, The global burden of disease. Harvard University Press, USA.

Mathers, C.D & Loncar, D, 2005, Updated projections of global mortality and burden of disease, 2002-2030: data sources, methods and results. WHO, Geneva.

Murray, C.J.L. & Lopez, A.D, 1996, The global burden of disease. Harvard University Press, USA.

Omran, A R, 1971, The epidemiologic transition: a theory of the epidemiology of population change. Milbank Memorial fund Quarterley, 49 (4), 509-538.

OECD/WHO, 2003, Poverty and health. DAC guidelines and reference series. OECD, Paris.

Popkin, B M, 2001, The nutrition transition and obesity in the developing world. The Journal of Nutrition, supplement, 871S-873S.

Popkin, B M, 2003, The nutrition transition in the developing world. Development policy review, 21 (5-6), 581-597.

Popkin, B M, 2004, The nutrition transition: an overview of world patterns of change. Nutrition Reviews, 62 (7), S140-S143

Reference List

Popkin, B M, 2006, Global nutrition dynamics: the world is shifting rapidly toward a diet linked with noncommunicable diseases. American Journal of Clinical Nutrition, 84, 289-298.

Popkin, B M & Gordon-Larsen, P, 2004, The nutrition transition: worldwide obesity dynamics and their determinants. International Journal of Obesity, 28 52-59.

Unwin and Alberti, 2006. UN, 2000,UN World population Prospects the 2000 revision,Vol 3 UNAIDS, 2002, AIDS epidemic update. December 2002. www.unaids.org UNAIDS, 2006, AIDS epidemic update. December 2006. www.unaids.org UNDP, 2006, Human Development Report, Basingstoke, Palgrave

Macmillan UNICEF, 2006, The State of the World’s Children.New York, Unicef World Bank, 2006, World development Report, Oxford, Oxford University

Press. WHO, 2003 & 2006 The World Health Report, Geneva, WHO.

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