Hodges Library Stacks RA651 .W65 vol.51 no.2-4 1998 TN: 681785 (AN 00 | ODYSSEY ENABLED jorid health statistics quarterly. Rapport trimestriel de This article ratstiques sanitaires mondiales. has been sent to you vo: 51 No: 2-3 by the DA: 1998, PG: 99-119 University of AU/TI: World Health Organization. Omran, AR; The Tennessee Epidemiologic Transition Theory Revisited 30 Years Later. TKN ‘TNUUTN ee Tu Lending String: Hodges Library *TKN,KLG)MUM,FDA,GUA Knoxville TN’ Tf Process: 20080621 ~8/22/08 Charges: No Charge 37996 Do not pay from this workform. lense send al 2 resend requests to Patron: Cossman, Jeralynn | i te m kek ): MFM Lending aria TO! MEM TN: 275413 3 or 7 . < Lending emai — Mississippi State University . = “trane you Library / Access Svs ee ee 3g #1 Hardy Street < Fax Mississippi State, MS 39762 | ecssrazms TATE g Lending Arie! 160.36.192.218 FAX Number: Email 662-325-3560 iislend@utk.edu Ariel Address: ariel. library.msstate.edu NOTICE: This material maybe Email: protected by blentine@tiorary.msstate-edu Copyright Law Request Number OCLC 45279515 (Title 17 US Code)The epidemiologic transition theory revisited thirty years later Abdel R. Omran Background “Aswearrive at thenewmillennium, documentingand reflecting on the past can guide the future. This is one of the functions of the Epidemiologic Transition, ‘Theory. The theory is based on the systematic appli- cation of epidemiologicinference tochanging health, ‘mortality, survival and fertility over time and place linked to their socio-economic, environmental, lifestyle, demographic, health care and technologi- cal determinants and/or correlatesin differentsoci- etal settings. There can be no doubt that a profound epidemiological change hasbeen taking place in the world over the last several centuries, albeit ata vary- ing pace and take-off time in different populations. ‘The purpose of this essay sto revisit che original 1971 presentation of the Epidemiologic Transition Theory, moving from a three-stage/three-model for- mulation toa five stage /fivemodel formulation. This will make use of the accumulation of information and insights over the last 80 years as partly demon- strated in Box 1, The epidemiologic transition Epidemiology is the study of health and disease patterns and their determinants and consequences in population groups. All of the transitions involved in both the dependent and independent variables are the subject of epidemiological study and, hence, are encompassed by the epidemiologic transition. Epidemiology incorporates the scientific capacity 10 analyze social, economic, demographic, health care, technological and environmental changes as they relate to health outcomes. Classifying all the changes in these variablesunder the “health wansition” would, however, be confusing. Health is a dependent vari- able of epidemiology, not vicewversa, Figure 1 dia- grammatically portrays the dynamics involved in the epidemiologic transition, Triggered by economic "This paper ian orginal esay by Abdel R. Omran, MD., De PH, Profewor in the Department of International Public Hetith, School of Public Health and Health Services, George ‘Washington Universi, Washington, D.C, USA. Dr Omran died in Apri 1999, Ar the time, be had completed the draft of this manuscript Several members ofthe facly of the Universiy feviewed the work including Dr Ayman El Mobandes, Dr Glen (Geelhood, Dr Daniel Hoffman, Dr Gilbert Kombe, Dr Richard Southby and Dr Wiliam Witers The final article was completed by Dr Rosalia Rodriguez Garcia, Profesor and Chait, and De [ames Banta, Profestor of the Deparment of tnternational Public Health, Thanks are extended abo to Susna De for her asiance in compleing the atl Wid hth statist. quart, 1 (1996) Boxt Evolution ofthe epidemiologic transition theory CConcaved by Oman nthe mid-1960s (1), the theory was published in its original form in 1971 (2). Subsequent applications (3), summaries (4) and a preliminary update (6jtolowed. Since then efforts for amore definitive update have been undertaken. This has been prompted further by ‘growing interest in the epidemiologic transition in the demographic (6), health 7,89) and soca science Iitera- ture (10), Additional, several papers nave used the righ ral 1971 version or its preliminary update in scholarly applications to specific populations (11,12). Papers by Dishansky and Ault in 1986 (13) and by Rogers and Hackenberg 14) suggested aFourt stage based primarily fn the experience of the USA. Frenk eta. (1989) (76) suggested a model for intermediate economies based pr- marly on the experience of Mexico. Constructive and insightful a5 these recommendations are, the definitive ‘update must perforee incorporate experiences based on wider geographic, temporal and conceptual inputs. The ravisied formulation wasbrieti describedin 1989 (76)and was applied more recenty tothe ransionsinthe Americas ia 1996 document commissioned bythe Pan American Health Organization (PAHO) (17) ‘and social development, the epidemiologic wansi- tion encompasses the changing disease and health patterns (the health transition), the changing fertik ity and population age structure leading to ageing (partsof the demographic transition), the changing lifestyles (the lifestyle transition) the changing health ‘care patterns (the health care transition), the medi- ‘cal and technological evolutions (the technologic transition), and the environmental and ecological changes (the ecological transition) ‘The relative role of mortality and fertility experi- ences in the transition dynamics is discussed under Proposition 1. The long-term dynamics of the tran- sition are classified into atleast five transition stages, which are described under Proposition 2. The par ticular determinants of mortality and fertility changes. are given thereafter, Different kinds of inequities are noted during the transition and are captured ‘under Proposition 3, Transition models characteriz- ing the dynamics, timing of the transition take-off, and subsequent changes in different country groups are briefly discussed in Proposition 4. Proposition 1: Relative role of mortality and ferility in the transition Within the complex dynamics of the epidemiologic transition, mortality is a most fundamental force, 9Fig. 4 ‘The epidemiologic transition dynamics sTaget powieyetange _s-Oreipaete Merge. __ Fame enenceand Receding Dogenaatve, sess, Dedinirg CVD ‘spire ually of fanine pagers Spd armade mortally. ageing and wh peste sieeaes ‘urging seeses—_nequalies Wealth anton changing pats of Heath, Determinants of disease and motalty change sur Disease. and Moray Detarminats ot fer decline “SOCIO-ECONOMIC DEVELOPMENT AND/OR INDUSTRIALIZATION Lifestyle and edueation ‘eanlton erty, igh ten cies. truce, young ten older ‘DEMOGRAPHIC "TRANSITION Heath care ston Contaues ¢ynamie change wth chraiy pls merging disease czeding to raeston mo ‘eetne i CDs: actual (Wes!) for poteial in non-western models ol ‘QUALITY OF LIFE FOR ALL Teholoneal Environments "ronson actos ow fine Taniton exerting its influence through rss in premodern | cee ve chrough declinesia modern times. Feri fpiisa potent co-azable staying atahigh evel in he | aries, then declining and becoming virtually re acceter of population grovth, Reversal oF stg | the Pace tthe traniuon is posible during economic, | Matteal environmental, morbidity or other eres.) vataliy The absence of continuows and tei ai Te at moray and ety | in premodern times and in preandustrial countries | we eeadee determininuestaements about thei ea Pre demographic impact. An asessment of ie Pos | ase came of variations in mortals, fertiiy, dix se Tagrern and age structure does allow | (188 Aes Mode! Ae Tne ad Sale Popltor Pets, Non es, Pn ey Pes male in the USA had a life expectancy of 88 years ‘compared to 47 yearsfor the white male. By 1992, the respective figures were 65 and 78 years. The black | Female was expected to live 34 years in 1900, 15 years Jess than the white female. By 1992, the gap was | shortened to 5.5 years when the white female ex- pected to live 80 years (See Table 2) (43). In South Africa, during the period 1981-1985, blacks suffered an infant mortality rate ranging from 94 to 124/1 000 live births and a life expectancy Wi hth statist. quart, 51 (1998) ranging from 49 to 55 years compared to an infant ‘mortality rate of only 12.8/1 000 and a life expect- fancy as high as 75.3 years for whites (Yach, 1988) (44). This means that the pace of the epidemiologic transition in most ethnically mixed societies is slower ‘among nonsvhites than among whites. Among the possible explanations are variationsin lifestyles, edu. Cation, poverty level, selfimage, access to services, disposable income, and overt or covert inequities and discrimination. 109Table 2 Life expectancy differential (years) by colour and sex waite Wonwnite Yer “ F ™ F m0 7 @ S u 910 80 5 u 8 1920 88 3 a a 1930 59 8 «8 50 1940 53 8 2 88 1950 or n 9 6 1950 8 m 3 65 1970 Cy % 0 68 1980 ® 0 co % 1992 2 aw & 4 Soweto Co or Hea eves Resta & earl Cant for eet Stes Heth Ute Stes Maryan, ator at fr a Sevens Rear & tara oto en States, 108 urea ote Cnt Mtonca! sateen Une Ss, cba as {1870 Ne on, Kas rational obeatons, 189. 3d Social class ciferental or inequity ‘While the transition produces change in all social classes, it usually starts earlier and proceeds more ‘quicklyamong the more affluentand privileged than. among the poor and disadvantaged sectors of the same society. This is clearly demonstrated by trend data from England and Waleswhere five social classes are identified by grouping similar occupations. The highest is the first, and the lowest is the fifth. The system has been in use throughout the 20th century. Infant mortality declined steadily and substantially ‘every social class, but the differential between classes persists. Although the numerical gap has narrowed, the ratio in the infant mortality rte of the lowest to the highest class has increased (Table 8) ‘.e inequities experienced by indigenous peoples In many countriesaround the world, there isa group ‘of peoplewhose ethnic, cultural, historical, linguistic ‘and territorial traits distinguish them as indigenous people. As documented in a 1998 PAHO report on Health in the Americas 5), indigenous people usu- ally live under adverse conditions, are subject 10 discrimination and have the lowest level of health. status and health care access. In Chile in 1992, for example, infant mortality rates among the indig- ‘enous people were 40 points higher than the na- tional average, and the life expectancy was 10 years lower in the case of the Aymara people. In Bolivia in 1998, 20% of indigenous children died before their first birthday, and 14% of those who survived their first year died before they reached school age. Even in wealthy countries such as the USA, the Native Americans (and other minorities) are groupscharac- terized by a disproportionate share of deaths, dis- ‘ease, disability and adverse health conditions. 110 Tables Infant Mortality Rate (per 1000 live births) by social class in England and Weles, 1920-1980. 1 0 mW Vv Rat Lowest ighest of Yer th class Vitel im 4662-770 ~ ae re i, ita e° en at “ go » 2x4 2 oei2 107) peealratesy [eat a Model 4 oe Sater tured som 10101800 ica vise moses © bw » | Model 3 Deathtes '° in 10 180 20 Delayed madels (20 Contry) ‘Sowwe: Onan RR The aed anton nthe Aner Mtr DC, Pan Amare He Organon arth Urey Mayan, 086 112 Rapp. times. statist sant. mond, 51 (1998)aa reay lications to describe the experience in eastern Eu- rope, the former USSR, and Japan (model 2a), where rigorousfertility control efforts (including widespread use of induced abortion) were used. The semi-west- ern version (model 2b) is used to encompass a similar wansition in European populations living outside Europe, North America or Australia. In- cluded, for example, are Europeans living in Argen- tina, Uruguay, Israeland South Africa, and the French in Algeria during the occupation. This model (with its two varianu) has some common features: (a) ‘Mortality and fertility declines came later than in the Classical Model; (b) Countries in this model, with a fewexceptions, have notyet entered the Fourth stage of the wansition; (c) Many countries in this model exhibit a continuing rise in cardiovascular mortality and some members of the former USSR have, as already mentioned, lost years oflife expectancy a880- ciated with social and economic crises. ‘One of the twonotable exceptionsis Japan, which started in the accelerated model, but soon joined the western countries in many respects during the later decades of the 20th century andis now leading them in having a longer life expectancy. Japan en- tered the Fourth stage during the 1970s, The other ‘exception is Israel, which has recently experienced declining death rates from cardiovascular diseases. The non-western transition models ‘These models describe epidemiological changes over time in Third World countries where mortalit decline was delayed until 1980-1950, and fertility decline was delayed further until after 1950. During the period, population growth rates reached un- precedented high levels. Differencesin the post-war patterns in mortality and life expectancy, and more distinctly the variation in fertility tends, distinguish three non-western models named according to the speed, timing, and magnitude of change, particu- larly fertility decline The rapid transition model ‘This model describes the experience of rapidly in- ustrializing or socially developing countries and territories (usually small, and mostly island entities). Prominent examples include the Chinese provinces of Taiwan and Hong Kong, Singapore, the Republic of Korea, Sri Lanka, Mauritius, Barbados, China, Chile, Cuba, Costa Rica, the French overseas depart- ments of Martinique, Guadeloupe, and Reunion, Jamaica, Bahamas, Puerto Rico, and Trinidad and "Tobago. Mortality in these countries began to de- line to moderate levels one or more decades before mid-cencury, but the decline in fertility o less than 5 children per woman was delayed until after mid- century, some time in the 1960s. These countriesare siillin the Third stage of the transition and have also ‘been victimized by emerging and resurgent disease on top of unfinished communicable and perinatal disease control. They are nevertheless showing signs Wa hth stats. quart, 5 (1998) of controlling the triple disease burden, and their health parameters are getting closer to those of the western models. For example, in the space of de- cades, the Republic of Korea experienced a rapid change from a predominance of communicable dis- ceases in the 1950s and 1960s (when 5 of the leading. causes of death were communicable diseases) to a predominance of degenerative and noncommuni- cable disease and fewer communicable diseases as leading causes by 1991. (50) The intermediate transition mode! ‘This represents the experience of countries with middle or lowermiddle levelsofincome. The mortal- ity dynamics, prevalence of various causes of death, ‘and fertility patterns fall between those in the rapid and slow models. In the intermediate model, some ‘countries cluster closer to the rapid model, such as Indonesia, Colombia, Mexico, Brazil, Panama, Ven- ezuela, Tunisia, Lebanon, and Thailand, Some other countries cluster closer to the slow model, such as India, Egypt, Morocco, Ecuador, Peru, Paraguay, and the Dominican Republic, and are characterized by having organized family planning programmes that have different degrees of success. On the health side, they face a huge overlap between continuing com- ‘municable diseases and malnutrition problems, and. the rising prevalence of degenerative and man-made diseases, The emerging diseases, particularly HIV/ AIDS, and the resurgent diseases, such as malaria and other oldsime scourges, complicate the picture further. Some countries, particularly Mexico, come close to the rapid model, but for the delay in its fertility decline. The slow transition mode! In this model, which describes the experience ofthe leastdeveloped and some less-developed counties in Africa, Asia, and Latin America, mortality started. todecline tomoderatelevelsaftermid-century, while fertility levels remained high until close to the last decade of the 20th century. Like the intermediate and rapid models, considerable overlap exists in this modelamong communicable diseases, malnutrition, and the rise in degenerative and man-made diseases. Countries in this model are also those that are least prepared to handle any one health burden, letalone three health burdensallatonce. HIV/AIDS, malaria, tuberculosis, and other emerging and resurgent dis- ‘ease abound in countries belonging to this model in sub-Saharan Africa, Latin America, and partsof Asia, ‘compounding further their morbidity burden, In their Global Burden of Disease study, Murray and Lopez examined the trends of causes of death compared with projections in 3 developing coun- tries that happen to belong to the 3 non-western models, In China (representing the rapid model), their stidy estimated that degenerative and chronic diseases increased incrementally to become respon- sible for 75% of causes of death in 1990, The study 113 OOOO OOOOprojected this to rise to 85% by 2020. For India, the study estimated an intermediate pace of the transi- tion in which the communicable disease group is still responsible for half the deaths in 1990 and is | projected to be responsible for 22% in 2020. In sub- Saharan Africa, the study confirmed the slow pace of the transition where communicable, perinatal, ‘maternal and nutritional diseases are projected to ‘be responsible for 39% of all deaths in 2020. | Mustration of the transition models in one world region | For illustration, the epidemiological experience of the region of the Americas will be used where the 5 major models coexist and where comparable data are available. The classification of the countries of the Americas into models is given in Box 8. Box Countries and teritories in the Americas classified under The Western Modes: The Classical Medet: USA and Canada Argentina and Paraguay ‘Bahamas, Barbados, Chile, Costa Rica, Cuba, Guadeloupe, Jamaica, Marisque, Puerto Rico, and Tindad and Tobago. ‘The Intermeolate Model: Upper Intermediate: | Lower intermediate: Bratt, Colombia, Mexico, Panama, and Venezuela Dominican Republi, Ecuador, Paraguay and Peru Bolivia, £ Salvador, Guatemala, Hai, Honduras, and Nicaragua, The Slow Mode: OF the criteria used in classifjing countries in different models, 4 are selected for a brief illustra- tion, These are the life expectancy at birth, the infant mortality race, total fertility rate (TFR), and an index of ageing (proportion of population aged 65 years and older). A weighted average for coun- tries in each model was calculated (for the TER, a simple average was used) (see Figure 8) Life expectancy The profiles of life expectancy depict a picture of improving survival in all models since at least 1950, with the classical model having the highest level (increasing from 69 years in 1950 11955 to 76 years in 1990-1995), and the slow model hhaving the lowest life expectancy, increasing from 48 years in 1950-1955 to 64 years in 1990-1995 (51). “Infant mortality Whereas the infant mortality rate is declining in all models since 1950, its level differs | from one model to the other. The highest level throughout was experienced by countries in the | slow model, and the lowest by countries in the classi- ‘al model; those in the intermediate model experi- ‘enced rates lower than those in the slow model and 14 higher than those in the other models. In 1950 1955 the rapid model had rates higher than the semiswestern model, butits rates soon dipped lower, probably because of more successful child survival programmes in the rapid model. Fertility The highest total fertility rate isfound in the slow model (7 children per woman in 1950~ 1955), with fertility starting to decline slowly since the mid-1970s. By the end of the century, fertility was still high (4 to 5 children per woman). The other ‘models start with relatively lower levels with further decline at an earlier date. The classical model starts ata higher level between 1950/1955 than the semi- western model, because of the baby boom. After the baby boom, the TFR declined rapidly to around 2 children, the lowest level among all models (52). ‘Age structure The classical model has the oldest ageing structure, with the proportion 65 years and ‘older increasing from 8% in. 1950-1955 to 12.5% in 1995-2000, The semiswestern model follows the pat tern ata lower level with the rapid model following atsome distance. The intermediate model and slow ‘model have a much younger population (53). ‘Transition in the eauses of death In the clasical ‘model (represented by the USA, Figure 3), the lead- ing causes of death are the degenerative diseases (cardiovascular diseases and neoplasms). On the ‘graph, the slight shrinking of the area due to declin- ing cardiovascular disease mortality after 1970 may be noted. Communicable diseases and perinatal ‘mortality were responsible for a very small propor: tion of deaths and the area is getting even smaller. ‘The semiwestern model (not shown in this figure) had a predominance of degenerative diseases (with no shrinkage of their area after 1970). Communica ble diseases and perinatal mortality have somewhat higher shares of deaths. "The rapid variant (represented by Trinidad and ‘Tobago in Figure 9), shows higher proportions for communicable diseases and perinatal mortality, with a gradual decline over time. A rise in proportionate mortality from degenerative diseases is noted over time. Accidents asa cause-ofdeath have also increased. ‘The pattern in the intermediate variant model (represented by Mexico in Figure 9), shows visibly higher levels for mortality from communicable dis eases and perinatal mortality in the 1960s, with an impressive decline thereafter. Proportionate mor- tality from cardiovascular diseases and neoplasms ‘was relatively modest in the 1960s, but started to show small additive increases thereafter. Accidents and violence as causes of death demonstrated im- pressive increases since 1970, ‘The slow variant model (represented by Nicara- gua in Figure 9), shows the highest proportionate mortality from communicable diseases and perina tal mortality with relative but small decline over time. ‘This model also shows the lowest proportionate mor- tality from degenerative diseases. Mortality from ac- cidents and violence shows some increase since 1978. ‘Rapp. times. statist. sant, mond, 61 (1998)ee Le expectancy at birth (years) 1s in key health indicators in the Americas, 1950-1985 lant moray (itn eats prt 00 is) 1950-85 1055-80 1900-85, 1965-70 1970-75 i Total fertity (average numberof lve births per woman) 1900-85 1905-80 1900-95 1995-00 2000-05 1990-05 1905-40 4 2000-05 1975-20 1970-75 3 1950-55 1985-60 1900-65, Percent population aged 65 years and over 7 addi —— cassia — § 1970-75, 1975-20 190-85 1006-00 1090-25 1008-00 2000-05 to5086 4 1965-60 1960-65 1965-70 1970-78 1975-80 Lower ‘ntmedate ~~“ Sow Sree aos, Wor option prope, 106 ton New Yor Une Naor, 1558 Conclusion Into the future: The Fit stage, Age of aspired quality of Ite with paradoxical longevity and persistent inequities ‘This Fifth stage for the mid-21st century and beyond is expected to be one of great human achievements in disease control, health promotion, and further prolongation of healthy life. Inevitably this stage will include paradoxical longevity, emerging new mor bidity and persistent inadequacies. There will be disparities between people because of the polariza- tion of socio-economic status within and berween Wid hth statist. quart, 81 (1896) 2 Te tradtional heath scenario inthe Ft stage ‘This seenaro is based on measuring health in the traditional way, in terms of morbidity and mortal, tind i logically an extension of the Fourth stage During the 2st century and beyond, if expectancy Should continue to rise to or exceed 90 years, esPe- Gilly for females, Thiscan be aresultof tro primary | mechanisms: a) anactualincreaein theaverage fe Span due to medical breakthroughs and favourable iMerylesand(b)arelativeincreaein the longevityof dinadvantaged groups. The increment of growth in | lifeexpectancywould become smaller andsmalleras | humarfkind reaches the upper asymptote of survival 115Fig. 9 Causes of death in diferent model countries, proportionate contributions at various years (Schematic) ‘Argentina 100% 20% = Mexico 108% aon oon aos won aon = 2on-} 20% % T——7—7 — 0% T T———+ 1980 1985 1970 1977 1980 1965 1991 1983 1060 1965 1870 1875 1981 1985 981 toD8 Trinidad & Tobago Nicaragua a4 om om T T T T T T Oe T u T T ee “Jem [J nenes [Eonar (EY vans Stem cow BD eee on earth, with the gender gap narrowing. However, longevity will continue to bea mixed blessing, hence its being called "paradoxical". While it means more years to live and contribute, it also means greater hanees for chronic morbidity, physical and psycho- logical impairments isolation, separateness, depres- sion, loss of independence, and decline in social status. Particularly females who survive to older ages ‘may be at great disadvantage in this regard. Further mounting medical, long-term care and nursing costs, which are beyond the financial ability of retired citizens will become more common, Thus, the age- ing process may spell increasing needs for social, emotional, economic, health and rehabilitative care, as well as psychological support systems. In some cases, longevity may specifically mean prolongation of agony. Some afflicted individuals may resort to cuthanasia and assisted suicides that are expected to increase among the aged, the disabled, and those living in unbearable pain or depression, Moral, legal 16 tnd retgiovs antagonism to thi practice wl come tive, ba id dining indvecef e We Conserve cultures cutie the Nes cay none itorelgion idout legiatie mesic Deganerav, seen manmade cases ae apttobe the lead eases fmnorbidny deste od tmoraly along ith muchinceasel arene Te ing cotdiontair moray a dete Clee vil more han compensate for dolce ts the Westand wilkecp GHDrardhe kadar eee ae weclen ar vaste sec | irom tee dices may tently devine oooh tins ushering the entry of these Coase earatsaip comes eae ree Cet | unidirectional; as mortality declines for most can- cers ew fons of malignant wold wie be fitureandwould energie oreo ance | fora cancer cure Beltginvtvedinbotn ened i eae ee pee eae [fief esata a are ‘Rapp. timest statist. sanit mond, 81 (1996)TT Depression is rapidly becoming a worldwide epi- demic and is party attributed to stressful lifestyles tnd competiivencis: The elie afforded from rel- fous or cultural supports weakening. An increase | Seaside isan ineviable consequence. The rsk of violent death s kel to increase. This mayemanate | From accidents, homicide suleide and military con- flew among nations, or rivalries between ethnic or other subgroups. Millions of refugees would be the fesult Ethnic cleansing campaigns and demographic wars may reach epidemic propordons at times, but Thay be mitigated by internadonal abitation and peacekeeping, The use of weapons of mass destruc Hon, including biowervorism, willbe a reat, despite treaties to contzol them. ‘Withoot established world, or national stems | of disaster telief and control, environmental cata trophes are added form of mass destruction, Io fuldidon, the environment is becoming more pol- Tuted in’ many locaons and is being altered by mman'smiadventures which wilundoubedly increase in dhe future, a8 wll global warming. Acceso fresh rater sources is becoming a serious concern and Wr be a source of the regional wars This is simply because the world sunning outoffresh waterin the face of increasing populations and evermounting industrial, agricultural, municipal and domeste rater demancs All these wil be joined by new cat- Cgories of diseases characterise of the space age. Now forms of manmade dieases are expected to tole with advanced indus, eleewonic, genetic Chemical innovations and radiation energy, aswell fs biological and chemical warfare. There wil likely be more enigmatic disease conditions tat would, at least fora while, challenge the existing diagnostic tnd therapeutic abilities, just as with the evolution SrHIV/AIDS or ofthe socalled Gulf War Syndrome. ‘The question about the fare of communicable diseases is examined in Box 4 5b The Health for Al (HEA) initiative: ‘The HEA initiative has been a global rallying point and organizing principle since its adoption within the 1978 Alma-Ata declaration. Medical break: throughs, innovative disease control, and health pro- notion technologiesduring the Fifth orlatestagesof | the epidemiological transition, will bring human- | kind closer to success for the rainbow of complete physical, mental and social well-being forall citizens (54). The renewal of the Health for All Strategy ings to the forefront concerns for human rights, equity, diversity, and development for all. Health ‘cannot be seen as isolated from the larger processes of social and human development (55). Also, eco- omic growth can not be regarded as a supragoal | ‘under which individual's health is nothing but a commodity. Health is not a commodity, and eco- omic growth is not the end, but the means to achieve better quality of life and social justice (56). For many, Health for Allemainsa far-reaching goal Mahi statist. quart, 81 (1996) Box4 Wilinfectiousdseases ever be extinguished? “The answer i eprttable because: ‘+ While some more infections wil be eraicated or elimi rated, new viruses or new strains (or mutations) of old viruses and bacteria ae likely to emerge. HIVIAIDS Is & prominent reminder. + Human belngs are encroaching on the jungle and may encounter yet new wild viruses or bacteria, International travelers can retura home within the incuba tion period of infectious diseases. Infectious diseases alsohave thehabitot coming backeven attr they are believed to have been cntrlled; many ofthe resurgent diseases demonstrate obstinate resistance to existing drugs. Infections would cortinueto plague, npartcula, the the chronically, the prematurely bor, the malnourshe the disadvantaged, those hospitalized (nosocomial nlec- tions) and those in high-risk groups. + Infections with opportunistic pathogens wouldalsothreaten ‘those whose immunity has been compromised by old or new pathogens or by chematherapy Certain viruses, bacteria or parasites have béen implicated inthe etiology of certain cancers. Examples incude: 2) the Epstein-Barr virus (EBV) in Burks lymphoma, Hodgkin's ‘ease and naso-pharyngeal cancer b) hepatisB virus {HBV) In hepatocellarcarinoma; c) human immuno deficiency virus (HIV) In Kapasts sarcoma; d) human papilloma vus (HPV) in eenical cancer) schistosoma hematobium in bladder cancar. Non-iral agents may be found to be involved In nonmalignant conditions such as Hefeobacterpyorinpepticuler and chlamydia pneumonia In cardiovascular diseases, This utopian goal should, however, be viewed more figuratively than literally. It should be appreciated that certain intrinsic and extrinsic factors may tend to tarnish the achievements. Fist, the nature of human beings as mortal and vulnerable to some physical, mental, or social ailment should restrict its complete expression. Second, the concept for All ‘would be virtually impossible to achieve with the continued persistence of inequities according to colour, ethnic origin, age, gender, social affluence, region, or residence, or biases according to political, religious, or cultural affiliation. Reduction of these inequities would be ameasure of progressin the Fifth stage. Third, the future of mankind will not be completely free from natural or man-made disasters, economic crisis or wars that contribute to the limited or extensive deterioration ofliving and health condi- tions somewhere in the world. Fourth, there is always the possibility of shortcomings of imperfect health care even in the mostaffiuent countzies. Fifth, health hazards can be presented by health care itself, which is getting much more aggressive and more likely to ‘take risks (57). Sixth, some of the powerful means of disease prevention are showing signs of fatigue. Or- iganisms are developing drug resistance on a scope ‘wider than ever expectedand in the case ofsuccessive generations of powerful antibiotics. Finally, there are "7no guarantees that promise that new diseases will not emerge, or that old diseases will not resurge. Of the disquieting sources for concern are four invisible threats to the future of mankind: viruses, the atom, the gene and continued population growth (see Box 5). Bors ‘The four Invsble pais inthe future of mankind * Viruses stand ovtas enigmatic pathogens withthe peculiar ability to mutate, changa virulence and find ways of com promising theirhostsimmunty, often detyingand neutral ‘zing medical imovatons. it would be catastrophic, for example, if viruses should evolve that exhibited ably as those of HIV, and could be al-bome or propagated by casval contact. ‘Momic energy will aways fascinate the human mind for eaceful, mecical and mitary purposes. tis welt rcall the devastation ofthe atomic bombs on Hiroshima and Nagasaki. Bombs that are even more powerful now exist and thelr potential use wil remain atest. ‘+ Recognition of the gene's role wil continue to expand as it Is discovered as a factor in increasing numbers of dlsorders, dysfunction, orbehavioual tats. Conversely, t has great potential in combating, or preventing disease or intcity. This field wil benefit from Intensive genome research and scienttic experimentation in genetic engi- neering. High rates of population growth wl become increasingly undesirable for economic, soca, Iestyle or health rea- sons. Population programmes wil include wel-managed ‘amily planing efots, pltical commitment, efforts by ron-governmental organizations (NGOs), acceptance of small family size norms, female education and higher socio-economic status for women, 5.c Beyond the Fifth stage: quality of lif, equity, evelopment, and social justice forall This emerging vision takes a holistic view of health, considers it an integral dimension of the quality of life, and views it in the context of development. It accentuates health potential, social participation, economic productivity, and social justice. This ap- proach will target the control of risk factors as a way to eliminate the root of human suffering. The new vision, which is implied in the definition of health in the WHO constitution, and renewal of the Health for Al Strategy, means that health will cease to be mea- sured solely in terms of mortality, morbidity and disability. Health will increasingly be measured in terms of human development, positive physical, ‘mental, social, and spiritual well-being the context of harmony with the environment; and equity in quality health care accessibility. To achieve quality of life, health is guaranteed as a human right for all This will have to await subsequent stages of the transition, hopefully within the third millennium. 18 References Omran, A. R. The Epidemiologic Transition. Epdenisbgie ‘Aspe of Heath and Population Dynan. A Facly Sena (Gonahigentntinie of Rural Huth ond Family Ping, Mar/Apr 1969 Bue) BY (1) 8-59 (1989. 2 Omran, AB. The Epidemiologic Teaslton: A Theory of the Epidemiology of Population Change. Mibank Menara Fan Quart 9800-838 (197), 8 Omran, A R."A Century of Epidemiologic Transition inthe ‘United Stats, Prelate Meine 6: 581 (1977, 4 Omrm, A.B. The Epidemiologic Transion. Intenatinal Encylopedia Population (Romeo New Yor: The Hee Pre, 1982 ‘Ss Omman, A. R. The Epidemiologic Tasition Theory A Preliminary Update Journal of Tp! Pda 98: 305-316 (a8). 6 Bagawa, E.On Mostly: (Presidential Address, Popslation ‘Awociaon of America annual meeting, St Loui, Misou, Apri 1977.) Denayrapy 4 (4): 881-889 (1977). 7 Jamison, D. & Mosley, H. Disease Consol Prortis in Developing Countries: Health Policy Responses to Epidemlogia Change Arcam ural of Pac Heth 5-22 (90), 8 Lan, John eo editors A Dicinary of Eide, Tied Elton, International Epideologicl Astocaon, 1995, 9 Bobadil J, Fret, T, Prem, J oan Re Stero,. The pienso! Tronsion na Heth rors The Wold Bank, Healt Secor Proves Review unpublited document, 1080. 10 Rogers, Rc & Hacheoberg, R. Extending Epidemiologic ‘Tranaion Theory: New Stage. Soda Bolg 34 (5-4): 234~ 248 (987, 11 Browdy D. & May, Demographic nd Epidemiologle “Trmitons among the Nar Indias Seal Bt 90.1-16 983), 12 EumSul, L. Epidemiologic Transion in Korea: A New Penpesin is opulton nd Developmen Sees. ule fie ipaton ond «Studies Cour 4 1-14 (1980), 18 Olsanaky.. de Au, B. The Fourth Stage of the Epidemiologic: Tramition; The Age of Delayed Degenerative Diseases. The ‘ion Menai Fd Quarry 64 (3) 855-201 (1966). 14 Roger Rb Hackenberg Ro. 15 Frenk, J Bobedle Jy Sepaveds, Je Cevatea, ML. Health Transiion in Middle Income Countriea, New Challenge fr Health Cae. Hath Pond Panning (0 35-99 (19). 16 Omran, AR. & Roudl, The Midéle East Population Population Reference Bureas. Washington, DO. Pale Population Bln 18 (1) (1983), 17 Omran, AR. The Edema Trost in the Americas Pan ‘American Health Organization and the Univers of Maryand, 1986. 18 Angel & Pearse, ted a Woy, WS. & Workin. ES orld Popudeton and Production: Teds and Ouch New York “Twentieth Century Fund, 1958. 19 Roatell, J.C. Late Ancient and Medieval Population Trasacons of he American Prsphicl Sai 8 June 1958) prs. 20 Landis, PHL de Hat, PK Population Prins: A Ctrl Inieetaton Nee York: Anerian Book Company, 1954 21 Rossel J.C. 0. ot 22 Herbaidak, HJ. English Population in the Eighteenth Ceny Etonic Hit sins Pn Seri, VE117-138 (988. 23 Gulfith, GT. Population Poon of Be oge of Melis Cambridge, Univer Press, 126 £24 Marshall, TH. The Poplaion Problem during he Indust Revoluson. A Note on the Present State of Conover. conic History Not Supplement othe Economic Journal (1929), 25 Hicks, JR. The Social Frameerk, New York: Oxford, Unity Pre, 1942 ‘Rapp. timest statist. sanit. mond, 61 (1986)stoic ing yet onal she Free nA 316 126 MaKeown, T ke Brown, R.G. Medical Evidence Related to English Populaon Change inthe 18h Century. Population Studies 26 (1955), ‘27 McKeown, Brows, R.G. le Record An Interpretation of “Modern Re of Population in Esrope. Population Suis 26 a7), 28 Myrdal A. Notion and Family, (1045) Cited in Mekeown & Brows, op at 29 United Nations, Wold Population Prstcs, 1954 Bon. New York, 1996. 90 United Nations, Wild Population Pripecs, 1996 Bilton New ‘ork, 1998. ‘31 World Hatt Organization. World Health Report 1996: Lif in the 21st entry, a vision for ll. Geneva, World Health ‘Organization, 1998. ‘92 National Center for Health Statistics, Comparabiiy of Causes of Death Stine, Figures and Tables, and Technical Notes Describing Trends in uchemie Heart Disease Moral. PHS, HEW: 148 (1978). 98 United Nation. (1998) opt 94 US Bureau of the Census. Historical soi of the Unit ‘Stats, cloia inet 1970. New York: Kraus International ‘Publication, 1989 ‘85 Murray, Jee Se Lopes, A.D. The global burden of disease. Cambridge, Masachunets Harvard School of Pubic Health fon behalf ofthe World Heals Organization and The World Bank, 1996. ‘36 WHO. (1996, op. ct ‘37 WHO. (1998), op. at 38 Redrguer-Garca Reta The Leia and Poly Eirenmnt for Adslcont Heats in Latin America and the Caran. ‘Washington D.C. Pan American Healin Organization, 199. 99 Bulatn, RA. &Stepbens, RW. Washington, D.C. The World Bank, 1989, 1992 40 Russel J.C. opie ‘41 Coal, J, & Demeny P. Regional Model Life Tales and Stele ‘Popultion Princeton, Princeton Universy Press, 1966. Wa hth statist. quar, 61 (1998) | | | 42 Unted Nations. (1998), op. 4 Health USA (1994), and irl States of he United Stes (aoee). 44 Yach, D. (1998), cited in Gwatkin, D. The epidemiologic trenton. Poly one pling impaton or deping counts Washington, D.C, National Academy Pres, 199, 45 Heath in the Ameriear. Washington, D.C, Pan American Health Organization, 199, 46 Office of the Registrar Genera, India, (1888), ceed in Gwatkin op ot 47 Boba Jet op ot {8 Murray, CJL ool. US. Pattrns of Mri by County and ‘Rac: 1965-1994, Center for Duease Cong and Harvard ‘School of Pubic Heath, US. Burden of Diseae and Injury Monograph Series, 1998. 49 United Nations (1998), oa [50 Choe, EH. Population Ang nthe Raul of Kae, UNESCAP ‘Asien Population (1989, Cited in US Bureas of the Census, (Global Aging inde he et Cnty Washington, D.C, 1956. 151 United Nations (199), op. a Tables A236 and A, ‘52 United Nasons (1098), op. TablesA18and A, 58 United Nations (1008), op. at Tables A 30 and ASI. [54 World Health Organization WHO Reform, Renee Heath For (AM Srey: Draft Poy or the 21a Cotary. Report ofthe Director General. Exectve Board 100th Sexion. Geneva, World Health Organization, 1997 ‘55 Redriguer Garcia, R Health and Development for ll. Wold ‘Hlth Forum 17. 344-846 (Round Tol) (199). 54 Rodrigues Garcia, R. Health Economics and Development: Working together for change. Inrnatonal peeves in never, dle! ond hath Shabi etal, editors New York, Springer, 1997 57 Last J Hazards of Health Care. dlc Heath and Human Buligy Appleton and Lang Pres 119