Individual: Five Analytical Moves
1
1. Complete the 5 moves on the chosen piece.
First Move: Read it silently, suspending judgment about what it means.
Second Move: Define significant parts—Draw on the piece to demarcate them.
Third Move: Look for patterns (The Method)
• List exact repetitions
•
List repetitions of similarity
•
List binary oppositions
•
Locate anomalies
•
Focus on one repetition or binary
Fourth Move: Make implicit explicit: so what? In other words, what is implied, but not
directly said? What is the significance of that, i.e., why is it important?
Individual: Five Analytical Moves
Fifth Move: Keep formulating questions and explanations
•
•
Are there any unanswered questions about the piece?
What conclusion did you come to about the piece?
2
THE FIVE MOVES
Please have read WA pgs 16-36 before viewing this presentation
WHAT MAKE
UP THE 5
MOVES?
The 5 Analytical moves (The Method) is a
process to help us understand analysis. It is a
formula that we can follow to have a basic
understanding of how to break down texts or
images and develop clear analysis.
THE 5 ESSENTIAL MOVES
Move 1: Suspend Judgment
Move 2: Define significant parts and how they are related.
Move 3: Make the implicit explicit. Push observations to
implication by asking “So what?” or “Why does this
matter?”
Move 4: Look for patterns or repetition and contrast and
for anomalies.
Move 5: Ask questions
MOVE 1:
SUSPENDING
JUDGEMENT
During this first move, you are looking
at a text or an image and seeing it for
what it really is, NOT what you
perceive it to be. This is a time for you
to hold back any assumptions or
judgements you have and begin to
look closely in an attempt to begin to
analyze it.
MOVE 2: DEFINE
SIGNIFICANT PARTS
AND HOW THEY ARE
RELATED
When looking at this image there are 3
significant parts.
1: The text bubble above the young
woman’s head. (Notice I did not say it’s
Snow White because I haven’t come to
that conclusion yet)
2. The older person in a cloak
3. The young woman
In this image the older person appears to
be offering an apple to the young
woman, who seems hesitant. She asks
“So you’re sure it’s organic?”
MOVE 2
CONTINUED
Notice and Focus
When we look at this image, we want
to slow down and make sure we are
really understanding what we are
seeing. We have to move past what
we know and think, what do her facial
expressions mean? Why is she dressed
like that? Why is she saying that?
What in this image is:
Interesting,
revealing/significant/strange? Why?
MOVE 3:
“SO WHAT?”
Now that we have decided that those
aspects are important, we begin to ask
ourselves, so what?
Why is it important that the young
woman is making a weird facial
expression? What could it mean?
Why is it important that the old woman
only has three fingers and a thumb?
What is important about the question if
the apple is organic?
MOVE 4: THE
METHOD
During this part of the process, we look
at the questions we already have and
begin to define what they mean.
We also identify any patterns,
repetitions, binaries, or anomalies.
WHAT REPEATS?
In this image, there are a few repetitions.
1. The pattern on the young woman’s
dress.
2. The hair bow
3. The line work in the sketch
“So what” does it mean? Why does it
matter that she has three dots on her
sleeve?
Is it significant to the culture of the dress?
BINARIES
A binary is an opposite of something else. Examples of binaries are:
Good vs. Evil
Young vs. Old
Life vs. Death
Black vs. White
Serious vs. Comical
Glasses vs. No glasses
However, we must remember that binaries are on a sliding scale and we often have
the problem in our own culture of thinking too much in binaries.
BINARIES
Binaries in this image are:
The look of surprise vs. the look of excitement
Young vs. old
Beautiful vs. ugly (a subjective binary)
Fancy vs. drab
Hesitation vs. eagerness
Black vs. white
People vs. Background
Words vs. image
So what is significant about these binaries? Why are
they important?
ANOMALIES
Anomalies are things that stand
out/things that don’t fit with the rest of
the image.
An example of an anomaly in this image
is the apple.
The text above her head.
The signature at the bottom of the page.
So, if the apple is the anomaly, what
makes it significant?
MOVE 5: REFORMULATING
QUESTIONS
When you write your essay, you will actually ask yourself these questions in the
paper. Take time to ask and try to understand what you are seeing. Also, take
time to answer the questions.
In this way, your paper will be formatted like:
Summarize the image
Define significant parts
Find the patterns, repetitions, binaries, and anomalies.
Focus on 1 of those aspects and question it.
Answer the questions to form a conclusion/ thesis statement at the End of your
paper
HOMEWORK
Now, obviously I did not answer all the questions, nor did I form the thoughts
into complete paragraphs. For your homework, you will find a discussion board
with 2 images for you to choose from and a document for you to fill out and
submit in the discussion board.
This is to practice visually analyzing an image.
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chapter
2
Health Determinants,
Measurements, and Trends
L earning O bjectives
By the end of this chapter the reader will be able to:
• Describe the determinants of health
• Define the most important health indicators
• Discuss the differences between incidence and prevalence;
morbidity, disability, and mortality; and noncommunicable and
communicable diseases
• Discuss the concepts of health adjusted life expectancy (HALE),
disability adjusted life years (DALYs), and the burden of disease
• Describe the leading causes of death in low-, middle-, and
high-income countries
• Describe the demographic and epidemiological transitions
VIGNETTES
Shawki is a 60-year-old Jordanian man who lives in Jordan’s
capital of Amman. Unfortunately, Shawki’s health has deteriorated in the last year. His blood pressure and cholesterol are
too high. He has developed diabetes. He is sometimes short
of breath. What are the causes of his ill and declining health?
Do these problems stem from any genetic issues? Could they
come from a lack of understanding about a healthy lifestyle
and diet? Could it be that Shawki lacks the income he needs
to eat properly and to ensure that he gets health checkups
when he needs them?
Life expectancy in Botswana prior to the spread of
HIV/AIDS was about 65 years.1 In 2009, life expectancy in
Botswana was 49 years.2 Life expectancy in Russia in 1985
was about 64 years for males and 74 years for females. By
2001, however, it had fallen to about 59 years for males and
97515_ch02_5944.indd 17
72 years for females, although by 2009 it had risen to 61 for
males and 74 for females.2
What does life expectancy measure? What are the factors contributing to its decline in both of these countries?
What has happened to trends in life expectancy in other
countries? Which countries have the longest and shortest life
expectancies, and why?
In Cambodia in 2008, families had, on average, 2.9 children3 and their life expectancy was about 61 years.4 Thirty
years ago, the demographic and epidemiological profile of
Thailand looked a lot like Cambodia looks today. Today,
however, Thai families have on average about 1.8 children5
and those children on average will live 69 years. Children in
Thailand rarely die, and when they do, 50 percent of them
die from injury.6 What causes these shifts in fertility and
mortality? Do they occur consistently as countries develop
economically? How long will it take before Cambodia has the
same fertility and disease burden that Thailand has today?
In Peru, poor people tend to live in the mountains, and
be indigenous, less educated, and have worse health status
than other people. In Eastern Europe, the same issues occur
among their ethnic groups that are of lower socioeconomic
status, such as the Roma people. In the United States, there
are also enormous health disparities, as seen in the relative
health status of African Americans and Native Americans.
If one wants to understand and address differences in health
status among different groups, then how do we have to measure health status? Do we measure it by age? By gender? By
socioeconomic status? By level of education? By ethnicity?
By location?
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18
Health Determinants, Measurements, and Trends
THE IMPORTANCE OF MEASURING
HEALTH STATUS
If we want to understand the most important global health
issues and what can be done to address them, then we must
understand what factors have the most influence on health
status, how health status is measured, and what key trends in
health status have occurred historically. We must, in fact, be
able to answer the questions that are posed in the narratives
above.
This chapter, therefore, covers four distinct, but closely
related topics. The first section concerns what are called
“the determinants of health.” That section examines the
most important factors that relate to people’s health status.
The second section reviews some of the most important
indicators of health status and how they are used. The third
section discusses the burden of disease worldwide and how
it varies across countries. The last section looks at how fertility and mortality change as countries become more developed and what this means for the types of health problems
countries face.
The Determinants of Health
Why are some people healthy and some people not healthy?
When asked this question, many of us will respond that good
health depends on access to health services. Yet, as you will
learn, whether or not people are healthy depends on a large
number of factors, many of which are interconnected, and most
of which go considerably beyond access to health services.
There has been considerable writing about the “determinants
of health,” and one way of depicting these determinants is shown
in Figure 2-1. The next section largely follows the approach to the
determinants of health that is discussed in “What Determines
Health” by the Public Health Agency of Canada6
The first group of factors that helps to determine health
relates to the personal and inborn features of individuals.
These include genetic makeup, sex, and age. Our genetic
makeup has much to do with what diseases we get and how
healthy we live. One can inherit, for example, a genetic
marker for a particular disease, such as Huntington’s disease, which is a neurological disorder. One can also inherit
the genetic component of a disease that has multiple causes,
such as breast cancer. Sex also has an important relationship
with health. Men and women are physically different, for
example, and may get different diseases. Women face the
risk of childbearing. They also get cervical and uterine cancers that men do not get. Women also have higher rates of
certain health conditions, such as thyroid and breast cancers.
For similar reasons, age is also an important determinant of
97515_ch02_5944.indd 18
health. Young children in developing countries often die of
diarrheal disease, whereas older people are much more likely
to die of heart disease, to cite one of many examples of the
relationship between health and age.
Social and cultural issues also play important roles in
determining health. Social status is an important health
determinant. There is good evidence that people of higher
social status have more control over their lives than people
of lower status, and people of higher social status also tend
to have higher incomes and education, both of which are
strongly correlated with better health7 In addition, the gender roles that are ascribed to women in many societies also
have an important impact on health. In such environments,
women may be less well treated than men and this, in turn,
may mean that women have less income, less education, and
fewer opportunities to engage in safe employment. All of
these militate against their good health.
The extent to which people get social support from family, friends, and community has also been shown to have an
important link with health.7 The stronger the social networks
and the stronger the support that people get from those
networks, the healthier people will be. Of course, culture is
also an extremely important determinant of health.7 Culture
helps to determine how one feels about health and illness,
how one uses health services, and the health practices in
which one engages.
The environment, both indoor and outdoor, is also a
powerful determinant of health. Related to this is the safety of
the environment in which people work. Although many people know about the importance of outdoor air pollution to
health, few people are aware of the importance of indoor air
pollution to health. In many developing countries, women
cook indoors with very poor ventilation, thereby creating an
indoor environment that is full of smoke and that encourages respiratory illness and asthma. The lack of safe drinking water and sanitation is a major contributor to ill health
in poor countries. In addition, many people in those same
countries work in environments that are very unhealthy.
Because they lack skills, social status, and opportunities,
they may work without sufficient protection with hazardous
chemicals, in polluted air, or in circumstances that expose
them to occupational accidents.
Education is a powerful determinant of health for several reasons. First, it brings with it knowledge of good health
practices. Second, it provides opportunities for gaining
skills, getting better employment, raising one’s income, and
enhancing one’s social status, all of which are also related
to health. Studies have shown, for example, that the single
best predictor of the birth weight of a baby is the level of
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The Determinants of Health
19
Figure 2-1 Key Determinants of Health
Policies and Interventions
Governance, Policies,
and Interventions
Governance, Policies
and Interventions
Physical Environment
• Water
• Sanitation
• Air pollution
Employment and
Working Conditions
Healthy Behaviors
and Coping Skills
Individual
• Genetic make-up
• Sex
• Age
Access to Health Services
Healthy Child
Development
Social Environment
• Socio-economic status
• Education
• Social capital
• Culture
• Gender norms
Source: Data from the Public Health Agency of Canada. What Determines Health. Available at: http://www.phac-aspc.gc.ca/ph-sp/determinants/
index-eng.php#determinants. Accessed November 19, 2010.
educational attainment of the mother.8 Most of us already
know that throughout the world, there is an extremely strong
and positive correlation between the level of education and
all key health indicators. People who are better educated eat
better, smoke less, are less obese, have fewer children, and
take better care of their children’s health than do people with
less education. It is not a surprise, therefore, that they and
their children live longer and healthier lives than do less well
educated people and their children.
Of course, people’s own health practices and behaviors
are also critical determinants of their health. Being able to
identify when you or a family member is ill and needs health
care can be critical to good health. As noted previously, however, one’s health also depends on how one eats, or if one
smokes, drinks too much alcohol, or drives safely. We also
know that being active physically and getting exercise regularly is better for one’s health than is being sedentary.
Another important determinant of future health is the
way in which families nourish and care for infants and young
children. Being born premature or of low birthweight can
have important negative consequences on health. There is a
strong correlation between the nutritional status of infants
and young children and the extent to which they meet their
97515_ch02_5944.indd 19
biological potentials, enroll in school, or stay in school.
In addition, poor nutritional status in infancy and young
childhood may be linked with a number of chronic diseases,
including diabetes and heart disease. 9
Of course, one’s health does depend on access to appropriate healthcare services. Even if one is born healthy, raised
healthy, and engages in good health behaviors, there will still
be times when one has to call on a health system for help.
The more likely you are to access services of appropriate
quality, the more likely you are to stay healthy. To address
the risk of dying from a complication of pregnancy, for
example, one must have access to health services that can
carry out an emergency cesarean section if necessary. Even if
the mother has had the suggested level of prenatal care and
has prepared well in all other respects for the pregnancy, in
the end, certain complications can only be addressed in a
healthcare setting.
The approach that governments take to different policies and programs in the health sector and in other sectors
has an important bearing on people’s health. People living
in a country that promotes high educational attainment, for
example, will be healthier than people in a country that does
not promote widespread education of appropriate quality,
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20
Health Determinants, Measurements, and Trends
because better educated people engage in healthier behaviors.
A country that has universal health insurance is likely to have
healthier people than a country that does not insure all of its
people, because the uninsured may lack needed health services. The same would be true, for example, for a country that
promoted safe water supply for all of its people, compared to
one that does not.
In fact, increasing attention is being paid to the “social
determinants of health.” From 2005 to 2008 WHO constituted a Commission on the Social Determinants of Health.
WHO also published the commission’s report in 2008. Some
of the important themes related to the report are:
• Health status is improving in some places in the
world but not in others.
• There are enormous differences in the health status of
individuals within countries, as well as across countries.
• The health differences within countries are closely
linked with “social disadvantage.”
• Many of these differences should be considered
“avoidable,” and they relate to the way in which people live and work and the health systems that should
serve them.
• In the end, people’s life circumstances, and therefore
their health, are profoundly related to political, social,
and economic forces.
• Countries need to ensure that these forces are oriented toward improving the life circumstances of
the poor, thereby enabling them to enjoy a healthier
life, as well. The global community should also work
toward this end.10
The discussion of heath and equity later in the book
will further touch on these points, which are also referred to
throughout the book in a variety of ways.
Key Health Indicators
It is critical that we use data and evidence to understand
and address key global health issues. Some types of health
data concern the health status of people and communities,
such as measures of life expectancy and infant and child
mortality, as discussed further hereafter. Some concern
health services, such as the number of nurses and doctors
per capita in a country or the indicators of coverage for certain health services, such as immunization. This book will
discuss health service data only briefly, mostly in Chapter
5 on health systems. Other data concern the financing of
health, such as the amount of public expenditure on health
or the share of national income represented by health
expenditure. This book also provides only a limited dis-
97515_ch02_5944.indd 20
cussion of health financing, which is also primarily in the
chapter on health systems.
There are a number of very important uses of data on
health status, which we shall explore further and discuss
throughout the book.11 We need data, for example, to know
from what health conditions people suffer. We also need to
know the extent to which these conditions cause people to be
sick, to be disabled, or to die. We need to gather data to carry
out disease surveillance. This helps us to understand if particular health problems such as influenza, polio, or malaria
are occurring, where they are infecting people, who is getting
these diseases, and what might be done to address them.
Other forms of data also help us to understand the burden of
different health conditions, the relative importance of them
to different societies, and the importance that should be
attached to dealing with them.
If we are to use data in the previously mentioned ways,
then it is important that we use a consistent set of indicators
to measure health status. In this way, we can make comparisons across people in the same country or across different
countries. There are, in fact, a number of indicators that are
used most commonly by those who work in global health and
in development work, as well, as noted later. These are listed
and defined in Table 2-1 and are discussed briefly below.
Among the most commonly used indicators of health
status is life expectancy at birth. Life expectancy at birth is “the
average number of additional years a newborn baby can be
Table 2-1 Key Health Status Indicators
Life expectancy at birth —The average number of years a
newborn baby could expect to live if current mortality
trends were to continue for the rest of the newborn’s life
Maternal mortality ratio —The number of women who die
as a result of pregnancy and childbirth complications per
100,000 live births in a given year
Infant mortality rate —The number of deaths of infants
under age 1 per 1000 live births in a given year
Neonatal mortality rate —The number of deaths to infants under
28 days of age in a given year per 1000 live births in that year
Under 5 mortality rate (child mortality rate)—The
probability that a newborn baby will die before reaching age
5, expressed as a number per 1000 live births.
Source: Adapted from Haupt A, Kane TT. Population Handbook.
Washington, DC: Population Reference Bureau; 2004; World Bank.
Beyond Economic Growth: Glossary. http://www.worldbank.org/
depweb/english/beyond/global/glossary.html. Accessed April 15, 2007.
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Key Health Indicators
expected to live if current mortality trends were to continue
for the rest of that person’s life.”12 In other words, it measures how long a person born today can expect to live, if there
were no change in their lifetime in the present rate of death
for people of different ages. The higher the life expectancy at
birth, the better the health status of a country. In the United
States, life expectancy at birth is about 78 years; in a middleincome country, such as Jordan, life expectancy is 73 years;
in a very poor country, such as Mali, the life expectancy is 48
years. Figure 2-2 shows life expectancy at birth by region.4
Another important and widely used indicator is the
infant mortality rate. The infant mortality rate is “the number
of deaths of infants under age 1 per 1000 live births in a given
year.”12 This rate is expressed in deaths per 1000 live births.
In other words, it measures how many children younger than
1 year of age will die for every 1000 who were born alive that
year. Each country seeks as low a rate of infant mortality as
possible, but we will see that the rate varies largely with the
income status of a country. Afghanistan, for example, has an
infant mortality rate of 135 infant deaths for every 1000 live
births, whereas in Sweden only about 2 infants die for every
1000 live births.13 (See Figure 2-3).
Although the infant mortality rate is a powerful indicator of health status of a country, most children younger
21
than 1 year of age who die actually die in the first month of
life. Thus, the neonatal mortality rate is also an important
health status indicator. This rate measures “the number of
deaths to infants younger than 28 days of age in a given
year, per 1000 live births in that year.”12 Like the infant
mortality rate, this rate will generally vary directly with the
level of income of different countries. Poorer countries will
have a much higher neonatal mortality rate then the richer
countries. The neonatal mortality rate is about 40 per 1000
live births in sub-Saharan Africa but about 5 per 1000 live
births in developed countries.14 The neonatal mortality rate
by region is portrayed in Figure 2-4.
The under-5 child mortality rate is also called the child
mortality rate. This is “the probability that a newborn will
die before reaching age five, expressed as a number per 1000
live births.”12 Like the infant mortality rate, this rate is also
expressed per 1000 live births. Of course, this rate is very
similar to the infant mortality rate, and here, too, the lower the
rate the better. This rate also varies largely with the wealth of a
country. In the developed countries the rate is generally about
3–5 per 1000 live births. However, in the poorest countries, the
rate can be as high as 200 per 1000 live births.16 The under-5
child mortality rate is depicted in Figure 2-5. As infant mortality declines, the under-5 child mortality rate becomes a more
Figure 2-2 Life Expectancy at Birth, by World Bank Region, 2008
90
80
70
Years
60
50
40
30
20
10
0
East Asia and
the Pacific
Europe and
Central Asia
Latin America
and the
Caribbean
Middle East
and
North Africa
Region/Group
South Asia
Sub-Saharan
Africa
High-Income
OECD
Source: Data from the World Bank. World Development Indicators, Data Query. Available at: http://databank.worldbank.org. Accessed June 29, 2010.
97515_ch02_5944.indd 21
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22
Health Determinants, Measurements, and Trends
Figure 2-3 Infant Mortality Rate, by World Bank Region, 2008
100
90
Deaths per 1,000 Live Births
80
70
60
50
40
30
20
10
0
East Asia and
the Pacific
Europe and
Central Asia
Latin America
and the
Caribbean
Middle East
and
North Africa
Region/Group
South Asia
Sub-Saharan
Africa
High-Income
OECD
Source: Data from the World Bank. World Development Indicators, Data Query. Available at: http://databank.worldbank.org. Accessed June 29, 2010.
Figure 2-4 Neonatal Mortality Rate, by WHO Region, 2004
45
Deaths per 1,000 Live Births
40
35
30
25
20
15
10
5
0
Africa
Americas
Europe
Eastern
Mediterranean
Southeast Asia
Western Pacific
Region/Group
Source: Data from World Health Organization. Neonatal and Perinatal Mortality: Country, Regional, and Global Estimates 2004. Geneva: WHO; 2007:
Table 2.
97515_ch02_5944.indd 22
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Key Health Indicators
23
Figure 2-5 Under-5 Child Mortality, by World Bank Region, 2008
160
Deaths per 1,000 Live Births
140
120
100
80
60
40
20
0
East Asia and
the Pacific
Europe and
Central Asia
Latin America
and the
Caribbean
Middle East
and
North Africa
Region/Group
South Asia
Sub-Saharan
Africa
High-Income
OECD
Source: Data from the World Bank. World Development Indicators, Data Query. Available at: http://databank.worldbank.org. Accessed June 29, 2010.
important health indicator. The relative standing of different
regions in under-five child mortality, as shown in Figure 2-5,
looks very similar to that for infant mortality.
The maternal mortality ratio is a measure of the risk
of death that is associated with childbirth. Because these
deaths are more rare than infant and child deaths, the
maternal mortality ratio is measured as “the number of
women who die as a result of pregnancy and childbirth
complications per 100,000 live births in a given year.”12
The rarity of maternal deaths and the fact that they largely
occur in low-income settings also contributes to maternal
mortality being quite difficult to measure. Very few women
die in childbirth in rich countries; for example, the maternal mortality rate in Sweden is 3 per 100,000 live births. On
the other hand, in very poor countries, in which women
have low status and there are few facilities for dealing
with obstetric emergencies, the rates can be over 1000 per
100,000 live births, as they are, for example, in Afghanistan,
Angola, and Burundi.18 As you can see in Figure 2-6, the
maternal mortality ratio is also very strongly correlated
with a country’s income.
97515_ch02_5944.indd 23
There are a few other concepts and definitions that
are important to understand as we think about measuring
health status, and they are summarized in Table 2-3. The
first is morbidity. Essentially, this means sickness or any
departure, subjective or objective, from a psychological or
physiological state of well-being. Second is mortality, which
refers to death. A death rate is the number of deaths per
1000 population in a given year.10 The third is disability.
Although some conditions cause people to get sick or die,
they might also cause people to suffer the “temporary or
long-term reduction in a person’s capacity to function.”21
There will also be considerable discussion in this book
and most readings on global health of the prevalence of health
conditions. This refers to the number of people suffering
from a certain health condition over a specific time period.
It measures the chances of having a disease. For global health
work, one usually refers to “point prevalence” of a condition,
which is “the proportion of the population that is diseased at
a single point in time.”18 The point prevalence of HIV/AIDS
among adults in South Africa, for example, is estimated to be
about 18%. This means that today about 18% of all adults
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Health Determinants, Measurements, and Trends
Figure 2-6 Maternal Mortality Ratio, by World Bank Region, 2005
1000
Deaths per 100,000 Live Births
900
800
700
600
500
400
300
200
100
0
East Asia and
the Pacific
Europe and
Central Asia
Latin America
and the
Caribbean
Middle East
and
North Africa
Region/Group
South Asia
Sub-Saharan
Africa
High-Income
OECD
Source: Data from the World Bank. World Development Indicators, Data Query. Available at: http://databank.worldbank.org. Accessed June 29, 2010.
between the ages of 15 and 49 in South Africa are HIV positive.19
The incidence rate is also a very commonly used term.
This refers to the rate at which new cases of a disease occur
in a population. Incidence measures the chances of getting a
disease. Incidence rate is “the number of persons contracting
a disease per 1000 population at risk, for a given period of
time.”12 It is usually specified as the number of people getting
the disease over a year, per 100,000 people at risk. In India,
for example, the incidence rate for TB in 2007 was 168 per
100,000.20 This means that for every 100,000 people in India,
168 in the last year got TB in 2007.
Many people confuse incidence rate and prevalence rate.
It may be convenient to think of prevalence as the pool of
people with a disease at a particular time and incidence as the
flow of new cases of people with that disease each year into
that pool. You should note, of course, that the size of the pool
will vary as new cases flow into the pool and old cases flow
out, as they die or are cured.
Finally, one needs to be familiar with how diseases
get classified. When you read about health, there will be
97515_ch02_5944.indd 24
discussions of communicable diseases, noncommunicable
diseases, and injuries. Communicable diseases are also
called infectious diseases. These are illnesses that are caused
by a particular infectious agent and that spread directly or
indirectly from people to people, animals to people, or
people to animals.21 Examples of communicable diseases
include influenza, measles, and HIV. Noncommunicable
diseases are illnesses that are not spread by any infectious
agent, such as hypertension, coronary heart disease, and
diabetes. Injuries usually include, among other things,
road traffic injuries, falls, self-inflicted injuries, and violence.22
Vital Registration
The quality of data on population and health depends in
many ways on the extent to which countries maintain a
system of vital registration that can accurately record births,
deaths, and the causes of death. Unfortunately, this is not
the case in many low- and lower-middle-income countries.23
They generally have only rudimentary systems for vital registration, which cannot fulfill either their statistical or their
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Measuring the Burden of Disease
legal purposes. In addition, access to vital registration systems is highly inequitable, with higher income groups enjoying much better access than less well off people (Figure 2-7).
There are also cultural barriers to timely vital registration, because people in many countries wait until a child is
a certain age before registering the birth. Coupled with the
lack of access to vital registration, this means the existence
of some children is never officially known, because they die
before their births are registered. There are also enormous
difficulties with accurate indications of causes of death in
countries that have weak health systems and a limited number of well-trained physicians. This is especially so for causes
of death of adults.
The former Director-General of WHO, Lee Jong-Wook,
noted in a speech to his colleagues that: “To make people
count, we first need to be able to count people.”23 To overcome the lack of effective vital registration systems in many
developing countries, a number of tools, such as surveys
and projection models, have been developed. Some, like the
Demographic and Health Surveys, have become a backbone
of information about health, population, and nutrition, and
now HIV, in low-income countries.
In the longer term, however, the world would be better
served by helping countries further develop their own vital
registration systems. This would allow countries and their
development partners to more accurately gauge the nature
25
of key demographic and health issues and the progress made
toward resolving them. Moving in this direction will require
assessments of vital registration systems. It will also require
programs to improve the organization and functioning of
vital registration departments. This will have to include,
among other things, strengthening their methods to improve
the quality of vital statistics, including for the causes of death,
and enhancing their approach to publishing data.25
Measuring the Burden of Disease
We have already seen in Chapter 1 that the definition of
health is “a state of complete physical, mental and social
well-being and not merely the absence of disease or infirmity.” Those who work on global health have attempted for
a number of years to construct a single indicator that could
be used to compare how far different countries are from the
state of good health, as defined previously. Ideally, such an
index would take account of morbidity, mortality, and disability; allow one to calculate the index by age, by gender,
and by region; and allow one to make comparisons of health
status across regions within a country and across countries.24
This kind of index would measure what is generally referred
to as “the burden of disease.”
One such indicator is health-adjusted life expectancy, or
HALE. It is a “health expectancy measure.” The HALE “summarizes the expected number of years to be lived in what
Figure 2-7 Percentage of Children 0–5 Whose Births Have Been Registered, by Income Quintile
100
87
90
80
70
62
60
56
57
50
Children in the
richest 20% of
households
40
30
20
Children in the
poorest 20% of
households
21
22
10
0
South Asia
Sub-Saharan
Africa
Middle East and
North Africa
Source: Data from UNICEF. Progress for Children: Achieving the MDGs with Equity. Available at: http://www.unicef.org/media/files/Progress_for_
Children-No.9_EN_081710.pdf. Accessed September 17, 2010.
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Health Determinants, Measurements, and Trends
might be termed the equivalent of good health.”25 This can
also be seen as “the equivalent number of years in full health
that a newborn can expect to live, based on current rates of
ill health and mortality.”26 To calculate the HALE, “the years
of ill health are weighted according to severity and subtracted
from the overall life expectancy.”7
WHO has calculated HALEs for most countries, using
a standard methodology. Table 2-2 shows life expectancy
at birth in 2004 for a number of low-, middle-, and highincome countries and how it compares with HALEs for those
countries in the same year. As you can see from Table 2-2, the
greater the number of years that people in any population are
likely to spend in ill health or with disability, the greater the
difference will be between life expectancy at birth and healthadjusted life expectancy.
The composite indicator of health status that is most
commonly used in global health work is called the disabilityadjusted life year, or DALY. This indicator was first used in
conjunction with the 1993 World Development Report of
the World Bank, and is a “health gap measure.” It is now
used in burden of disease studies. In the simplest terms, a
DALY is:
. . . a unit for measuring the amount of health
lost because of a particular disease or injury. It
is calculated as the present value of future years
Table 2-2 Life Expectancy at Birth and Health Adjusted Life Expectancy, Selected Countries, 2004
Country
Afghanistan
Bangladesh
Bolivia
Brazil
Cambodia
Cameroon
China
Costa Rica
Cuba
Denmark
Ethiopia
Ghana
India
Indonesia
Jordan
Malaysia
Nepal
Niger
Nigeria
Peru
Philippines
Sri Lanka
Turkey
United States of America
Vietnam
Life Expectancy/Health-Adjusted Life Expectancy
Males
42/35.3
62/55.3
63/53.6
67/57.2
51/45.6
50/41.1
70/63.1
75/65.2
75/67.1
75/68.6
49/40.7
56/49.2
61/53.3
65/57.4
69/59.7
69/61.6
61/52.5
42/35.8
45/41.3
69/59.6
65/57.1
68/59.2
69/61.2
75/67.2
69/59.8
Life Expectancy/Health-Adjusted Life Expectancy
Females
42/35.8
63/53.3
66/55.2
74/62.4
58/49.5
51/41.8
74/65.2
80/69.3
80/69.5
80/71.1
51/41.7
58/50.3
63/53.6
68/58.9
73/62.3
74/64.8
61/51.1
41/35.2
46/41.8
73/62.4
72/61.5
75/64.0
73/62.8
80/71.3
74/62.9
Source: Data from WHO. Core Health Indicators. Available at: http://www3.who.int/whosis/core/core_select_process.cfm. Accessed September 24, 2006.
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Measuring the Burden of Disease
of disability free life that are lost as the result
of the premature deaths or causes of disability
occurring in a particular year.27
The DALY is a measure of losses due to illnesses, disabilities, and premature death in a population. A DALY
measures how many healthy years of life are lost between
the population being measured and the “healthiest” possible population, which is used as a standard. It does this by
adding together the losses of healthy years of life that occur
from illness, disability, and death. The value of disability is
based on values that have been established for the severity
of different disabling conditions. The calculation of a DALY
“discounts” losses so that losses from ill health, disability,
and death in the future are worth less than losses that occur
today, just as a dollar you get in the future will be worth less
than one you would get today.11, 25–30 This is why the DALY
is referred to as a “present value.”
For calculating DALYs, health conditions are generally
broken down into three categories:32
Group 1—communicable, maternal, and perinatal conditions (meaning in the first week after birth), and nutritional disorders
Group 2—noncommunicable diseases
Group 3—injuries, including, among other things, road
traffic accidents, falls, self-inflicted injuries, and violence
To get a better sense of the meaning of DALYs, it will be
valuable to construct a few simple examples of what goes into
their calculation and how they would be used. Consider, for
example, that a male can expect under the standard used to
live to be 80 years old. Now let us suppose that this person
dies of a heart attack at 40 years of age. That person would
have lost 40 years of life. The value of this loss, discounted to
the present, would be part of the calculation of DALYs.
Let us also imagine that a woman, who is 40 years of
age, has diabetes that has disabled her in a number of ways.
In principle, she should live to the standard used of 82.5
years of age. In practice, however, the person’s disability is
so severe that her quality of life is equal to only about half
of what it would be if she were in a “disease free” state. Even
if she were to live to be 80 years of age, therefore, she would
have lost about half of the quality of her last 42.5 years due
to disability. The value of this loss, discounted to the present,
would also be part of the calculation of DALYs.
The DALYs for the society in which the two people are living would be a composite of the data calculated from the losses
due to the premature death of the first person and the disability
of the second.
97515_ch02_5944.indd 27
27
In reality, of course, many health conditions produce
both disability and premature death. Let us suppose that a
man gets TB at 45 years of age. In the absence of treatment,
let us say that he dies at 47 years of age. He suffered two
years of disability and lost 33 years of life due to his illness,
compared to the standard used for longevity. A person who
suffers a severe road traffic injury at age 50 may live, let us
say, 10 years with severe disability due to his injuries and then
at age 60 die due to those injuries. He would have lost quality
of life years during the period of his disability and 20 years of
life from premature death, compared to the standard against
which DALYs are calculated.
A society that has more premature death, illness, and disability has more DALYs than a society that is healthier and has
less illness, disability, and premature death. One of the goals of
health policy is to avert these DALYS in the most cost-efficient
manner possible. If, for example, a society is losing many hundreds of thousands of DALYs due to malaria that is not diagnosed and treated in a timely and proper manner, what steps
can be taken to avert those DALYs at the lowest cost?
An important point to remember when considering
DALYs, compared to measuring deaths, is that DALYs take
account of periods in which people are living in ill health or
with disability. By doing this, DALYs and other composite
indicators try to give a better estimate than measuring deaths
alone of the true “health” of a population. This is easy to
understand. Most mental health problems, for example, are
not associated with deaths. However, they cause an enormous amount of disability. Several parasitic infections, such
as schistosomiasis (which is discussed in Chapter 11), also
cause very few deaths, but enormous amounts of illness and
disability. If we measured the health of a population with an
important burden of schistosomiasis and mental illness only
by measuring deaths, we would miss a major component of
morbidity and disability and would seriously overestimate
the health of that population. The next section on the global
burden of disease will make the concept of DALYs clearer to
you, especially as you see how DALYs compare to deaths for a
number of health conditions. Other sections of the book will
also make extensive use of the concept of DALYs.
Indeed, calculating DALYs requires information on
disease prevalence and incidence that is not always available.
In addition, the health expectancy measures are more widely
used in developed countries, given the health information
available to them. A number of critiques of DALYs have
been written.29 Nonetheless, this book will repeatedly refer to
DALYs because this measure is so extensively used in global
health work. In addition, a considerable amount of important analysis has been carried out that is based on the use
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Health Determinants, Measurements, and Trends
of DALYs for measuring overall health status and assessing
the most cost-effective approaches to dealing with various
health problems. These uses of the DALY will be discussed
in Chapter 3.
The Global Burden of Disease
As you start a review of global health, it is important to get
a clear picture of the leading causes of illness, disability, and
death in the world. As noted earlier, it is also very important to understand how they vary by age, sex, ethnicity, and
socioeconomic status, both within and across countries. It
is also essential to understand how these causes have varied
over time and how they might change in the future. These
topics are examined briefly below and in much greater detail
throughout the book.
As discussed earlier, it is important to note that the
tables that follow on the burden of disease are based on a
consistent set of 2001 data that was part of a study on the
global burden of disease. The most up-to-date data on specific diseases is generally given in the chapters that review
those diseases.
Table 2-3 shows the 10 leading causes of death and the
10 leading causes of DALYs lost for low- and middle-income
countries and for high-income countries. Both deaths and
DALYs are ranked in order of importance.
The table indicates that the leading causes of death in
low- and middle-income countries are noncommunicable
diseases, which account for about 54% of all deaths. This
is followed by communicable diseases at about 36% of all
deaths and then injuries at about 10% of all deaths.30
Table 2-3 The 10 Leading Causes of Death and DALYs, 2001
Low- and Middle-Income Countries
Percentage of
Cause
Total Deaths
1. Ischemic heart disease
11.8
2. Cerebrovascular disease
9.5
3. Lower respiratory infections
7.0
4. HIV/AIDS
5.3
5. Perinatal conditions
5.1
6. Chronic obstructive pulmonary disease
4.9
7. Diarrheal diseases
3.7
8. Tuberculosis
3.3
9. Malaria
2.5
10. Road traffic accidents
2.2
Percentage of
Cause
Total DALYs
1. Perinatal conditions
6.4
2. Lower respiratory infections
6.0
3. Ischemic heart disease
5.2
4. HIV/AIDS
5.1
5. Cerebrovascular disease
4.5
6. Diarrheal diseases
4.2
7. Unipolar depressive disorders
3.1
8. Malaria
2.9
9. Tuberculosis
2.6
10. Chronic obstructive pulmonary disease
2.4
High-Income Countries
Cause
1. Ischemic heart disease
2. Cerebrovascular disease
3. Trachea, bronchus, and lung cancers
4. Lower respiratory infections
5. Chronic obstructive pulmonary disease
6. Colon and rectal cancers
7. Alzheimer’s and other dementias
8. Diabetes mellitus
9. Breast cancer
10. Stomach cancer
Cause
1. Ischemic heart disease
2. Cerebrovascular disease
3. Unipolar depressive disorders
4. Alzheimer’s and other dementias
5. Trachea, bronchus, and lung cancers
6. Hearing loss, adult onset
7. Chronic obstructive pulmonary disease
8. Diabetes mellitus
9. Alcohol use disorders
10. Osteoarthritis
Percentage of
Total Deaths
17.3
9.9
5.8
4.4
3.8
3.3
2.6
2.6
2.0
1.9
Percentage of
Total DALYs
8.3
6.3
5.6
5.0
3.6
3.6
3.5
2.8
2.8
2.5
Source: Adapted with permission from Lopez AD, Mathers CD, Murray CJL. The burden of disease and mortality by condition: data, methods, and
results for 2001. In: Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL, eds. Global Burden of Disease and Risk Factors. Washington, DC and
New York: The World Bank and Oxford University Press; 2006.
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The Global Burden of Disease
In order of rank, ischemic heart disease and cerebrovascular disease are the two leading causes of death in low- and
middle-income countries. However, all but one of the next
leading causes of death in these countries is communicable.
The third leading cause of death is lower respiratory conditions, related to pneumonia, often in children. The fourth
leading cause is HIV/AIDS. The next are perinatal conditions,
linked with the death of newborns. TB, diarrheal disease,
and malaria are also major killers. Road traffic accidents are
the 10th leading cause of death in low- and middle-income
countries.31
Noncommunicable diseases are also the leading causes
of deaths in high-income countries. However, in other
respects, the picture of deaths that emerges in high-income
countries is quite different from that in low- and middleincome countries. In high-income countries almost 87% of
the deaths are from noncommunicable causes, 7.5% are from
injuries, and only 5.7% are from communicable causes. In
high-income countries, the first three leading causes of death
are heart disease, stroke, and lung and related cancers. The
fourth, and the only communicable cause among the leading causes of death, is lower respiratory infections, which is
associated in high-income countries mostly with death from
pneumonia of older people. Chronic obstructive pulmonary
disease is the fifth leading cause of death and colon and rectal
cancers are the sixth.31
If we look at DALYs, rather than deaths, for low- and
middle-income countries, communicable diseases and injuries become slightly more important and noncommunicable
diseases somewhat less important in percentage terms than
they were for deaths. In terms of individual conditions, diarrheal disease, malaria, and perinatal conditions become more
important percentages than they were for deaths. However,
the most significant difference is for unipolar depressive
disorders (depression), which were not in the 10 leading
causes of death, but which are in the 10 leading causes of
DALYs. This stems from the fact that this mental illness,
which is discussed more in Chapter 12, is not associated with
many deaths but is associated with an exceptional amount
of disability in almost all countries. In fact, when we look
at DALYs compared to deaths for high-income countries,
the relative shares of DALYs by cause group is generally not
very different than it is for deaths. However, for high-income
countries, as well as low- and middle-income countries,
unipolar depressive disorders become very important, as do
Alzheimer’s disease and other dementias. As noted earlier
and in the chapter on communicable diseases (Chapter 11),
DALYs are also an important measure for understanding the
impact of the neglected tropical diseases.
97515_ch02_5944.indd 29
29
Causes of Death by Region
As you would expect, the burden of disease varies by region,
as shown in Table 2-4. In general, the higher the level of
income within the region, the more likely it is that the leading
causes of the burden of disease will be noncommunicable.
The lower the level of income, the more likely it is that the
leading causes of the burden of disease will be communicable. What is most important to note is the remarkable extent
to which the burden of disease in the Africa region remains
dominated by communicable diseases. The relative importance of communicable diseases in the South Asia region
also sets that region apart. Throughout the book, in fact, the
relatively high burden of communicable diseases in South
Asia and sub-Saharan Africa will be highlighted. 34
Causes of Death by Age
Tables 2-5 and 2-6 show the leading causes of death by age
group for both low- and middle-income countries and highincome countries.
It is clear from Table 2-5 that children in low- and middle-income countries often die of communicable diseases
that are no longer problems in the more developed countries.
You can also see that HIV/AIDS and TB are among the leading causes of death in low- and middle-income countries
among adults, whereas no communicable disease is among
the 10 leading causes of death in the high-income countries.
Causes of Death by Gender
It is also important to examine deaths by gender. Table 2-7
shows deaths by gender for low- and middle-income countries.
For this group of countries, the causes of death among men
and women are largely alike. However, it is important to note
that, even in these countries, heart disease and stroke are the
leading causes of death among both genders, that men die much
more than women of road traffic accidents, and that diabetes
has become the 10th leading cause of death among women.
The Burden of Deaths and Disease Within
Countries
As you consider causes of death and the burden of disease
globally and by region, age, and sex, it is also important to
consider how deaths and DALYs would vary within countries, by gender, ethnicity, and socioeconomic status. In
most low- and middle-income countries, the answer to this
is relatively simple:
• Rural people will be less healthy than urban people.
• Disadvantaged ethnic minorities will be less healthy
than majority populations.
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Health Determinants, Measurements, and Trends
• Women will suffer a number of conditions that relate
to their relatively weak social positions.
• Poor people will be less healthy than better-off people.
• Uneducated people will be less healthy than better
educated people.
In addition, people of lower socioeconomic status will
have higher rates of communicable diseases, illness, and
death related to maternal causes and malnutrition than will
people of higher status. Lower socioeconomic status people
will also suffer from a larger burden of disease related to
Table 2-4 The 10 Leading Causes of the Burden of Disease in Low- and Middle-Income Countries by Region, 2001
East Asia and Pacific
1. Cerebrovascular disease
2. Perinatal conditions
3. Chronic obstructive pulmonary disease
4. Ischemic heart disease
5. Unipolar depressive disorders
6. Tuberculosis
7. Lower respiratory infections
8. Road traffic accidents
9. Cataracts
10. Diarrheal diseases
Latin America and the Caribbean
1. Perinatal conditions
2. Unipolar depressive disorders
3. Violence
4. Ischemic heart disease
5. Cerebrovascular disease
6. Endocrine disorders
7. Lower respiratory infections
8. Alcohol use disorders
9. Diabetes mellitus
10. Road traffic accidents
South Asia
1. Perinatal conditions
2. Lower respiratory infections
3. Ischemic heart disease
4. Diarrheal diseases
5. Unipolar depressive disorders
6. Tuberculosis
7. Cerebrovascular disease
8. Cataracts
9. Chronic obstructive pulmonary disease
10. Hearing loss, adult onset
Percentage of
Total DALYs
7.5
5.4
5.0
4.1
4.1
3.1
3.1
3.0
2.8
2.5
Percentage of
Total DALYs
6.0
5.0
4.9
4.2
3.8
3.0
2.9
2.8
2.7
2.6
Percentage of
Total DALYs
9.2
8.4
6.3
5.4
3.6
3.4
3.2
2.3
2.3
2.0
Europe and Central Asia
1. Ischemic heart disease
2. Cerebrovascular disease
3. Unipolar depressive disorders
4. Self-inflicted injuries
5. Hearing loss, adult onset
6. Chronic obstructive pulmonary disease
7. Trachea, bronchus, and lung cancers
8. Osteoarthritis
9. Road traffic accidents
10. Poisonings
Middle East and North Africa
1. Ischemic heart disease
2. Perinatal conditions
3. Road traffic accidents
4. Lower respiratory infections
5. Diarrheal diseases
6. Unipolar depressive disorders
7. Congenital anomalies
8. Cerebrovascular disease
9. Vision disorders, age-related
10. Cataracts
Sub-Saharan Africa
1. HIV/AIDS
2. Malaria
3. Lower respiratory infections
4. Diarrheal diseases
5. Perinatal conditions
6. Measles
7. Tuberculosis
8. Road traffic accidents
9. Pertussis
10. Protein-energy malnutrition
Percentage of
Total DALYs
15.9
10.8
3.7
2.3
2.2
2.0
2.0
2.0
1.9
1.9
Percentage of
Total DALYs
6.6
6.3
4.6
4.5
3.9
3.1
3.1
3.0
2.7
2.3
Percentage of
Total DALYs
16.5
10.3
8.8
6.4
5.8
3.9
2.3
1.8
1.8
1.5
Source: Reprinted with permission from Lopez AD, Mathers CD, Murray CJL. The burden of disease and mortality by condition: data, methods, and
results for 2001. In: Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL, eds. Global Burden of Disease and Risk Factors. Washington, DC and
New York: The World Bank and Oxford University Press; 2006:91.
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Risk Factors
Table 2-5 The 10 Leading Causes of Death in Children Ages 0–14, by Broad Income Group, 2001
Low- and Middle-Income Countries
Percentage of
Cause
Total Deaths
Perinatal conditions
20.7
Lower respiratory infections
17.0
Diarrheal diseases
13.4
Malaria
9.2
Measles
6.2
HIV/AIDS
3.7
Congenital anomalies
3.7
Whooping cough
2.5
Tettanus
1.9
Road traffic accidents
1.5
High-Income Countries
Cause
Perinatal conditions
Congenital anomalies
Road traffic accidents
Lower respiratory infections
Endocrine disorders
Drownings
Leukemia
Violence
Fires
Meningitis
Percentage of
Total Deaths
33.9
20.0
5.9
2.5
2.4
2.4
1.9
1.8
1.2
1.2
Source: Adapted with permission from Lopez A, Begg S, Bos E. Demographic and epidemiological characteristics of major regions, 1990–2001. In:
Lopez A, Mathers C, Ezzati M, Jamison D, Murray C, eds. Global Burden of Disease and Risk Factors. Washington, DC and New York: The World
Bank and Oxford University Press; 2006:70.
Table 2-6 The 10 Leading Causes of Death in Adults 15–59, by Broad Income Group, 2001
Low- and Middle-Income Countries
Percentage of
Cause
Total Deaths
HIV/AIDS
14.1
Ischemic heart disease
8.1
Tuberculosis
7.1
Road traffic accidents
5.0
Cerebrovascular disease
4.9
Self-inflicted injuries
4.0
Violence
3.1
Lower respiratory infections
2.3
Cirrhosis of the liver
2.2
Chronic obstructive pulmonary disease
2.2
High-Income Countries
Cause
Ischemic heart disease
Self-inflicted injuries
Road traffic accidents
Trachea, bronchus, and lung cancers
Cerebrovascular disease
Cirrhosis of the liver
Breast cancer
Colon and rectal cancers
Diabetes mellitus
Stomach cancer
Percentage of
Total Deaths
10.8
7.2
6.9
6.8
4.4
4.4
4.0
3.1
2.1
2.0
Source: Adapted with permission from Lopez A, Begg S, Bos E. Demographic and epidemiological characteristics of major regions, 1990–2001. In:
Lopez A, Mathers C, Ezzati M, Jamison D, Murray C, eds. Global Burden of Disease and Risk Factors. Washington, DC and New York: The World
Bank and Oxford University Press; 2006:70.
smoking, alcohol, and diet than would be the case for betteroff people. These points are fundamental to understanding
global health and will also be highlighted throughout the
book.
97515_ch02_5944.indd 31
Risk Factors
As we discuss the determinants of health and how health status is measured, there will be many references to risk factors
for various health conditions. A risk factor is “an aspect or
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Health Determinants, Measurements, and Trends
Table 2-7 The 10 Leading Causes of Death Ordered by Sex, in Low- and Middle-Income Countries, 2001
Males
Cause
Ischemic heart disease
Cerebrovascular disease
Lower respiratory infections
Perinatal conditions
HIV/AIDS
Chronic obstructive pulmonary disease
Tuberculosis
Diarrheal diseases
Road traffic accidents
Malaria
Females
Percentage of
Total Deaths
11.8
8.5
6.7
5.4
5.4
4.7
4.1
3.6
3.1
2.3
Cause
Ischemic heart disease
Cerebrovascular disease
Lower respiratory infections
HIV/AIDS
Chronic obstructive pulmonary disease
Perinatal conditions
Diarrheal diseases
Malaria
Tuberculosis
Diabetes mellitus
Percentage of
Total Deaths
10.8
7.2
6.9
6.8
4.4
4.4
4.0
3.1
2.1
2.0
Source: Data from Lopez A, Begg S, Bos E. Demographic and epidemiological characteristics of major regions, 1990–2001. In: Lopez A, Mathers
C, Ezzati M, Jamison D, Murray C, eds. Global Burden of Disease and Risk Factors. Washington, DC and New York: The World Bank and Oxford
University Press; 2006:70.
personal behavior or life-style, an environmental exposure,
or an inborn or inherited characteristic, that, on the basis
of epidemiologic evidence, is known to be associated with
health-related condition(s) considered important to prevent.”35 Risks that relate to health can also be thought of as
“a probability of an adverse outcome, or a factor that raises
this probability.”36 We are all familiar with the notion of risk
factors from our own lives and from encounters with health
services. When we answer questions about our health history,
for example, we are essentially helping to identify the most
important risk factors that we face ourselves. Do our parents
suffer from any health conditions that might affect our own
health? Are we eating in a way that is conducive to good
health? Do we get enough exercise and enough sleep? Do
we smoke or drink alcohol excessively? Are there any special
stresses in our life? Do we wear seat belts when we drive?
If we extend the idea of risk factors to poor people in
low- and middle-income countries, then we might add some
other questions that relate more to the ways that they live.
Does the family have safe water to drink? Do their house and
community have appropriate sanitation? Does the family
cook indoors in a way that makes the house smoky? Do the
father and mother work in places that are safe environmentally? We might also have to ask if there is war or conflict in
the country, because they are also important risk factors for
illness, death, and disability.
97515_ch02_5944.indd 32
If we are to understand how the health status of people
can be enhanced, particularly poor people in low- and
middle-income countries, then it is very important that we
understand the risk factors to which their health problems
relate. Table 2-8 shows the relative importance of different
risk factors to deaths and DALYs in low- and middle-income
countries, compared to high-income countries. These are
shown in the table in order of their importance by category
of risk.
When we consider low- and middle-income countries,
the most striking factor is the extent to which malnutrition is
a risk factor. Another important point is the extent to which
other nutrition-related risk factors are important for deaths
and DALYs, such as high blood pressure and high cholesterol. Deaths and DALYs attributable to the risks of smoking
and unsafe sex make up the other most significant risk factors
in low- and middle-income countries.37
In high-income countries, there is little undernutrition
but a considerable amount of overweight and obesity. It is
not surprising, therefore, that three of the most important
risk factors for both deaths and DALYs in high-income
countries are high blood pressure, high cholesterol, and
overweight and obesity. Nor is it surprising that, despite
important progress in reducing the prevalence of smoking in
some countries, tobacco remains the leading risk factor for
both deaths and DALYs in high-income countries.37
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Demography and Health
Table 2-8 The Leading Risk Factors for the Burden of Disease, 2001, Low- and Middle-Income and High-Income
Countries, Ranked in Order of Percent of Total DALY
Low- and Middle-Income Countries
DALYs
Deaths
High blood pressure (12.9)
Childhood underweight (8.7)
Childhood underweight (7.5) Unsafe sex (5.8)
Smoking (6.9)
High blood pressure (5.6)
High cholesterol (6.3)
Smoking (3.9)
Unsafe sex (5.8)
Low fruit and vegetable
intake (4.8)
Alcohol use (3.9)
Indoor smoke from
household use of solid
fuels (3.7)
Overweight and obesity (3.6)
Unsafe water, sanitation,
and hygiene (3.2)
Unsafe water, sanitation,
and hygiene (3.7)
Alcohol use (3.6)
High cholesterol (3.1)
Indoor smoke from
household use of solid
fuels (3.0)
Low fruit and vegetable
intake (2.4)
Overweight and obesity (2.3)
High-Income Countries
DALYs
Deaths
Smoking (12.7)
Smoking (12.7)
High blood pressure (17.6)
High blood pressure (9.3)
High cholesterol (10.7)
Overweight and obesity (7.2)
Overweight and obesity
High cholesterol (6.3)
(7.8)
Physical inactivity (4.8)
Alcohol use (4.4)
Low fruit and vegetable
intake (4.2)
Urban air pollution (1.0)
Physical inactivity (3.2)
Illicit drug use (0.5)
Low fruit and vegetable
intake (2.7)
Unsafe sex (0.6)
Unsafe sex (0.4)
Iron-deficiency anemia (0.5)
Alcohol use (0.3)
Child sexual abuse (0.5)
Source: Data used with permission from Lopez A, et al. Global Burden of Disease and Risk Factors. Washington, DC and New York: The World Bank
and Oxford University Press; 2006:10.
Demography and Health
There are a number of trends related to population that are
extremely important to people’s health. Among the most
important of these are:
•
•
•
•
•
Population growth
Population aging
Urbanization
The “demographic divide”
The demographic transition
These are briefly discussed below, along with their implications for health. Other important matters related to population, such as the relationship between fertility and the health
of women and children, are discussed in other chapters.
Population Growth
The population of the world is about 6.9 million38 and is still
growing. As shown in Figure 2-8, it is estimated that by 2050
97515_ch02_5944.indd 33
the population of the world will be about 9.2 million. As also
shown in the figure, the overwhelming majority of population growth in the future will occur in low- and middleincome countries. This reflects the facts that fertility is falling
only slowly in many countries that have had high fertility
rates historically, while many of the high-income countries
have very low fertility. At a minimum, we should expect that
increasing population growth in low-income countries will
put substantial pressure on the environment, with its attendant risks for health. It will also mean that infrastructure,
such as water supply and sanitation, will have to be provided
to an increasing number of people—in the countries that
have the largest service gaps, can least afford to expand such
services, and will face substantial impacts on health as a
result. Increasing population will also make it more difficult
for low-income countries to provide education and health
services, with additional consequences for the health of their
people in the future.
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Health Determinants, Measurements, and Trends
Figure 2-8 World Population—1950 to 2050
10
9
8
Global population:
1900 1.6 billion
2000 6.1 billion
2011 7 billion
2050 9.2 billion
Billions
7
5
5
4
3
Developing countries
2
1
50
45
20
40
20
35
20
30
20
25
20
20
20
10
15
20
05
20
00
20
95
20
90
19
85
19
80
19
19
70
75
19
65
19
60
19
55
19
19
50
19
20
Developed countries
0
Source: Adapted from Haub, Carl and PRB. Data from United Nations Population Division. World Population Prospects, The 2008 Revision. Available
at: http://esa.un.org/UNPP. Accessed December 4, 2010. The figure is based on the medium UN variant, with an average world fertility rate of 2.0 in
2050.
Population Aging
As shown in Table 2-9, the population of the world is aging.
This is especially true in high-income countries that have
low fertility, but this is occurring in other countries, as well.
One impact of population aging is that it changes the ratio
between the share of the population that is working and the
share of the population that is 65 years of age or more. This
is called the elderly support ratio. Whereas this ratio is 19 in
Niger, for example, it is already approaching 1 in Japan.40
Population aging and the shift in the elderly support ratio
have profound implications for the burden of disease and
for health expenditures and how they will be financed. In
the simplest terms, people will live longer and spend more
years with morbidities and disabilities related to noncommunicable diseases. This will raise the costs of health care. In
addition, the large numbers of older adults for every working person will make it difficult for countries to finance that
health care.
Urbanization
Table 2-9 Percentage of the Population Projected
to Be Over 65 Years of Age
Developed countries
Developing countries
2010
2050
15.9
5.8
26.2
14.6
Source: Adapted from Haub, Carl and PRB. Data from United
Nations Population Division. World Population Prospects, The 2008
Revision. Available at: http://esa.un.org/UNPP. Accessed December
4, 2010. Data is shown only for the medium population variant of
the UN.
97515_ch02_5944.indd 34
In the last decade, the majority of the world’s population has
lived in urban areas for the first time in world history. People
are continuing to move from rural to urban areas, especially
in low- and middle-income countries, in which important
shares of the population have continued to live in rural areas
until recently. Continuing urbanization will also put enormous pressure on urban infrastructure, such as water and
sanitation, schools, and health services, which are already in
short supply in many countries. Gaps in such infrastructure,
as well as the development of crowded and low-standard
housing, for example, could have substantial negative consequences for health.
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Demography and Health
The Demographic Divide
There is an exceptional difference in the demographic indicators and future demographic paths of the best-off and
the least-well-off countries, as suggested in the two sections
above. The highest income countries generally have very low
fertility, declining populations, and aging populations. By
contrast, fertility in the lowest income countries is generally
still high, although it is declining slowly. In addition, the
population is still growing in these countries and will continue to grow for some time. As will be discussed throughout
the book, and related to the demographic divide, there is
also an enormous difference in the health circumstances of
the high- and low-income countries. Table 2-10 portrays the
demographic divide.
The Demographic Transition39
One important demographic trend of importance is called
the demographic transition. This is the shift from a pattern of
high fertility and high mortality to low fertility and low mortality, with population growth occurring in between.
When we look back historically at the countries that
are now high-income, we can see that they had long periods
historically when fertility was high, mortality was high, and
population growth was, therefore, relatively slow, or which
might even have declined in the face of epidemics. Beginning
around the turn of the nineteenth century, however, mortality in those countries began to decline as hygiene and nutrition improved and the burden of infectious diseases became
less. In most cases, this decline in mortality went before
much decline in fertility. As mortality declined, the population increased and the share of the population that was of
younger ages also increased. Later, fertility began to decline
and, as births and deaths became more equal, population
growth slowed. As births and deaths stayed more equal, the
share of the population that was of older ages increased.
The demographic transition is shown graphically in
Figure 2-9.
The first population pyramid reflects a country with
high fertility and high mortality. The second population
pyramid is indicative of a country in which mortality has
begun to decline but fertility remains high. This would be
similar to the demographics one would find, for example, in
a number of countries in sub-Saharan Africa that are undergoing demographic transition. The third pyramid looks more
like a cylinder than a pyramid. This reflects a population in
which fertility has been reduced and in which there is a larger
share of older people in the population than in the first and
second pyramids. This would be similar to the demographics
that one would find in a number of low-fertility, aging populations in Western Europe.
The Epidemiologic Transition40
The epidemiologic transition is closely related to the demographic transition, as suggested throughout the previous
discussion. Historically there has been a shift in the patterns
of disease that follows the trends noted below:
• First, high and fluctuating mortality, related to very
poor health conditions, epidemics, and famine
Table 2-10 The “Demographic Divide”: The Example of Nigeria and Japan
Nigeria
Population 2009 (millions)
Population 2050 (millions)
Lifetime births per woman
Annual number of births
Percentage of population below age 15
Percentage of population age 65+
Life expectancy at birth
Infant deaths per 1000 births
Annual number of infant deaths
Percentage of adults with HIV/AIDS
153
285
5.7
6.2 million
45
3
47
75
465,000
3.1
Japan
128
95
1.4
1.1 million
13
23
83
2.6
2900
—
Source: Data from Population Reference Bureau. 2009 World Population Data Sheet. Available at: http://www.prb.org/Publications/
Datasheets/2009/2009wpds.aspx. Accessed November 24, 2010.
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Health Determinants, Measurements, and Trends
Figure 2-9 The Demographic Transition: (A) High Fertility/High Mortality; (B) Declining Mortality/High Fertility;
(C) Reduced Fertility/Reduced Mortality
Age
Male
Female
Age
Male
Age
Female
80+
80+
80+
75-79
75-79
75-79
70-74
70-74
70-74
65-69
65-69
65-69
60-64
60-64
60-64
55-59
55-59
55-59
50-54
50-54
50-54
45-49
45-49
45-49
40-44
40-44
40-44
35-39
35-39
35-39
30-34
30-34
30-34
25-29
25-29
25-29
20-24
20-24
20-24
15-19
15-19
15-19
10-14
10-14
10-14
5-9
5-9
5-9
0-4
0-4
0-4
10 8
6
4
2
0
2
4
6
8 10
10 8
6
4
2
0
2
4
6
8 10
Male
10 8
6
4
Female
2
0
2
4
6
8 10
PERCENT OF TOTAL POPULATION
PERCENT OF TOTAL POPULATION
PERCENT OF TOTAL POPULATION
(A)
(B)
(C)
Source: Reprinted from U.S. Census Bureau. International population reports WP/02. Global Population Profile: 2002. Washington, DC: U.S. Government
Printing Office; 2004:35.
• Then, progressive declines in mortality, as epidemics
become less frequent
• Finally, further declines in mortality, increases in
life expectancy, and the predominance of noncommunicable diseases
Figure 2-10 shows examples of two sets of countries.
The first has a burden of disease profile that is pretransition. The second is of a developed country that has completed its epidemiological transition.
You can see in Figure 2-10 how the pattern of disease
differs between the two types of countries. You can also see
the changes that will occur over time, as the low-income
country develops and the burden of disease moves from one
that is dominated by communicable diseases to one that is
dominated by noncommunicable diseases.
The pace of the epidemiologic transition in different societies depends on a number of factors related to the determinants of health that were discussed earlier. In its early stages,
the transition appears to depend primarily on improvements
in hygiene, nutrition, education, and socioeconomic status.
Some improvements also stem from advances in public health
97515_ch02_5944.indd 36
and in medicine, such as the development of new vaccines
and antibiotics.41
Most of the countries that are now high-income went
through epidemiologic transitions that were relatively slow,
with the exception of Japan. Most developing countries have
already begun their transition; however, it is still far from
complete in most of them.
In fact, most low-income countries are in an ongoing
epidemiologic transition and many of them, therefore, face
significant burdens of communicable and non-communicable diseases, and injuries at the same time. This strains the
capacity of the health system of many of these countries. It is
also expensive for countries that are resource poor to address
a substantial burden of all three of these types of diseases
simultaneously.
Progress In Health Status
As noted in the introductory chapter, there has been substantial progress in improving health and raising life expectancy
in many parts of the world. However, as also noted, those
gains have not been uniform across regions. Rather, life
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Progress In Health Status
37
Figure 2-10 The Burden of Disease by Group of Cause, Percent of Deaths, 2001
Group 3
10%
Group 1:
Communicable, maternal,
and perinatal conditions
and nutritional disorders
Group 2:
Noncommunicable diseases
Group 3:
Injuries
Group 3
6%
Group 1
7%
Group 1
36%
Group 2
54%
Group 2
87%
HIGH-INCOME COUNTRIES
AVERAGE LOW- AND MIDDLE-INCOME COUNTRIES
Source: Data used with permission from Lopez AD, et al. Global Burden of Disease and Risk Factors. Washington, DC and New York: The World Bank
and Oxford University Press; 2006:8.
expectancy in sub-Saharan Africa and South Asia continue to
substantially lag that in other regions. In addition, for countries that had a life expectancy in 1960 of less than 50 years,
the pace of improvements in life expectancy in sub-Saharan
Africa has been much slower than in any other region.
Table 2-11 shows life expectancy in 1960, 1990, and 2008
by World Bank region, including for high-income countries.
The table also shows the percentage gain in life expectancy
over three different periods, 1960 to 2008, 1960 to 1990, and
1990 to 2008.
Table 2-11 Life Expectancy and Percentage Gain in Life Expectancy, 1960–2008, by World Bank Region
Life Expectancy (Years)
World Bank Region
1960
1990
2008
Percentage Gain
(1960–2008)
Percentage Gain
(1960–1990)
Percentage Gain
(1990–2008)
East Asia and the Pacific
Europe and Central Asia
Latin America and the Caribbean
Middle East and North Africa
South Asia
Sub-Saharan Africa
High-income OECD
46
—
56
47
43
41
69
67
69
68
64
58
50
76
72
70
73
71
64
52
80
57%
—
30%
51%
49%
27%
16%
46%
—
21%
36%
35%
22%
10%
7%
1%
7%
11%
10%
4%
5%
Source: Data from the World Bank. World Development Indicators, Data Query. Available at: http://databank.worldbank.org. Accessed July 6, 2010.
No data for Europe and Central Asia for 1960.
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Health Determinants, Measurements, and Trends
Life expectancy grew over each successive period in each
region; however, the increases in Europe and Central Asia
were very small in the period 1990–2008, largely reflecting
the social and economic consequences of the break-up of the
former Soviet Union and the impact of changes on the health
system, as well. The slow progress in improving life expectancy in sub-Saharan Africa between 1990 and 2008 mostly
reflects the negative impact on life expectancy of the HIV/
AIDS epidemic, as well as slow economic progress in some
countries and political conflict. By contrast, the dramatic
increases in life expectancy from 1960 to 2008 in the East Asia
and the Pacific region suggest the rapid pace of economic
development in that region, usually accompanied by substantial investments in improving nutrition, education, and
health. The region was also relatively free of conflict.
The factors that lead to improvements in health are
complex, as suggested by the determinants of health that you
reviewed earlier in this chapter. Additional comments are
made at the end of this chapter and in Chapter 3 about these
factors, including the role, for example, of nutrition, education, political stability, and scientific improvements. Many
other chapters also include comments on the progress in
improving the health of women and children and in addressing particular causes of illness, disability, and death.
The Burden of Disease: Looking Forward
The burden of disease in the future will be influenced by a
number of factors that will continue to change. Some of these
will relate to the determinants of health discussed earlier in
the chapter. Some will relate to the demographic forces just
discussed, including population growth, population aging,
and migration. The burden of disease in the future will also
be driven, among other things, by:
•
•
•
•
•
Economic development
Scientific and technological change
Climate change
Political stability
Emerging and re-emerging infectious disease
These are discussed very briefly in the following sections.
Chapter 12 offers additional comments on emerging and reemerging infectious diseases.
Economic Development
The economies of low-income countries will need to grow
if those countries are to generate the income they need to
invest in improving people’s health. The impact of economic
development on health will depend partly on the extent
97515_ch02_5944.indd 38
to which economic growth is equitable across population
groups. It will also depend on the extent to which countries
are able—or choose—to use their increased income to invest
in other areas that improve health, such as water, sanitation,
hygiene, and education. The extent and appropriateness of
their investments in health, such as in low-cost, high-yielding
efforts in health, will also be critical.
Scientific and Technological Change
As you will read about further throughout the book and in
Chapter 16, scientific and technological change have had an
enormous impact on health and will continue to do so in
the future. This is easy to understand, as one considers the
development of vaccines or new drugs, such as antibiotics or
antiretroviral therapy. The development of new diagnostics
for TB, for example, would make an enormous difference
to the health of the world, as would the development of a
vaccine against HIV or malaria. As also discussed in Chapter
16, the impact of scientific and technological change on the
low-income countries of today will depend to a large extent
on the pace at which they are able to effectively adopt any
improvements when they are developed.
Climate Change
The impact of climate change on health is not clear; however,
it is anticipated that climate change and its attendant impact
on weather and rising sea levels could directly and indirectly
have an important impact on health. On the indirect side,
climate change could alter the nature of the food crops that
can be grown in different places and lead to migration from
some places to others that are deemed more habitable. On
the more direct side, climate change could lead to weather
changes and adverse weather that harms people’s health. It
could also lead to the disappearance of disease vectors in
some places as the weather is no longer hospitable to them,
while allowing the emergence or re-emergence of disease vectors in other places.
Political Stability
In low-income countries, political stability appears to be
necessary to achieving long-term gains in health. There is
substantial evidence, for example, that the lack of political
stability has been a major impediment to progress in achieving the MDGs in a number of countries. It is not hard to
imagine, for example, how conflicts in Liberia, Sierra Leone,
and the Democratic Republic of the Congo could set back
health status for many years. These conflicts led directly to
substantial illness, disability, and death. In addition, by causing a breakdown in infrastructure, such as water, sanitation,
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The Burden of Disease: Looking Forward
and electricity, as well as the erosion of health services, they
also had enormous indirect impacts on health.
Emerging and Re-emerging Infectious Diseases
It is not possible to predict if and when new diseases will
emerge or diseases already known will re-emerge. It is also
not possible to know how well individual countries and
the world will do in recognizing any such problems and
addressing them quickly and effectively. What is clear is that
pandemic flu, for example, could have a major impact on
future disease patterns. It is also clear, for example, that if
the growth of drug-resistance for, say, malaria, outpaced our
ability to produce safe and effective drugs to fight malaria,
this, too, could have a substantial impact on the burden of
disease.
Projecting the Burden of Disease
Given the complex array of factors that influence health
status and will drive future changes in the burden of disease,
it is difficult to predict with any certainty how the burden
of disease will evolve in different countries in the next two
decades. Nonetheless, it is possible, using models, to project
the future burden of disease, given assumptions about key
health determinants and how they will evolve in different
parts of the world. WHO has projected the burden of disease
in 2030 by country income group.
Table 2-12 examines trends in the 10 leading causes
of the burden of disease between 2004 and 2030, by country income group (low, lower-middle, upper-middle, and
upper). In cases where there is very little difference between
the tenth and eleventh leading cause of DALYs lost, the table
also shows, in parentheses and without enumeration, an
eleventh cause of disease.
The main message of the table is clear: over the period
2004 to 2030, it is projected that there will be substantial
changes in the burden of disease in all country income
groups. In the simplest of terms, we can see for low- and
lower-middle-income countries there will be a substantial
shift away from communicable diseases and towards noncommunicable diseases and accidents and injuries. HIV/
AIDS is projected to be the only communicable disease in
the top 10 causes of DALYs lost in low-income countries,
and no communicable diseases are predicted to be in the
top 10 for lower-middle-income countries. Unipolar depressive disorders, ischemic heart disease, and cerebrovascular
disease become more important causes of DALYs lost for
both income groups. Some causes we associate with aging
populations, such as hearing loss and refractive errors, also
become more prominent, even in low-income countries.
The projected growth of diabetes in all income groups is also
evident in the table.
For the upper-middle-income countries, the burden
would continue to shift in similar ways, as noted above. TB,
which was the eleventh leading cause of DALYs lost, would
decline in relative importance, and no communicable disease
would be in the top 10. Adult-onset hearing loss and arthritis,
however, would join the top 10 leading causes of DALYs lost,
clearly reflecting the aging populations in these countries.
Table 2-12 Trends in the 10 Leading Causes of the Burden of Disease, by Income Group, 2004–2030
2004
Percentage of
Total DALYs
Low-income countries
827,669
1. Perinatal conditions
2. Lower respiratory infections
3. Diarrheal diesease
4. HIV/AIDS
5. Malaria
6. Unipolar depressive disorders
7. Ischemic heart disease
8. Other unintentional injuries
9. Tuberculosis
10. Road traffic accidents
Cerebrovascular disease
11.28%
9.30%
7.15%
5.18%
3.96%
3.20%
3.14%
2.94%
2.70%
2.02%
1.73%
Projected in 2030
Percentage of
Total DALYs
718,076
Perinatal conditions
Unipolar depressive disorders
Road traffic accidents
Ischemic heart disease
Lower respiratory infections
Cerebrovascular disease
HIV/AIDS
Other unintentional injuries
Chronic obstructive pulmonary disease
Hearing loss, adult onset
Refractive disorders
8.56%
5.75%
5.53%
5.23%
4.95%
3.14%
3.13%
3.09%
3.08%
2.59%
2.56%
(continues)
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40
Health Determinants, Measurements, and Trends
Table 2-12 (Continued)
2004
Percentage of
Total DALYs
Lower-middle-income countries
451,827
1. Perinatal conditions
2. Unipolar depressive disorders
3. Cerebrovascular disease
4. Other unintentional injuries
5. Ischemic heart disease
6. Road traffic accidents
7. Chronic obstructive pulmonary disease
8. Lower respiratory infections
9. Refractive errors
10. Diarrheal disease
Alcohol use disorders
Upper-middle-income countries
6.06%
5.22%
4.72%
4.37%
4.18%
3.89%
3.25%
3.13%
2.72%
2.61%
2.51%
121,032
Unipolar depressive disorders
Cerebrovascular disease
Chronic obstructive pulmonary disease
Ischemic heart disease
Road traffic accidents
Refractive errors
Hearing loss, adult onset
Perinatal conditions
Diabetes mellitus
Alcohol use disorders
Other unintentional injuries
6.43%
6.03%
5.90%
5.16%
5.04%
3.29%
3.14%
2.93%
2.74%
2.72%
2.66%
97,332
1. HIV/AIDS
2. Ischemic heart disease
3. Cerebrovascular disease
4. Unipolar depressive disorders
5. Other unintentional injuries
6. Perinatal conditions
7. Road traffic accidents
8. Violence
9. Alcohol use disorders
10. Diabetes mellitus
Tuberculosis
High-income countries
8.32%
8.23%
5.13%
4.46%
3.86%
3.21%
3.15%
3.03%
2.91%
2.08%
2.01%
122,092
Ischemic heart disease
HIV/AIDS
Unipolar depressive disorders
Cerebrovascular disease
Diabetes mellitus
Violence
Alcohol use disorders
Road traffic accidents
Hearing loss, adult onset
Osteoarthritis
8.16%
6.20%
6.02%
5.57%
4.20%
3.89%
3.08%
2.97%
2.78%
2.32%
1. Unipolar depressive disorders
2. Ischemic heart disease
3. Cerebrovascular disease
4. Alzheimer’s and other dementias
5. Alcohol use disorders
6. Hearing loss, adult onset
7. Chronic obstructive pulmonary disease
8. Diabetes mellitus
9. Trachea/bronchus/lung cancers
10. Road traffic accidents
8.19%
6.34%
3.90%
3.59%
3.45%
3.44%
3.00%
2.97%
2.96%
2.56%
Projected in 2030
Percentage of
Total DALYs
424,681
122,207
Unipolar depressive disorders
Ischemic heart disease
Alzheimer’s and other dementias
Hearing loss, adult onset
Cerebrovascular disease
Alcohol use disorders
Osteoarthritis
Trachea/bronchus/lung cancers
Refractive errors
Self-inflicted intentional injuries
8.46%
6.54%
5.53%
4.07%
3.76%
3.32%
2.75%
2.74%
2.40%
2.39%
Source: Data from World Health Organization. Global Burden of Disease (GBD). Available at: http://www.who.int/healthinfo/global_burden_disease/en. Accessed September 14, 2010.
The projected burden of disease in high-income countries
also suggests an increase in burdens associated with aging,
such as dementias, hearing loss, and refractive disorders.
Mental health issues are projected to increase in importance in all income groups over the period 2004 to 2030.
The largest percentage increases will occur in low-income
countries, probably reflecting the extent to which these issues
97515_ch02_5944.indd 40
arise as people lose connections with their families and their
culture group, as often occurs in modernizing and globalizing economies in which people leave their native places to
migrate to cities in search of employment. As noted earlier,
the neglected tropical diseases are not treated as a group in
the burden of disease data, like those shown in Tables 2-3 to
2-8. We should anticipate that the burden of these diseases
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The Development Challenge Of Improving Health
41
From this figure, one can see that, generally, the health
of a country does increase as national income rises. However,
one can also see that there are some countries, such as China,
Costa Rica, Cuba, and Sri Lanka, that have achieved higher
average life expectancies at birth than one would have predicted for countries at their level of income.
To a large extent, countries like those above achieved
these important health gains as a result of:
will remain substantial for many years to come, but that their
burden will decline consistently between 2004 and 2030.
The Development Challenge Of Improving
Health
One of the key development challenges facing policy makers in
low-income countries is how they can speed the demographic
and epidemiologic transitions at the lowest possible cost. How
can Niger, for example, improve its health status as rapidly as
possible and at the least possible cost? Will it be possible for the
people of Niger to enjoy the health status of a middle-income
country, even if Niger remains a low-income country?
Figure 2-11 shows national income of a sample of countries, plotted against life expectancy at birth for females in
those countries.
• Focusing on investing in nutrition, health, and education, particularly of their poor people
• Improving people’s knowledge of good hygiene
• Making selected investments in health services that at
low cost could have a high impact on health status, such
as vaccination programs for children and TB control
Figure 2-11 Gross Domestic Product per Capita and Female Life Expectancy at Birth, Selected Countries, 2004
Afghanistan
Argentina
Bangladesh
Bolivia
Brazil
Cambodia
40,000
Cameroon
Canada
35,000
Chile
China
Costa Rica
GDP per Capita
30,000
Cuba
Denmark
25,000
Ethiopia
Ghana
Haiti
20,000
India
Indonesia
15,000
Jordan
Malaysia
10,000
Nepal
Niger
Nigeria
5,000
Pakistan
Peru
0
40
50
60
70
LIFE EXPECTANCY AT BIRTH
80
90
Philippines
Singapore
Sri Lanka
Turkey
United States of America
Vietnam
Source: Data from WHO. Core Health Indicators. Available at: http://www3.who.int/whosis/core/core_select_process.cfm. Accessed September 24, 2006.
97515_ch02_5944.indd 41
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42
Health Determinants, Measurements, and Trends
These themes will also be discussed throughout this book.
Indeed, in the long run, economic progress will help
to bring down fertility, reduce mortality from communicable diseases, and help to produce a healthier population.
However, at the present rates of progress in improving health
in most low-income countries, these changes will take a very
long time to occur. One great public policy challenge for
these countries and their governments, therefore, is how they
can “short-circuit” this process and reach reduced levels of
fertility, lower mortality, and better health for their people,
even as they remain relatively poor.
Case Study
The State of Kerala
Having begun to review health status and how countries
can speed improvements in health, it will be valuable to end
this chapter by examining a well-known case of a place that
improved health status considerably, even at relatively low
levels of income. One of the best known of such success stories concerns Kerala State in India.
Introduction
Kerala is a coastal state in Southwestern India with a population of more than 31 million people.42 Despite having
only slow rates of economic growth and a state per capita
income lower than that of many other states in India, the
health indicators for Kerala are the best in India and rival
those in developed countries. What approach did Kerala take
historically to produce such high levels of health, even in the
face of relatively low income? What factors contributed to
improvements in health status? What lessons does the Kerala
experience suggest for other countries and for other states
within India?
The Kerala Approach
One of the primary reasons why people in Kerala have such
high levels of health has been the emphasis that the state put
on education and the exceptionally widespread access to
education in Kerala. The state introduced free primary and
secondary education in the early part of 20th century.43 In
addition, Kerala has always put important emphasis on the
education of females.
Kerala also made an early commitment to widespread
health services for its people. The state created, for example,
an extensive network of primary healthcare centers. This
provided its citizens, throughout the state, with access to free
basic health care and free family planning services. This was
coupled with programs to promote exclusive breastfeeding
97515_ch02_5944.indd 42
and the improved nutrition of infants, children, and pregnant women. The central government supported the family
planning program, the maternal and child health program,
and the universal immunization program in all of India, but
they were implemented far more effectively and efficiently in
Kerala than in other states of India.44
The place of women in Kerala society also contributed
to the uptake of education by females and improvements
throughout Kerala in nutrition and health status. The role of
women in many communities in Kerala differs from the roles
ascribed to women in many other parts of India. In much of
the rest of India, especially in parts of North India, women are
regarded by families as liabilities rather than as assets. In most
of India, this is partly represented in cultural terms by the fact
that the family of a bride must pay a dowry to the family of the
groom. In Kerala, however, women have been treated differently for over a century. They have been seen culturally much
more as assets to families and they could inherit and own
land, giving them a financial independence and power which
was unrivalled among women elsewhere in India.45
It is also important to note that Kerala has historically
been run by a government that has traditionally placed a
premium on community mobilization on important social
issues, such as education, greater empowerment of women,
health, nutrition, and land reform. Many of these efforts
were carried out in ways that raised social awareness about
health and nutrition. In 1989, Kerala launched a total literacy
campaign, for example, and by the start of the World Literacy
Year in 1990, Ernakulam district in Kerala was declared
India’s first totally literate district.46
Given widespread education in Kerala and the place
of women in society, it is not surprising that Kerala went
through the demographic transition quite early and well
before other places in India. Women with more education
are more likely to work and marry later and thus have wider
choice in economic and social pursuits. They also have a better knowledge of and easier access to family planning methods and lower fertility than do women with less education.47
The Impact
What were the impacts on health status of the emphasis
that Kerala placed on education, health, nutrition, and the
empowerment of women? Although it is not possible to
scientifically indicate which policy contributed what share
of better health, we can say that for many years the people
of Kerala have enjoyed the best educational attainment of
any group within India. In the 2001 census, the literacy rates
of people aged 7 years and above for India were about 65%
on average, with about 76% for males and 54% for females.
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Main Messages
Kerala, however, had the highest literacy rate in the country,
with about 91% overall and about 94% for males and 88%
for females.49 Kerala also boasts one of the highest newspaper readerships in the world, another feature that promotes
the value of women, education, nutrition, and health. It also
helps to raise political awareness and the demands of people
for participation in and solutions to their concerns, su...
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