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Lifestyle Diseases Amid a Post-demographic and Epidemiologic Transition

September 30, 2011

Leading newspapers, such as the Financial Times, Washington Post, and the New York Times have been covering the UN High-Level Meeting on NCDs by labeling this new burden of health conditions and their amelioration as ‘lifestyle diseases”. In this context, the transition from parasitic and infectious diseases to such chronic conditions as cancer, cardiovascular diseases, diabetes and upper respiratory diseases can be laid at the feet of high salt intake, alcohol consumption, smoking, and diets suffused with trans-fats—the byproducts of ‘lifestyles’ choices … diseases of the rich world.

On October 31, planet earth will gain its seven billionth inhabitant, with a world average life expectancy of 70 years of age; in 1979, world population was slightly more than 4 billion with life expectancy at 59. Since salt, alcohol tobacco use, and trans-fats were in use in 1750, when the world population was 791 million, a time marking the advent of the Industrial Revolution, which ushered dramatic improvements in lower fertility, smaller family size, lower crude death rates, reduced infant mortality and higher life expectancy, and greater individual prosperity, it can reasonably be asked: why didn’t the presence of these ‘lifestyle’ conditions thwart this massive increase in the world’s population? And if it didn’t, can the effects of that Revolution be reversed by a Political Declaration of the UN which stipulates that reductions in NCDs can be accomplished through ‘lifestyle’ changes which reduce their use and return the world to …what?  And, since ‘lifestyle diseases’ imply the freedom of choice, and behavior modification moves at a snail’s pace, what effect can prevention have on the “388 million who will die in the next ten years from a chronic disease.”

Although the Industrial Revolution began in Europe, in time it affected the entire world. Nearly 90% of children in developing countries survive to be adults, even in some of the poorest countries in Sub-Saharan Africa. The four chronic diseases targeted by the UN High-Level Meeting (cancer, CVDs, diabetes, and upper respiratory diseases) are the inevitable consequence of populations having passed through the demographic and into the epidemiological transition. These phenomena can be traced to the beginning of the Industrial Revolution. It proceeded at a greater pace in developing countries since the 1960s as health development aid was largely targeted on reductions in infant and maternal mortality, and the outcome of family planning programs that lowered fertility. When more and more children survived through such effective and low cost interventions as immunizations, they became the new cohorts for chronic conditions. In 1996, a collaborative study by WHO, the World Bank, and Harvard School of Public Health found that “adults under the age of 70 in Sub-Saharan Africa today face a higher probability of death from a noncommunicable disease than adults of the same age in the Established Market Economies.”

We are now in a period of history when adult ill-health is far more costly than non-adult ill health. And the former has economic consequences that are greater than their health consequences. Developing countries aren’t hemorrhaging in their national health budgets from an ever decreasing burden of infectious and parasitic diseases. But, the rapt attention drawn to them by donor agencies over 50 years has diverted these countries from the unfunded macroeconomic liabilities set in train by the sequential increase in the number of chronically sick people in their working age populations. The central policy issue faced by low and middle-income countries lies not in the realm of a continued focus on communicable diseases. Rather, by failing to assign a proper value to the consequences of post-demographic and epidemiological changes, policy-makers drastically underestimate the societal costs involved in sustaining a competitive economy in the 21st Century by addressing chronic diseases within a macroeconomic context.

From the time of antiquity to 1750, the world’s population amounted to only 791 million, in the absence of tobacco use, with the possible exception of the some tribes in the Americas, but with fatty meats as a dietary stable, salted whenever possible—and when not, death often followed, and washed down with relatively course forms of alcoholic libations.  The consumption of these items can be seen as largely baking in the DNA base for humanity’s entrance into the Industrial Revolution.

Proponents addressing NCDs through ‘lifestyle” changes believe they can close the barn door on this galloping horse of demographic and epidemiological  history. True, smoking cessation can greatly reduce lung and esophageal cancers, and curbing salt intake can influence lower blood pressure readings.  Still, the avoidance of one form of mortality from a chronic disease merely postpones it, leading in time to another. It is a grim fact that somewhere along life’s uncertain path, death’s arrow will unerringly find us all. The only questions are: where, when, and at what cost to family and society.

Ignoring the relentless reality of the post-demographic and epidemiological transition, particularly its effects on aging, guarantees that the global health community’s approach to NCDs via “lifestyle changes” will be one that is owned by donors. If there is no support from them for the treatment of 388 million that will die in the next ten years—effective measures of prevention notwithstanding, then neither will there be any political and fiscal support by the affected countries themselves for “lifestyle” changes—unless donors assume their costs.

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