what was common to industrialization everywhere, and in what ways did it vary from place to place?
Am J Lifestyle Med. Author manuscript; bachelor in PMC 2010 Jul 1.
Published in final edited form as:
PMCID: PMC2805833
NIHMSID: NIHMS134943
The Epidemiologic Transition: Irresolute Patterns of Mortality and Population Dynamics
Robert E. McKeown
Section of Epidemiology and Biostatistics, Arnold Schoolhouse of Public Wellness, Director, Wellness Sciences Research Cadre, University of South Carolina, Columbia, SC 29208, ude.cs.xobliam@nwoekcmr, Phone: 803-777-7353
Abstract
The epidemiologic transition describes changing patterns of population age distributions, mortality, fertility, life expectancy, and causes of expiry. A number of critiques of the theory have revealed limitations, including an insufficient business relationship of the office of poverty in determining disease risk and bloodshed, a failure to distinguish adequately the take a chance of dying from a given cause or set of causes from the relative contributions of diverse causes of death to overall bloodshed, and oversimplification of the transition patterns, which do not fit neatly into either historical periods or geographic locations. Recent developments in epidemiologic methods reveal other limitations. A life form perspective prompts examination of changes in causal pathways beyond the life bridge when considering shifts in the historic period distribution of a population equally described by the epidemiologic transition theory. The ecological model assumes multiple levels of determinants acting in complex and interrelated ways, with higher level determinants exhibiting emergent properties. Development, testing, and implementation of innovative approaches to reduce the risks associated with the sedentary lifestyle and hyper nutrition in adult countries should non overshadow the continuing threat from infectious diseases, especially resistant strains or newly encountered agents. Interventions must fit populations and the threats to wellness they feel, while anticipating changes that will emerge with success in some areas. This will crave new ways of thinking that become beyond the epidemiologic transition theory.
Keywords: epidemiologic transition, epidemiologic methods, bloodshed rates, life expectancy, causal models
Introduction
The epidemiologic transition describes changing patterns of population distributions in relation to changing patterns of mortality, fertility, life expectancy, and leading causes of decease. The perspective has its origins in census, just finds a compatible conceptual home in public health and epidemiology in particular. This newspaper is intended to provide a general overview of the concept, with historical and recent data from the United States and other countries to illustrate cardinal ideas. The newspaper and so proposes a few reasons to consider as revisions to the theory, and finally suggests some implications for epidemiologic methods and public health interventions.
The very term "epidemiologic transition" raises the question of transition from what to what? There are two major components of the transition: (1) changes in population growth trajectories and limerick, specially in the historic period distribution from younger to older, and (2) changes in patterns of bloodshed, including increasing life expectancy and reordering of the relative importance of different causes of death.
Though the ideas where non original to him, A. R. Omran is typically credited with formulating the theory of the epidemiologic transition in the course that came to be oft cited. In his 1971 articleone he wrote: "Conceptually, the theory of epidemiologic transition focuses on the complex modify in patterns of health and disease and on the interactions between these patterns and their demographic, economical and sociologic determinants and consequences." Since the 1971 publication the theory has been adopted and adapted, revised and criticized, demonstrating both its influence and limitations. The perspective taken in this paper is that the theory is most relevant as a mode of looking at and understanding the relation amidst affliction, mortality patterns, and population dynamics rather than as a definitive explanation or prediction.
The original formulation: Omran's Five Propositions
The first proposition
Omran's formulation of the theory consisted of five propositions. Suggestion 1 was: "The theory of epidemiologic transition begins with the major premise that mortality is a key factor in population dynamics. 1" At first glance this seems self-evident and of little heuristic value; withal, this proffer is grounded in the insight that declining bloodshed is typically followed by declining fertility, and information technology is the combination of lower birth rates also as lower death rates and higher life expectancy that produce the altered population age distribution. If nascency rates remained stable, the process of alter in the shape of the population distribution would follow a different pattern.
The second proffer
The second proposition was: "During the transition, a long-term shift occurs in bloodshed and disease patterns whereby pandemics of infection are gradually displaced by degenerative and human being-made [sic] diseases as the chief form of morbidity and primary cause of death. one" Because this suggestion is actually at the eye of the theory and includes changes in patterns of mortality and morbidity also as in the age distribution, it is more complex and requires more than extended elaboration.
The first transition
Omran posits three typical phases of transition. The kickoff transition phase, called the "Historic period of Pestilence and Famine", is characterized by loftier and fluctuating mortality rates, variable life expectancy with low average life bridge, and periods of population growth that are not sustained. Armelagos et al., 2 advise that the earliest transition dates to pre-history (Neolithic menstruum, approximately x,000 years ago) across geographically widely separated cultures. According to their reading of the evidence, the transitions were a result of the transformation from hunter-gatherer societies to agrestal societies, with more settled life required in order to tend cultivated crops and domesticated animals. The modify in patterns of livelihood and living conditions also meant changes in population size and density and daily life in closer proximity to animals. The reduction in homo and fauna migration created a new kind of ecological imbalance. In that location was an increment in infectious diseases as a result of exposure to human and animal waste and contaminated water and the reciprocal manual of organisms between homo and beast hosts. The disease patterns that emerged were determined past increasing microbial exposures, dietary deficiencies considering the food supply, though perchance more reliable in adept years, was less diverse, illnesses due to inadequate food storage, increased transmission rates and endemic illness equally a result of increased population density, eventual evolution of global merchandise with a concomitant increase in potential for disease spread over wide geographic regions, and increased bloodshed which, in keeping with the epidemiologic transition model, would atomic number 82 to increased birth rate.
The 2d transition
The 2nd transition phase is characterized as the "Age of Receding Pandemics", and is marked by declining bloodshed rates that become steeper as epidemics occur less frequently, an increase in boilerplate life expectancy from about 30 years to about 50 years of age, and more sustained population growth that somewhen becomes exponential. This transition occurs in the early on modernistic period and is characterized by a shift in patterns of disease and mortality from primarily infectious diseases to what take come up to be called "chronic" diseases. The theory proposes that this shift is accompanied by a shift in the population age distribution as early infectious disease deaths decline and deaths from chronic and degenerative disease increase, the latter a result not only of the receding competing run a risk from infectious diseases, simply also of the new environmental hazards that came with industrial development and increasing urban living.
Explanations for these changes are multi-faceted and complex and include changes in the relationships in the classic matrix of amanuensis, host, and environment; socioeconomic, political, and cultural changes; improved living conditions and standard of living, including the contributions of the sanitary motility to h2o and sanitary services, improved nutrition, better personal hygiene, and less overcrowding; medical and public health advances and interventions; better understanding of infectious diseases with acceptance of the germ theory and adoption of antiseptics and pasteurization; lower fertility and longer nascency intervals with better infant and kid survival; and increasing lifespan resulting in an older population.
The third transition
The third transition phase is termed the "Historic period of Degenerative and Man-Made [sic] Diseases". In this phase it is theorized that infectious disease pandemics are replaced equally major causes of decease by degenerative diseases, and infectious agents as the major contributor to morbidity and mortality are overtaken by anthropogenic causes. With declines in mortality rates, boilerplate life expectancy increases to > 50 years, fertility becomes more important to population growth, and the anthropogenic and biologic determinants of disease also change. This transition is typically associated with the tardily 19th and 20th centuries in developed countries. Figure 1 depicts average life expectancy at birth in the United States from 1900 to 2004, overall and past sex. Note life expectancy increases from less than fifty years of age at the beginning of the 20thursday century to over 75 years at the beginning of the 21st century. Notation also the abrupt, but transient drib in life expectancy as a outcome of the flu pandemic of 1918. This illustrates the impact that a pandemic can have on life expectancy and population distribution. Figure 2 presents survival curves for the US population for the years 1900–02 (death registration states just), 1949–51, and 2004. Notation the dramatic increase in median survival time, indicated by the horizontal dotted line. Notation also the sharp drib at the beginning of the 1900–02 curve, indicating very loftier babe bloodshed.
US Life Expectancy at Birth Overall and by Sex, 1900 – 2004
Data from National Center for Wellness Statistics
Usa Population Survival Curves, 1900–02, 1949–51, 2004
Note: Median line represents one-half of the population has died and one-half remain alive, and so betoken at which median line crosses each survival curve is the median survival time for that cohort. Data for 1900–02 from death registration states only. Data from National Center for Health Statistics.
The third proposition
Proposition three states that "During the epidemiologic transition the almost profound changes in health and illness patterns obtain among children and young women."i This phenomenon is largely a consequence of failing baby and maternal bloodshed and a consistent drib in fertility. Note in Figure i that the deviation in life expectancy between women and men is greater in the terminal half of the 20thursday century than in the first one-half, no dubiety reflecting reduced rates of perinatal maternal mortality. Similarly, Figure 3 shows population pyramids for the United states of america in 1900, 1950, and 2000. The reduction in fertility over time is clear, every bit is the increasing proportion of older people in the population. Note the touch of the low on births evident in the 1950 diagram as well equally the leading edge of the post-war "baby boom". The baby boom bulge is evident in the 2000 diagram.
US Population Distribution by Historic period and Sexual practice, 1900, 1950, 2000
Data from National Middle for Health Statistics
The fourth proposition
The fourth proffer holds that "The shifts in health and illness patterns that characterize the epidemiologic transition are closely associated with the demographic and socioeconomic transitions that constitute the modernization complex. 1" This proposition in some ways bridges the other propositions in that, consistent with the third, it is characterized by lower fertility and longer birth intervals, and in keeping with the 2nd and fifth information technology is posited that improved socioeconomic status leads to better nutrition and sanitation, which in turn ameliorate health and reduce morbidity and mortality.
The 5th proffer
The final suggestion outlines iii basic models of the epidemiologic transition that are a role of "peculiar variations in the pattern, the step, the determinants and the consequences of population change. i" These three models are "the classical or western model, the accelerated model and the contemporary or delayed model." They roughly correspond respectively to (1) the experience of developed countries that evidence tiresome declines in death rates followed by lower fertility that accompanies modernization; (2) the experience of countries, such as Nippon, where the grade of the transition was much more rapid and the amount of time required to reach the milestone mortality rate of 10 deaths per 1000 population is much shorter; and (3) the experience of developing countries where there have been more recent declines in mortality, but non in fertility rates considering babe and maternal mortality rates notwithstanding remain high.
Transitions in epidemiology and public health
Information technology is instructive to consider historical transitions in epidemiology and public health that in some ways mirror the transitions described above. The modern public health movement had its origins in the Sanitary Movement of the 18th and early 19th centuries, with its focus on customs characteristics, economical conditions, and environmental influences. Improvement of living weather was seen as a means of improving health. This determinative period in the history of public health continues to exist relevant, reflecting a rudimentary version of the current understanding of the determinants of wellness as multifactorial and contextual. 3
By the end of the 19th century, the germ theory of disease had matured and largely displaced the miasma theory on the ground of scientific advances in bacteriology, chemistry, and medicine as well as epidemiology. The recognition of infectious diseases equally major contributors to morbidity and mortality, the rapid evolution of new knowledge and tools, and the effectiveness of public wellness efforts in reducing the incidence of and bloodshed from some infectious diseases led to increasing dominance of this theory, which dramatically shaped public health programs and practice, and contributed to steep declines in bloodshed from infectious diseases in the U.S. and other developed countries. The other side of this evolution was that public health came to be viewed largely through the lens of communicable diseases prevention and control.
Consistent with the transition theory, by mid-20th century, public wellness attention shifted to chronic disease prevention and control, with emphasis on adventure factor epidemiology and interventions directed toward individual behavior and lifestyle. The earlier dominance of germ theory and microbiology may have narrowed the view of the mission of public health, putting the population focus and developing quantitative approaches in competition with the microscope, but new developments in understanding genetic and cellular processes (a potential new "germ theory") take been accompanied by renewed interest in both psychosocial characteristics and broader contextual and ecology influences. This broader perspective on the determinants of wellness and disease encompasses but goes beyond traditional take chances factor epidemiology. It includes explicit attention to the complication of systems and the challenges of integrating multiple levels from the genetic to the personal to social, political, and economic contexts across the life span.
This methodological transition has been particularly evident in the remarkable evolution of epidemiology as a bailiwick since World State of war Ii.4 These changes have resulted from developments on several interrelated fronts both within and outside the field. Theories of health and affliction accept received greater attention, with broader concepts of wellness equally encompassing more than than the absence of illness. A renewed focus on population health, as well as development of more complex causal models reflecting new discoveries focused greater attention on more thoughtful considerations of causal inference and caption of causal associations, not simply identification of run a risk factors. The continuing threat from infectious diseases and increasing attention to health disparities have challenged traditional adventure factor approaches. Some of the more recent discoveries in communicable diseases have arisen from an approach and conceptual framework and methodology rather distinct from that of the golden age of late 19th and early 20th century microbiology. Awareness of the importance of a life span perspective has also been accompanied by increased attention to etiologic investigations of degenerative diseases of aging formerly thought to exist unavoidable. Alongside explorations of genetic causes has been renewed interest in inquiry on environmental factors, both as external causal agents and as potential modifiers of genetic causes, with the goal of understanding processes in guild to develop more effective preventive interventions. While retaining intervention and prevention as goals, epidemiologists now seek to incorporate systems perspectives within an ecological model with its multi-leveled approach and life span considerations.
In sum, the eco-epidemiologic5 , vi approach is characterized past a life course perspective, recognition of multiple, interrelated levels of causation, and an emphasis on models that are more integrated rather than fragmented.vii The implications for our inquiry methods parallel those 3 components. First, the life course perspective requires us to think in terms of changes in causal pathways across the life span when considering shifts in the age distribution of a population every bit described by the epidemiologic transition theory. Second, the causal models on which nosotros rely must allow for multiple levels of determinants acting in circuitous and interrelated ways, oft synergistically or with feed-back loops or reciprocal lines of causality. Farther, we accept to consider that college level or "upstream" determinants may have emergent properties that are more than the aggregate of their elective parts, so that nosotros must consider them along with the lower level elements in our models and analysis. Finally, when considering the multiple levels of the ecological model, we rely on the understanding that affliction occurs in individuals, but interventions can occur at any level, including communities.
The 2002 Institute of Medicine follow-up report8 emphasized the "public" attribute of public wellness, that is, "healthy people in healthy communities." This in some ways is a recapitulation of the Sanitary Movement's emphasis on living conditions, but goes across that earlier perspective. There has been a rich discussion in the public wellness literature on the definition and nature of healthy communities. For purposes of this paper, the disquisitional development is that public health professionals increasingly recognize an organic notion of community, emphasizing that private health is accomplished or threatened past larger scale contextual factors, including social networks, environs, education, economical opportunity, and other characteristics of communities, many of which prove emergent properties every bit described above.eight
This emerging perspective sees the whole range of determinants as integral to personal and community health and well-beingness.3 , 5 – 6 The mod ecological model of public wellness exercise stresses the multiple dimensions that constitute our lives, relationships and environments, and, therefore, contribute to health and health or disease and disability.viii Further, the threat of emerging infectious diseases continues to have global significance in an era of resurgent multidrug resistant tuberculosis, pandemic AIDS, and widespread distribution of vector borne diseases. These demonstrate that the transitions cannot be neatly categorized into either historical periods or geographic locations. The multilevel view of the ecological model also reminds usa that the various and shifting foci observed in the historical stages of public wellness must be incorporated into a more encompassing view with more circuitous models, systems, and processes rather than the simple identification of isolated risk factors.
Critiques of the theory
The epidemiologic transition theory appears to have some confirmation in recent trends that were characterized by increased life expectancy and a shift in the population age distribution to older ages equally well every bit the concomitant increment in the numbers of people living with chronic degenerative disease. These changes have profound bear upon on public health planning, health intendance resources and workforce development, and a range of social, political, and financial policies. While such changes consistent with the theory accept been evident, the theory has not been without its critics and a number of issues remain controversial. Caldwell writes that the original theory "fails to grasp the global nature and historical sequence of the mortality transition equally it spread.nine" Criticisms of the original theory reverberate continuing development in theories of health and disease, disagreement well-nigh the role of advances in medicine relative to public health interventions, and debate about the relative importance of diverse contributors to the unquestioned changes in mortality and disease patterns, peculiarly with regard to diet, poverty, and income inequalities.
One of the arguments made today is that the emergence of cities and organized societies that triggered the get-go transition came with social stratification that is a precursor of the disparities in social position and wealth observed in later stages and prominent however. 2 The argument is that wealth and poverty and their relative distribution play cardinal roles in health and well being in each stage. Pearson 10 has argued that the roles of income and education in the most recent stage are paradoxical in that, compared to those who are poor and less educated, wealthier and more educated persons tended to be earlier adopters of lifestyles that contributed to the increased risk of those diseases that now constitute the major causes of death, but they were also earlier adopters of treatments and lifestyle changes that later on reduce the chance of morbidity and mortality. The result, according to Pearson is that poor and poorly educated populations may experience later peaks in the incidence of the diseases that define the 3rd transition phase, just also continue to endure from elevated rates of those chronic diseases after rates accept begun to decline among those better off. Pearson argues that this requires simultaneously working for economic development and improved education to reduce perinatal, infectious, and nutrition-related diseases while implementing proven strategies to discourage adoption of those detrimental behaviors and exposures associated with chronic diseases in more than prosperous segments of the population. Note that these differences are nearly evident in comparisons of developed and underdeveloped countries, simply also concord for different segments of the population within the same land.
It tin can be argued that the publication of Omran's paper came at a time of naïve optimism concerning mortality patterns, causes of morbidity and mortality, and global progress in life expectancy. In 1969 testimony before congress the US Surgeon General said that it was "time to close the volume on infectious disease as a major wellness threat. ii" Though it might take been impossible at that point to foresee the global emergence of HIV/AIDS and other so-called emerging infectious diseases and the serious challenges of antibiotic resistance, ecological disruption with its consequences for health and environment (including contributing to emerging diseases) was taking place, and the devastating impact of infectious disease on the poor and those living in developing or under-developed countries was evident. More recently, and somewhat ironically, recognition of the continuing impact of infectious diseases and inadequate nutrition, coupled with ecological disruption, has come with an emphasis on the role of poverty in poorer outcomes and wider disparities. Armelagos et altwo., write: "While disease and death are inevitable, a major cause of unnecessary, premature, preventable affliction and expiry is unproblematic; it is extreme poverty."
Another criticism of the traditional theory is that it fails to distinguish adequately the run a risk of dying from any given cause or gear up of causes from the relative contributions of the various causes of death to overall bloodshed.xi To take an example comparing age groups in the Usa rather than historical periods or countries, accidents (unintentional injuries) are the leading cause of death amongst persons fifteen to 24 years quondam in the The states, bookkeeping for 46% of all deaths in that age group in 2004, while among those ages 65 to 74 they accounted for merely over two% of all deaths. All the same, the crusade-specific rate (as an approximate of the risk) of death from accidents in 2004 was 37.iv/100,000 in the younger group versus 46.3/100,000 in the older group. Every bit patterns of illness and bloodshed change, there are changes in the relative contribution of unlike causes to overall mortality that may not reflect changes in bodily risk. For instance, in this country rates of mortality of cardiovascular disease (CVD) have been declining, merely CVD remains the leading cause of death overall. If the risk of dying from i causes decreases, the relative proportions of other causes volition increment even if the actual risk remains the same. Actual risk for death from a specific cause could even pass up while the proportion of deaths attributed to that crusade goes upwards if risk of decease from other causes declines more rapidly. Heuveline et al accept shown the people in the poorest quintile suffer consistently college mortality in all three of the major categories of illness used by the Globe Health System than those in the richest quintile, and the most of the backlog bloodshed is primarily due to the higher gamble of communicable diseases.12 Both the relative contributions and the actual risk of death from the major crusade of expiry categories vary widely across countries, even between countries in the same region, as well equally across population groups within a country. Figure 4 shows the relative contributions of the three major crusade of death categories, though non the actual risk associated with each, for 9 countries to illustrate this point graphically. The bespeak is that the epidemiologic transition theory oversimplifies the patterns and relations among take a chance of mortality, bloodshed causes, and life expectancy. The patterns are clearly more complex than only declining mortality rates from infectious diseases and increasing rates of decease from the so-chosen chronic diseases and do not fit neatly into either historical periods or geographic locations.
Percent Years of Life Lost to Major Crusade of Expiry Groups for Selected Countries
Note: YLL=Years of life lost; Com Dz = Infectious disease; NonCom Dz=Noncommunicable diseases; CHN=Cathay; VNM=Viet Nam; EGY=Egypt; KEN=Kenya; CUB=Republic of cuba; COL=Colombia; NIC=Nicaragua; HTI=Haiti; USA=United States. Data from Globe Health Organization
A further complexity now being recognized is that the distinction betwixt infectious and chronic disease is non clearly demarcated. Not merely is information technology the case that some infectious diseases have chronic disease characteristics, just we take come to recognize the importance of infectious agents and related inflammatory processes in the etiology of a number of chronic diseases and adverse outcomes, such as cervical cancer (HPV), gastroduodenal ulcer (H Pylori), and cardiovascular disease (inflammation), and at that place is more research now on links to outcomes equally divergent every bit diabetes, preterm delivery, and some mental illnesses. The other side of that circuitous moving picture is that many of the characteristics and behaviors we have establish to be protective for chronic illness may besides provide some protection against infectious illness or reduce the severity of sequelae.
Implications for epidemiologic methods and determination
The theory of epidemiologic transition has been useful in laying out an overarching perspective on changing demographic patterns. The various criticisms of the theory suggest it is most relevant as a way of looking at and understanding the relation amidst disease, mortality patterns, and population rather than as a definitive explanation or prediction. Amidst the major critiques of the theory is that the overemphasis on mortality rather than disease causality and morbidity misses critical pieces of circuitous phenomena. The focus on mortality and life expectancy gives insufficient attention to disability and quality of life. Further, our understanding of and approach to causal inference have matured in the nearly four decades since Omran's original article appeared. The importance of the ecological model and what has been called eco-epidemiology have enriched our thinking and our methods and enhanced our understanding of differential patterns of morbidity and mortality within and across populations and different segments of populations.
Though it is truthful that the brunt from infectious diseases has been surpassed in many countries by the burden from chronic disease and mental disorder, it is withal the case in many countries and in many populations within countries that morbidity and bloodshed from infectious disease, poor nutrition, and perinatal complications boss, with poverty being the most evident shared feature. We cannot assume that the prove of the epidemiologic transition means we can redirect our attention and resources away from those determinants of death and disease that nonetheless threaten the lives and well being of a big portion of the world's population. But we must also recognize that those aforementioned populations will be victims of the obesity, CVD, hypertension, and diabetes epidemics that now characterize the US. Even as we continue to develop, test, and implement innovative approaches to reduce the risks associated with the sedentary lifestyle and hyper nutrition in developed countries, nosotros must besides recognize the standing threat from infectious diseases, especially resistant strains or agents that are newly encountered. The relative protection we have enjoyed from many infectious diseases is no longer a foregone decision. At the same time we need to address multiple fronts in developing countries: historical threats from infectious agents, malnutrition, and perinatal complications, likewise every bit emerging threats of the aforementioned sort nosotros at present meet from resistant strains of infectious agents and contact with new agents, and the looming emergence and increasing importance of the chronic and degenerative diseases that are likely to follow successful programs to increase education and reduce poverty. 1 of the lessons of the epidemiologic transition is that interventions must fit the population and the threats to health information technology currently experiences, while we anticipate the changes that success in one area are probable to bring out and the new challenges that volition emerge. This will require new means of thinking that become beyond the epidemiologic transition theory.
Acknowledgements
Based on paper originally presented at Arizona Country University, Mesa, AZ on February 28–29, 2008.
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