The Health of Adults in the Developing World
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- Title
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The Health of Adults
in the Developing World - extracted text
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Margaret A. Phillips
CPHE
The Health of Adults
in the Developing World
A Summary
Editors
Richard G. A. Feachem
Tord Kjellstrom
Christopher J. L. Murray
Mead Over
Margaret A. Phillips
The World Bank
Washington, D.C.
© 1993 The International Bank for Reconstruction
and Development I THE WORLD BANK
1818 H Street, N.W.
Washington, D.C. 20433, U.S.A.
This booklet is a summary of a book published by Oxford University Press
for the World Bank.
All rights reserved
Manufactured in the United States of America
First printing September 1993
The findings, interpretations, and conclusions expressed in this study are
entirely those of the authors and should not be attributed in any manner to
the World Bank, to its affiliated organizations, or to members of its Board
of Executive Directors or the countries they represent.
Cover design by Hal Baskin and Karin Shipman.
Library of Congress Cataloging-in-Publication Data
The health of adults in the developing world : a summary / edited by
Richard G. A. Feachem ... [et al.].
p. cm.
ISBN 0-8213-2591-4
1. Public health—Developing countries. I. Feachem, Richard G.,
1947- .
11. International Bank for Reconstruction and
Development.
[DNLM: 1. Health Status. 2. Developing Countries. 3. Public
Health.
WA395 H43431 1993]
RA441.5.H4542
1993
613’.O434’O91724—dc20
DNLM/DLC
for Library of Congress
93-29946
CIP
A Note to the Reader
This booklet is the third in a series summarizing the main points of full-length
World Bank books. The Health of Adults in the Developing World focuses on the
fact that half or more of health sector resources in developing countries are
consumed by the age group that supports society. The book makes recommen
dations centered around the proposition that governments are financing too
much inefficient and inequitable adult health care. If such expenditure were
reduced,resources would be freed for cost-effective care, especially nowneglected preventive intervention.
Hi
Concents
A Note to the Reader
iii
The Scope
2
The Age Focus 2
The Disease and Mortality Focus
3
The Need
4
The Adult Health Policy Vacuum
The Importance of Adult Health
4
6
The Changing Picture of Adult Health—The Health Transition
I0
The Emerging Agenda for Adult Health
13
The Findings
14
An Agendafor Improving the Information Available
for Decisionmaking
Researching the Levels and Causes of Adult Ill Health
Exploring the Consequences of Adult 111 Health
19
Identifying the Determinants of Adult 111 Health
20
An Agenda for Action
Principles and Provisos
17
18
21
21
Specifics for Action
23
Questions for Intervention-Related Research
33
An Agenda for Policy
36
Contents of the Book
iv
The Health of Adults
in the Developing World
Demographic trends in developing countries have increased the absolute and
relative importance of adults and their health problems without a correspond
ing response from policymakers. As a result of substantial reductions in child
mortality during the last two to three decades, nearly 90 percent of children in
developing countries survive to be adults, even in some of the poorest countries
of Sub-Saharan Africa as a result of substantial reductions in child mortality
during the last decade. Too many of these adults still die relatively young. In
Africa, 38 percent of fifteen year olds do not survive to see their sixtieth
birthdays. Among the survivors, many suffer from chronic impairments, fre
quent illnesses, and injuries. The ill health of adults imposes a major burden on
health services as well as large, negative consequences on families, communi
ties, and societies. The book summarized here seeks to place adult health firmly
on the agenda of health policymakers and researchers, and to stimulate discus
sion, research, and action.
Sick adults consume more than half of health sector resources in developing
countries, yet the development of policy in both the curative and preventive
areas is rudimentary. A poor understanding of health needs and solutions leads
to poor allocation of resources. Throughout the developing world, tuberculosis,
cardiovascular diseases, cancers, and injuries are major causes of adult ill health.
Yet each is, in various ways and for different reasons, seriously neglected in
research and policy.
In the absence of improved understanding and policy in the area of adult
health, expenditure on the treatment of sick adults will continue to grow
rapidly, as it has in the developed world. Much of this expenditure may be
inappropriate in the sense that there may be alternative investments of more
benefit to public health. Such alternatives may lie in other forms of adult
treatment, in the prevention of adult disease, and in fostering the health of
children. Resources may also be more efficiently allocated by being better
targeted on particularly disadvantaged groups. The efficiency and equity of the
allocation of health sector resources are concerns that lie behind this booklet
and demand better understanding and improved policy formulation. Adult
2
THE HEALTH OF ADULTS IN THE DEVELOPING WORLD
health issues must be identified and analyzed if the runaway juggernaut of
expenditure is to be controlled and properly directed.
The Scope
Divergent views about what adult health means have slowed productive discus
sion about adult health and ill health. For some, adult health means control of
chronic disease; for others, it is mainly a concern of relatively wealthy countries;
for still others, the term implies a focus on urban elites rather than rural masses.
For some, the term suggests prevention, whereas for others it implies sophisti
cated curative technology in secondary or tertiary hospitals. In this booklet, the
concept of adult ill health includes all major health conditions, be they
communicable, noncommunicable, or injuries. It embraces the poor and the
wealthy, the urban and the rural, the employed and the unemployed, men and
women. It covers both diseases experienced by adults and childhood exposures
to risk factors for adult disease.
The Age Focus
This booklet defines adults as those aged fifteen through fifty-nine years, children
as those younger than fifteen years—either preschool (zero through four years)
or school-age (five through fourteen years), and the elderly as those aged sixty
years and older. These categories, like any others, are somewhat arbitrary, but
have several advantages. Adults, aged fifteen through fifty-nine years, include
nearly all those in society who are economically productive, biologically
reproductive, and responsible for the support of children and elderly depen
dents. Adults are not a homogeneous group, and some of the analyses in this
booklet distinguish younger (fifteen to thirty-nine years) from older (forty to
fifty-nine years) adults. Younger adults are more at risk from maternal ill health,
injuries, and alcohol and drug use. Older adults are more likely to suffer from
cardiovascular diseases and cancers.
The danger in using any set of age categories is that of forgetting that all
adults were once children, that most will become elderly, and that the concern
should be for the health of individuals throughout their lifetimes. Several
interventions to improve adult health target children. Such interventions
include hepatitis B immunization and education about sexual behavior, to
bacco use, and dietary habits. Just as experiences in childhood can affect adult
health, what happens during the adult years can have important repercussions
for the elderly.
The classic example is tobacco. There is considerable data to demonstrate
that although tobacco is an important cause of adult ill health, it is of even
Jll
greater importance for the elderly. Recommendations made in this booklet for
reducing tobacco use among adults have important implications for the elderly.
A separate but related intergenerational dimension of adult health is the effect
that adult ill health or death has on the health of younger and older family
members.
The age-based analysis in this booklet has the potential to generate a debate
about the equity of investment in adult versus child health. Such a debate is
unproductive because the policy decisions that need to be made are not a matter
of choosing between different groups of people—they are the same people at
different ages. Poor children, who suffer excessive morbidity and mortality rates,
become poor adults, who also suffer excessive morbidity and mortality rates.
Given that cost-effective interventions exist to improve adult health, it is
equitable to seek to preserve the health of disadvantaged adults who were once
disadvantaged children.
The Disease and Mortality Focus
Most adult mortality is due to fewer than ten major causes, and in some
countries half of all adult mortality is attributable to only three causes—cancers,
cardiovascular diseases, and injuries—widely thought to be afflictions of afflu
ence. A detailed understanding of what is known and not known about these
major causes of death is essential to formulating appropriate prevention and
case management policies.
However, focusing on diseases and injuries, and more specifically on mortal
ity from specific diseases and injuries, has limitations. It falls short of addressing
the World Health Organization’s concept of “positive health”—a state of
complete mental, physical, and social wellbeing. Such a focus underplays the
significance of diseases such as mental illness, osteoarthritis, guinea worm, and
onchocerciasis, whose morbidity and disability effects are disproportionately
high with respect to their mortality effects. A focus on mortality may misrep
resent the importance of several underlying causes of death, such as diabetes
and malnutrition. Outcomes not related to death, but which nonetheless
increase welfare, such as attentive health staff and comfortable health service
surroundings, also are minimized implicitly in importance. Furthermore, the
choice of disease groupings, which arc to some extent arbitrary, may influence
the conclusions about priority diseases.
Available data, however, present a vague and incomplete picture of morbid
ity and fail to provide any solid information on several important causes of adult
morbidity (for example, mental illness). Although mortality data misrepresent
the importance of several health conditions, the reality is that mortality
statistics represent the only continuous source of information on an unequivo
cal manifestation of health status.
4
THE HEALTH OF ADULTS IN THE DEVELOPING WORLD
The need to go beyond a disease-specific approach is most acute when
analyzing determinants and consequences and when making recommendations
for policy. Many diseases share common determinants and children become
orphans when their parents die from whatever cause. To overcome the danger
that a partial health picture, drawn from cause-specific mortality data, may
influence recommendations for priority action inappropriately, particular at
tention should be paid to determinants that are likely to have major effects on
morbidity and whose effects are broader than a single disease. The prime
example is tobacco use, which is a major risk factor for three groups of important
adult diseases—cancers, cardiovascular disease, and chronic obstructive lung
disease. This booklet identifies prevention of tobacco use as being, partly for
this reason, especially cost-effective.
The book summarized here does not emphasize health services issues such as
financing, training, decentralization, or the balance among primary, secondary,
and tertiary facilities. These substantial topics, which concern the whole
population and not just adults, have received considerable attention elsewhere.
In addition, many of the solutions to adult ill health lie outside traditional
health services. The book attempts only a superficial analysis of socioeconomic
determinants of adult ill health and the macroeconomic solutions they imply.
The Need
Developing countries and most international agencies, including the World
Bank, lack policies that explicitly address major health problems among adults,
except those associated with pregnancy or caused by tropical disease (for
example, malaria). Except for the World Health Organization, few agencies or
governments have, or are even thinking of, policies for reducing tobacco use
and traffic accidents, even though these issues may be as important for the
health of developing country populations as diarrhea or leprosy.
The Adult Health Policy Vacuum
Over the past thirty years, the focus of intellectual and research activity in
international public health has been in two distinct areas—tropical diseases
and the health of children. Tropical diseases are not a precisely defined group,
but they are all communicable and they are caused mostly by protozoan or
helminthic parasites with complex life cycles. Malaria, onchocerciasis, schisto
somiasis, and the trypanosomiases are examples of tropical diseases that have
received much attention. Some microbial infections, notably cholera and
leprosy, have also been studied. The more recent emphasis on children s health
in general, and on the communicable diseases of childhood in particular, has
led to major advances in the case management and prevention of diarrhea,
SUMMARY
5
measles, polio, and tetanus in childhood. Increasing efforts are now being
directed to the treatment and prevention of acute respiratory infections in
childhood, which are responsible for a substantial proportion of deaths in
childhood throughout the developing world. In the last few years, interest has
broadened to include risk factors for perinatal and maternal death, and maternal
health has become a major separate focus of concern.
The origins of the interest in tropical diseases and child health were quite
different. The focus on tropical diseases came from the association made in
colonial times between tropical medicine and the study and treatment of
parasitic diseases. The colonial powers found that the health of their expatriate
civil servants and their military personnel was threatened by a group of parasitic
diseases that were either of limited importance in Europe (for example, malaria)
or nonexistent (for example, African sleeping sickness). The private sector,
influential throughout the colonial period, found that these same diseases
threatened the health of their expatriate managers and their indigenous work
force. In addition, missionary doctors became involved with caring for people
with selected endemic diseases, especially leprosy. The discoveries in the late
nineteenth century of the basic biology and life cycles of the important para
sites of people living in the tropics created a tradition of equating tropical
medicine with a particular group of diseases, mainly parasitic, that continues
to this day.
The child health focus has a more analytic pedigree. In the 1950s and 1960s,
demographers showed the horrifying magnitude of death rates in childhood in
developing countries. At the same time epidemiologists showed that the
majority of these deaths were attributable to a short list of communicable
diseases superimposed upon a background of low birth weight, malnutrition,
and environmental squalor. This led to strategics for improving child health by
immunizing against selected diseases, reducing exposure to environmental and
behavioral risk factors, and promoting selected cost-effective approaches to
case management. More recently, better documentation of the magnitude and
nature of maternal illness and death has stimulated a parallel concern for the
health status of mothers. With the exception of malaria, the diseases principally
responsible for the high sickness and death rates of children and their mothers
are not those traditionally equated with tropical medicine.
Tropical diseases and children’s health have not only dominated thinking
in the academic and research community over the past thirty years, they also
have influenced the strategies of development agencies and developing-coun
try governments profoundly. Development agencies, particularly bilateral and
nongovernmental agencies, have concentrated their efforts on tropical diseases,
children’s health, and maternal health. Developing-country governments have
tended to target these same areas through special programs in the context of
the overall development of health services. This strong focus has been both
6
THE HEALTH OF ADULTS IN THE DEVELOPING WORLD
appropriate and effective. As a result, the incidence of some tropical diseases
and the rates of child death in developing countries have been reduced greatly.
However, a large and obvious gap in knowledge remains. Adult health
problems not caused by tropical diseases have not been addressed. They include
the following:
• Cancers
• Cardiovascular diseases
• Chronic obstructive lung disease
• Diabetes
• Injuries
• Sexually transmitted diseases (including AIDS)
• Tuberculosis
For some of these conditions, especially tuberculosis, the epidemiology is well
known, and agencies have had considerable experience in case management
and prevention. For others, such as injuries, little is known about their levels,
causes, distribution, and determinants among adults, and many developing
countries have yet to initiate specific preventive measures. This policy vacuum
within governments and agencies has serious consequences that are discussed
in the following paragraphs.
The Importance of Adult Health
Adults comprise more than half of the population of the developing world,
numbering about 2.05 billion in 1985 or 56 percent of the population (table 1),
and this adult population is growing (figure 1). Even in Sub-Saharan Africa,
the region with the lowest proportion, 49 percent of the population is adult.
The majority of adults live in Asia and the Pacific (1.41 billion). China alone
has more adults than the three non-Asian regions combined, and India has
twice as many as any non-Asian region (figure 2).
Adult death rares in developing countries are higher than generally recog
nized. Boys who reach fifteen years of age in developing countries have about
a 25 percent chance of dying before age sixty, and in some countries this risk is
over 50 percent, compared with the average in industrial countries of about
12 percent. More than 10 million adults die in developing countries each year.
This mortality and the morbidity that inevitably accompanies it place consid
erable demands on health services: adults are major consumers of health sector
resources.
Health risks that adults take may have adverse effects on the health of other
age groups. This can happen directly, as in the effects of maternal smoking on
the fetus, or indirectly as a result of the important role adults play in their
SUMMARY
7
Table 1. Population by Broad Age Groups, World and Major Regions, 1970-2015
Region and year
Percent of population
aged (years)
0-14
15-59
60+
World
1970
1985
2000
2015
37.5
33.7
31.2
27.5
54.2
57.5
59.2
61.3
8.3
8.8
9.6
11.2
1004
1414
1866
2350
1000
1371
1805
2280
2004
2784
3672
4630
Industrialized Countries
1970
1985
2000
2015
26.6
22.1
19.9
18.7
59.2
61.9
61.7
59.8
14.2
16.0
18.4
21.4
299
364
392
398
322
366
388
391
621
730
780
789
41.8
37.5
34.1
29.3
a
Industrial Market Economies
52.2
56.0
58.6
61.7
6.0
6.5
7.4
9.1
704
1050
1476
1953
679
1005
1415
1887
1383
2054
2891
3840
26.0
20.7
18.6
17.4
59.0
62.0
62.4
59.4
15.0
17.3
19.0
23.2
196
236
255
251
205
235
250
245
401
471
505
496
Industrial Nonmarket Economies3
1970
27.7
1985
24.5
2000
22.4
2015
21.0
59.6
61.5
60.4
60.7
12.6
13.7
17.2
18.3
103
127
137
147
117
130
137
146
220
257
273
292
Latin America and the Caribbean
1970
42.5
1985
37.6
2000
31.9
2015
25.5
51.5
55.7
60.5
64.3
6.0
6.8
7.6
10.2
74
112
160
206
73
112
160
206
147
224
320
412
Sub-Saharan Africa
1970
1985
2000
2015
50.5
49.4
50.4
54.2
4.7
4.6
4.5
4.8
73
111
180
292
75
114
183
295
148
226
363
587
Developing Countries
1970
1985
2000
2015
1970
1985
2000
2015
44.8
46.0
45.1
41.0
Population aged 15-59
years (millions)
Men Women Total
(Table continues on the follounng page.)
8
THE HEALTH OF ADULTS IN THE DEVELOPING WORLD
Table 1 (continued)
Region and year
Percent of population
aged (years)
0-14
15-59
60+
Population aged 15-59
years (millions)
Men Women Total
Middle East and North Africa
1970
44.6
1985
42.7
2000
41.3
2015
35.4
49.6
52.1
53.4
58.5
5.7
5.2
5.3
6.1
63
101
158
241
61
95
148
229
124
196
306
471
Asia and the Pacific
1970
1985
2000
2015
40.9
35.0
30.6
25.1
52.8
58.0
61.1
64.1
6.2
7.0
8.4
10.8
492
727
980
1214
469
684
925
1158
961
1411
1905
2373
India
1970
1985
2000
2015
40.4
39.2
33.4
27.4
53.6
54.6
59.4
63.8
6.0
6.3
7.2
8.7
154
217
309
405
144
201
291
383
297
417
600
788
China, Hong Kong, and Taiwan
1970
39.7
1985
29.6
2000
26.4
21.6
2015
53.5
62.2
63.3
64.5
6.8
8.2
10.2
14.0
237
345
426
485
217
317
396
461
447
662
823
946
Other Asia and Pacific
1970
1985
2000
2015
50.5
55.1
59.7
64.0
5.5
5.8
6.9
8.8
109
165
244
24
108
167
237
314
217
332
481
638
44.0
39.0
33.4
27.2
a. Throughout this book, the developed countries (or industrialized countries) are divided
into those with market economies and those with nonmarket economics (the former communist
countries), as listed in appendix tables A-le and A-lf. No account is taken of recent political
and economic changes in central Europe, because the data analyzed predate these changes.
Source: Bulatao and others (1990).
families. Adults form the majority of the productive work force and the majority
of those on whom others depend. When adults become ill or die, dependents
may suffer from lack of care or from a deterioration in the family food supply or
income. The effect is likely to be greater in developing countries where the
dependency burden per capita is higher (0.78 dependents per adult) than in
developed countries (0.61 dependents per adult). Among developing countries,
the dependency burden is lowest in Asia, at 0.73, and highest in Sub-Saharan
SUMMARY
9
Figure 1. Growth in the Adult Population by World Region, 1970-2015
Source: Bulatao and others (1990)
Africa, at 1.02. Finally, ill health during the adult years is probably an important
determinant of subsequent ill health as adults age and become elderly.
Not only does adult ill health impose a substantial burden on society, but the
nature of this ill health differs in several important respects from childhood
illness. Adult ill health involves more noncommunicablc disease, more long
term morbidity and more disability, and is more strongly related to lifestyle risk
factors. Because of these differences, policymakers cannot reduce adult ill health
simply by expanding policies that have been effective in improving child health.
Some may worry that emphasizing adult health will shift attention away from
the health of children. They may point out that infectious diseases and
malnutrition in childhood still constitute unfinished business, that many of the
factors making it imperative to improve child health still exist. Some argue that
the elderly rather than children or adults arc the proper new concern of
developing countries; that the elderly arc at greater risk of ill health and often
arc less well served than adults by current health care systems; and that they
are, as a group, growing at a faster rate than the adult population.
All this is true, but would not be affected by the proposal that more attention
be devoted to adult health since such attention does not require that resources
10
THE HEALTH OF .ADULTS IN THE DEVELOPING WORLD
Figure 2. Distribution of Adult Population by Developing Regions, 1985
LAC: Latin America and the Caribbean
SSA: Sub-Saharan Africa
MENA: Middle East and North Africa
Source: Bulatao and others (1990).
should be shifted away from children or the elderly. The proposal is simply that
policymakers and researchers should examine what is known and not known
about adult health and decide whether current practices and allocation of
resources are appropriate for this large and growing segment of the population.
The Changing Picture of Adult Health—The Health Transition
Paradoxically, the shift in prominence toward diseases suffered by adults and
the elderly in developing countries is being accompanied by a fall in age-specific
death rates from some of these diseases—including noncommunicable diseases.
The picture is complex and the terminology used to explain it is not always
consistent. For these reasons, and because an understanding of the nature of
these changes in disease patterns is essential for designing effective adult health
policy, this booklet offers a new characterization and a new terminology for
these phenomena.
The phrase health transition is used here to refer to all those changes in the
levels and causes of illness and death that are occurring in developing countries
and have taken place to a large extent already in developed countries. The term
epidemiologic transition is sometimes used to describe this, but because it refers
also to the more limited phenomenon of shifts in the relative importance of
different diseases, it is not used in this booklet. The health transition is the net
result of the operation of three components, not all working in the same
direction: the demographic component, the risk factor component, and the
therapeutic component.
THE demographic component. The age structures of populations are chang
ing throughout the developing world. As a result of declining fertility and
mortality rates, populations are becoming older and the median age is rising.
The growth in the adult population in developing countries is more rapid than
the growth in the population as a whole. For example, between 1970 and 1985,
the adult population grew at an annual rate of 2.6 percent, whereas the total
population grew only at 2.2 percent. Although these growth rates are expected
to slow, adult growth rates will still be larger than for the whole of the
population over the next few decades. As a result, adults will continue to
increase as a proportion of the total population, reaching 62 percent by 2015,
and almost doubling in number between 1985 and 2015 (table 1). The adult
population will grow fastest in Sub-Saharan Africa, at an annual rate of
3.2 percent between 1985 and 2000, with the Middle East and North Africa
next (3.0 percent), followed by Latin America and the Caribbean (2.4 percent)
and Asia and the Pacific (2.0 percent). Between 1985 and 2015, the number
of adults will increase 160 percent in Sub-Saharan Africa, 140 percent in the
Middle East, 80 percent in Latin America, and 70 percent in Asia.
This aging of the population—the faster growth of the adult population
compared with that of children or of the population as a whole—results in adult
illness (notably from noncommunicable disease) and adult deaths becoming
relatively more common. In the absence of commensurate declines in morbidity
and mortality rates, the rapid increase in the number of adults leads to rapid
increases in the number of adults who become sick and who die.
THE RISK FACTOR COMPONENT. Changes in the prevalence of exposure to risk
factors, and in the magnitude of the risks, alter age-specific morbidity and
12
THE HEALTH OF ADULTS IN THE DEVELOPING WORLD
mortality rates. The risk factor component of the health transition influences
the demographic component through changes in age-specific mortality rates,
but is unaffected by the demographic component. It takes the form of changes
in exposure to the underlying causes of specific diseases in specific age groups,
such as those that accompany the development process—urbanization, indus
trialization, and changing lifestyles—as well as particular risk-averting inter
ventions, such as vaccination and environmental sanitation. Risk factor effects
are manifest in both absolute and relative terms. In absolute terms, rates of adult
communicable and reproductive ill health are declining overall (although the
rates of some specific diseases are increasing, notably AIDS and tuberculosis)
because of declining exposure to certain, fairly well understood risk factors.
Somewhat counterintuitively, adult death rates from many noncommunicablc
diseases are declining also, although for reasons not clearly understood. Some
suspected risk factors for noncommunicablc disease in adults are difficult to
measure (for example, certain social and psychological factors) and others
remain unidentified (for example, putative viral etiologies for certain cancers).
In relative terms, because disease and death rates are declining faster among
children than adults, and because rates of communicable and reproductive ill
health are declining faster than rates of noncommunicablc disease, the risk
factor component works to increase the relative importance of noncommuni
cable disease and adult ill health.
THE THERAPEUTIC COMPONENT. The therapeutic component refers to changes
in the probability that an ill or infected individual will become chronically ill
or die (the case-fatality rate) as a result of changes in access to, use of, and
effectiveness of curative health services. As with the demographic and risk
factor components, the therapeutic component of the health transition causes
changes in both absolute and relative rates of chronic impairment and death.
In absolute terms, improvements in modem chemotherapy reduce the rates of
adult death and chronic impairment from several causes, such as tuberculosis
and onchocerciasis. In relative terms, there has been generally more progress
(due largely to antibiotics) in reducing communicable disease case-fatality rates
than the case-fatality rates from injuries, cardiovascular diseases, or cancers.
The result is that these latter causes of death become relatively more important
in the absence of other changes.
The increase in the absolute number of sick and dead adults is due to the
demographic component, the effects of the risk factor and therapeutic compo
nents being in the opposite direction. The relative increase in adult deaths
compared to childhood deaths is caused by the demographic and risk factor
components, although mainly by the former. The relative increase in certain
causes of adult ill health (notably many noncommunicablc diseases) compared
with other causes is due to the risk factor and therapeutic components.
SUMMARY
13
Vague statements about the rising importance of noncommunicable dis
eases and injuries—statements that fail to clarify whether they refer to the
number of deaths, proportions of deaths, or crude, age-standardized or
age-specific rates of death—have created much confusion. However, despite
a widespread belief to the contrary, age-specific rates for many particular
noncommunicable diseases and for noncommunicable diseases as a whole
are declining in developing countries, while their numbers, both absolutely
and relative to communicable diseases, are increasing. The dominant cause
of the increased importance of noncommunicable disease during the
health transition is demographic change, combined with declining rates
of communicable diseases caused by changes in risk factors and therapeu
tic services.
Current health sector and development policies affect the health transi
tion in several ways. They have an impact on the demographic component,
accelerating the aging of the population by reducing mortality and fertility
rates and increasing life expectancy; they have a complex influence on risk
factors, tending to reduce exposure to many risk factors and increase expo
sure to others; and they lower case-fatality rates by improving health
services. The relationship between development and the health transition
has yet to be fully elucidated.
For policymakers, the central adult health problem is the rising absolute
number of adults who are sick and dying from noncommunicable diseases
and injuries. The demands of this politically vocal group will inevitably
lead to rapidly growing expenditure unless preventive action is taken.
The main cause of this central adult health problem is the growth in the
adult population, much of which is unavoidable during the next few de
cades. The main solution lies in reducing exposure to risks (thereby reducing
age-specific disease rates) and lowering case-fatality rates by increasing the
use of effective curative services.
The Emerging Agenda for Adult Health
The remainder of this booklet summarizes findings based on already
available data that sometimes confirm and sometimes challenge existing
assumptions about adult health. The booklet also identifies areas for
further research and makes recommendations for action. Recommenda
tions are centered around the proposal that governments focus on reduc
ing expenditure on inefficient and inequitable adult health care and
thereby free resources for the implementation of cost-effective interven
tions, many of which are preventive. This reflects, in part, a concern that
improvements in the health of adults should not be at the expense of
children.
14
THE HEALTH OF ADULTS IN THE DEVELOPING WORLD
The Findings
The review of adult health on which this booklet is based supports some widely
held views, but also challenges several generally accepted notions, especially
regarding adult mortality. The key findings are summarized below.
Surviving childhood is not the only health hurdle in developing countries.
• Mortality statistics clearly support current international concern for the
health of children in developing countries: 38 percent of all deaths in
developing countries occur among children younger than five years old,
and 97 percent of these deaths are avoidable. However, it is also true that
27 percent of all deaths in developing countries occur in the adult age
group (fifteen to fifty-nine years), and 72 percent of these are avoidable.
Deaths of adults account for about half of all potential years of life lost
(using productivity weighting and discounting at 8 percent).
• In some developing countries (for example, Sierra Leone), the probability
of dying in the forty-five years between the ages of fifteen and sixty years
is greater than 50 percent. The average in developing countries is 25 per
cent for men and 22 percent for women, very much higher than in the
developed market economies, where the average is about 12 percent for
men and 5 percent for women.
• The burden of adult ill health is increasing. The adult population of
developing countries is large (comprising 56 percent of the total) and
growing at a faster rate than the whole population. If adult mortality rates
do not decline steeply, adult deaths (particularly those from noncommu
nicable diseases and injuries) will increase, both in number and relative
to all deaths.
• High adult mortality rates are accompanied by substantial levels of
morbidity, although methodological problems frustrate efforts to quantify
this in a consistent and comparable fashion.
The ill health of adults has serious consequences for the individual, his or her family
and society.
• Adult ill health consumes a major proportion of health care resources
(more than three-quarters in some countries). Families bear an important
part of this burden, spending on average at least as much as governments
spend on health care.
• Adults comprise the majority of the labor force, and the ill health or death
of adults generally has adverse effects on productivity. The losses are
probably substantial, though difficult to measure because they are often
SUMMARY
15
obscured, deflected, or delayed through compensatory reallocation of
labor away from income-generating activities, education, or child care.
These coping mechanisms, which ameliorate the impact of adult ill
health, themselves impose costs.
• Adults are the ones on whom other family members depend. The death
or ill health of adults can harm the health of, or even kill, other members
of the household—the mortality rates of infants whose mothers die can
be as high as 90 percent.
• Poor adults suffer more frequently from severe ill health, are more likely
to depend on regular physical work, have fewer resources with which to
cope, and consequently are more heavily penalized by ill health. In the
poorest households, ill health can be catastrophic, leading to asset sales
and irreversible impoverishment.
• Societies probably cope with the frequency and unpredictability of adult
ill health by maintaining a labor surplus and minimizing labor specializa
tion. The efficiency losses from these coping processes may be of immense
importance in understanding the slow pace of development in some
countries.
The nature, distribution, and trends of adult mortality challenge preconceptions.
• Noncommunicable diseases (including cardiovascular diseases and
cancers) and injuries are the leading causes of adult death in most
developing countries with adequate mortality data. Furthermore, these
diseases, which are commonly thought of as diseases of the rich, in
aggregate cause higher rates of death in poorer countries than in less
poor countries and higher rates of death among poorer people within
a country. Many developing countries face these major challenges from
noncommunicable diseases and injuries while at the same time con
tinuing to have high rates of certain communicable diseases of adults,
such as tuberculosis.
• Age-specific adult death rates of most diseases, including many noncommunicablc diseases, are falling. Fifty percent of the recent decline in adult
mortality rates in some countries is due to a fall in noncommunicablc
disease. Despite this, adult deaths from noncommunicablc diseases are
increasing both in absolute numbers (because of the growing number of
adults) and in relative importance (because mortality rates from commu
nicable and childhood diseases arc decreasing even more rapidly).
• Men aged fifteen through fifty-nine years have higher mortality rates than
women of the same ages in nearly all developing countries, and the
difference in some countries is large. Even during the reproductive years
(fifteen to thirty-nine years), men in nearly all countries have higher
16
THE HEALTH OF ADULTS IN THE DEVELOPING WORLD
mortality rates than women. Although death rates are lower among
women than men, comparisons with developed countries reveal that
women’s avoidable mortality is higher.
• In countries with acceptable cause-specific data, injuries are responsi
ble for about 25 percent of the adult male mortality rates and 37
percent of age-standardized adult years of potential life lost. Rates arc
generally lower among women. There are no consistent patterns over
time or in relation to overall mortality risk. Injury rates appear to be
determined by distinct, location-specific sets of social, cultural, and
economic factors.
Although information on the determinants of adult health is incomplete, enough is
known to improve adult health through preventive interventions.
• The determinants of adult health are many and diverse, providing multi
ple opportunities to promote health and prevent disease.
• Many determinants of adult ill health in developing countries arc behav
ioral and include smoking, alcohol consumption, and dietary habits. The
prevalence of some important risk factors (notably smoking) is increasing.
Past and present increases in these risk factors and the lag between
exposure and disease development mean that death rates from some
diseases (notably lung cancer) will rise inevitably over the next few
decades.
• There is no clear relationship between overall adult mortality levels
and the cause-of-death structure, which suggests that the health tran
sition and its determinants are not the same everywhere. Child mor
tality is not closely associated with adult (especially male) mortality,
and the socioeconomic correlates of adult mortality are distinctly
different from those for child mortality. These observations suggest
that developing countries cannot address adult health problems by
expanding successful child health policies. They also suggest that
countries are not locked into an inevitable experience of the health
transition and that they can take action to avoid some of the undesir
able manifestations of the transition—for example, by curbing tobacco
use by women before it is too late.
The lack of data on adult ill health in developing countries is a serious obstacle.
The picture of adult health can be sketched only vaguely and is least clear
for mortality in poorer countries, for morbidity everywhere, and for the conse
quences of adult ill health.
SUMMARY
17
An Agenda for Improving the Information Available
for Decisionmaking
Government policymakers need to know the rates and distribution of disease
to plan new programs and evaluate them. Relevant data can be obtained
through two complementary approaches: the routine collection and analysis of
health statistics, and a research program focusing on practical questions regard
ing the diseases, other health issues, and the delivery system of a particular
country.
HEALTH STATISTICS. Basic health data collection is often considered in two
categories: surveillance (including diseases and/or risk factors such as cases of
tuberculosis or cervical cancer, numbers of cigarette smokers or alcohol drink
ers) and vital statistics (birth and death records). Few developing countries give
priority to either. Data quality may be questionable even when collection
occurs. Data that are collected may not be analyzed or used to influence health
policy.
RESEARCH. When countries are struggling to provide even basic health
services, it is not difficult to view research as a luxury that they can ill afford.
The contrary view, cogently argued in 1990 by the Commission on Health
Research for Development, is that research is essential for these countries
precisely because of the need to empower those who must accomplish more
with fewer resources. The research agenda to clarify the nature, causes, and
consequences of adult ill health is potentially a very large one. Ignorance
in itself, however, is insufficient justification for research. Fortunately, the
topics that merit investment in research (that is, for which the benefits
outweigh the costs of research) are a small subset of this vast sea of
unknowing.
The following sections identify general areas in which ignorance is a serious
obstacle to good decisionmaking and research has a high probability of provid
ing the necessary information at reasonable cost. Some of these research topics
are appropriate areas of involvement for international and donor organizations.
But the majority must be undertaken by developing countries themselves, with
external assistance where necessary, for the purpose of establishing their own
health policies. If the 1990 proposals by the Commission on Health Research
for Development for fostering research on the health problems of developing
countries are heeded, there is a good chance that the research topics outlined
below will be more than a wish list. They will require the establishment
of appropriate institutional and financing mechanisms to expand research
capacities.
18
THE HEALTH OF .ADULTS IN THE DEVELOPING WORLD
Researching the Levels and Causes of Adult 111 Health
The conclusions presented in this booklet provide a provocative counter to the
argument that the study of the levels and causes of adult ill health is unnecessary
because enough is known already about the major problems. Without an
examination of the existing evidence, for example, how many policymakers
would have predicted that the three leading causes of adult female death in El
Salvador and Mauritius are the same as those in the United States—namely,
cardiovascular diseases, cancer, and injuries? Such findings, based on the
routine collection of mortality data, are an important start, but major informa
tion gaps remain.
Low health standards and poor data quality go together. The result is that
the least is known about countries where adult health is the worst. For
example, mortality analysis can only be done in countries that have reason
ably good cause-specific data. This excludes Sub-Saharan Africa, the poor
est region in the world. The relative importance of causes of adult ill health
is likely to be different in the poorest countries. The data from India hint
at this. Countries with good data may be an inappropriate basis from which
to make global generalizations. More information is needed on adult mor
tality in the poorest countries, particularly those in Sub-Saharan Africa and
South Asia.
There are good reasons why acceptable data have not been generated in
many poorer countries: collecting data is expensive, and increasing coverage
and accuracy adds substantially to costs. Modeling is a potential alternative.
However, the dangers of using modeling to generate data on adult mortality are
particularly severe for the least developed countries, for which the baseline data
are poorest. Even for those countries that have reasonably reliable mortality
data, questions remain about the real importance of certain causes of death.
Current approaches to attributing cause of death can seriously underestimate
the role of certain chronic conditions such as diabetes and chronic obstructive
lung disease. Inexpensive and easy-to-use methods for collecting and analyzing
data on adult mortality, by improving vital statistics systems or adopting
innovative approaches, need to be developed.
Reliable, comparable data are even more scarce for adult morbidity than for
mortality. It is templing to conclude that any research on adult morbidity in
developing countries would he worthwhile. This would be a mistake. Many
previous studies, for example, have focused on single diseases—an approach
that can lead to overestimate, and have employed inconsistent definitions
and measurements of morbidity, Basic methodological work is needed to clarify
the kinds of morbidity data that are useful and how they should be interpreted.
Once some consensus on met hr ah t. at hicvcd, selected countries should collect
SUMMARY
19
data on the nature and level of community morbidity and disability. Determin
ing the relationship between adult morbidity and mortality in these countries
will clarify the ways in which mortality statistics are inadequate for identifying
priority health problems and will help to generate simpler methods for estimat
ing morbidity.
Much greater attention should be paid to the collection and use of good data
on health services utilization. Such data tell policymakers precisely what kinds
of morbidity prompt people to seek care and what demands arc placed on private
and public health care systems-—information that is crucial for health care
planning and resource allocation.
Exploring the Consequences of Adult III Health
Morbidity and mortality statistics are summary measures for distressing and
sometimes catastrophic events, but inadequate for capturing the full effect of
these events especially on poor families. Reliance on such indicators probably
explains why the current understanding of the ramifications of adult ill health
and death is so rudimentary.
There are at least two important reasons for exploring further the conse
quences of ill health and death. First, such exploration opens up new
possibilities for ameliorating the effect of adult ill health. These possibilities
include attacking the root causes and reducing the occurrence of morbid
events. There may also be scope to enhance existing coping strategies and
to facilitate family recovery. Second, ill health is not a homogenous state
and can have very different consequences from one individual to another
depending not only on the nature of the ill health but also on the social and
economic environment. Rational justification of intervention priorities
should take these differences into account. What distinguishes the conse
quences of different kinds of ill health, of ill health experienced at different
ages, in different economic circumstances, or by men or women? The effect
of catastrophic illness or injury and mortality in poorer households deserves
particularly close attention.
Coping processes that societies have evolved for mitigating the consequences
of ill health will need special attention both for an understanding of how they
might appropriately be reinforced and to capture the full costs of adult ill health
and death. Formal and informal insurance are two coping mechanisms that
should be studied in diverse cultural contexts. Too little is known about the
efficiency losses incurred in developing countries that establish national insur
ance programs. An assessment of these costs arrayed against the benefits of such
programs would provide information for making better decisions about the
extension of insurance programs to other developing countries.
20
THE HEALTH OF ADULTS IN THE DEVELOPING WORLD
Identifying the Determinants of Adult III Health
The basic pathogenesis and pathophysiology of several important diseases of
adults in developing countries (For example, most cancers) are not understood
adequately. This ignorance is an obstacle to the development of techniques for
prevention or cure. Most of these health problems, however, are shared by
industrial countries, which have both the incentive and the resources to
undertake basic biomedical research the results of which are likely to be broadly
applicable everywhere.
A similar rationale argues against major investments by developing countries
in basic research on the nature of associations between adult diseases and their
risk factors. Much of this basic research is being conducted already in industrial
countries and can be applied to less developed countries. It is highly likely, for
example, that the relationship between the quantity, type, and years of cigarette
smoking and the risk of lung cancer is similar in Britain and Burkina Faso.
Existing data and research on risk factors should be exploited.
Nevertheless, there is some justification for supporting certain original
studies of certain risk factors in developing countries. In some settings, such
research may play an important advocacy role. In addition, there may be
environmental or genetic factors that have received little attention because
they occur infrequently in industrial countries. Infectious causes of noncom
municable diseases are one example. Some puzzles, such as the apparently
inverse trends in the rates of certain noncommunicable diseases and their
putative risk factors, might be explained by previously unknown or under
estimated etiologies. Furthermore, some risk factors have been evaluated inad
equately in industrial countries (for example, certain lifestyle and
socioeconomic risk factors, various risk factor combinations, and exposure to
risk factors in childhood). Examples of much needed risk factor research in
selected developing countries include the study of diet and indoor air pollution
in relation to a variety of diseases of the lungs and circulatory system.
In contrast to the cultural transferability of date on the effects of risk factors,
the level of exposure to these factors varies greatly by location. The high rates
of smoking in Papua New Guinea tell nothing about smoking rates in Paraguay.
Data on exposures to many key risk factors are poor and must be improved—
alcohol and tobacco use, diet, exercise, sexual habits, environmental and
workplace exposures, and injury risk factors are important examples. Without
information on the nature, extent, time trends, and combinations of exposures
to important risk factors, it is difficult to design appropriate preventive strate
gies. It is also important to know which people are at risk and how they are
likely to respond to government action. This information helps to target and
mould interventions. Strategies may be different for men and women, for
younger and older adults, for urban and rural populations, for industrial workers
SUMMARY
21
and bureaucrats. In the United States, for example, the young are more
responsive to increases in the price of cigarettes than is the population as a
whole.
For the same reason, it is crucial to understand the determinants of determi
nants—why, for example, do people smoke or not smoke? Information on the
nature and relative importance of cultural, economic, and educational factors
in influencing risky behavior is needed for the design and delivery of interven
tions. Such information may be largely specific to a particular country or
population group.
An Agenda for Action
The results from the research proposed above should arm developing countries
with information on the major health problems of their adults, as well as the
consequences and determinants of these problems. Good health policymaking
depends on such information. But it requires more. It requires an understanding
of the options available for tackling these problems and their full costs and
benefits. That adult health problems exist, or even that they are demonstrably
serious in their effects, is not enough to justify a role for government in
prevention or treatment: the technology may not be available or may be hugely
expensive and largely ineffective, or the private sector may provide services
efficiently and equitably.
This booklet does not attempt to analyze policy options. Its objective—to
document what is known of health problems facing adults in developing
countries—is more modest. Nevertheless, the major findings derived from
existing data arc pregnant with implications for action. Not to clarify these,
where possible, and not to warn against possible misreadings of the data would
be both irresponsible and a wasted opportunity.
Principles and Provisos
There are several observations and some caveats to stress in presenting this set
of proposals. First, any analysis requires some organizing principle with which
to categorize problems and responses. These categories inevitably impose
limitations. Diseases and their determinants have largely structured the analy
ses summarized in the main book and have directed the nature of the recom
mendations that emerge. Rcanalysis from a different perspective, perhaps using
institutions, inputs, or income levels as the organizing principle, could reveal
a complementary set of proposals.
Second, the database on the effectiveness and resource requirements of
interventions is not very firm. Much of the information available about the
costs and benefits of alternative strategies is limited to government costs and
22
THE HEALTH OF ADULTS IN THE DEVELOPING WORLD
direct health outcomes and ignores equity despite the fact that most societies
value it. Even within this limited framework, there is substantial ignorance
about the achievements and costs of alternative approaches to improving adult
health. Further research on this topic is strongly recommended.
Third, generalizations can be dangerous. Countries differ not only in the
diseases with which they are grappling, but also the technical, economic, and
political environments in which they must implement health policy. Not all
the proposals have equal relevance everywhere. The focus on common, impor
tant and generally poorly managed diseases has generated a list of interventions
likely to be broadly relevant, but these interventions need careful consideration
by each developing country government in the light of its own particular
circumstances.
One factor that may critically influence the desirability of investment in any
given intervention in a particular country is the nature of the alternative
investments that must be sacrificed. Appropriate decisions about government
investment in adult health depend on how such investments would be used
otherwise. If governments devote more resources to pain relief for cancer
sufferers, would this be at the expense of fewer surgeries for advanced cancer
patients, fewer actions for preventing motor vehicle collisions, fewer vaccina
tions for children, or fewer improvements in housing? Assessment of the
desirability of investing in pain relief may well depend on the answer. Political,
institutional, and financial structures all constrain choices for government
spending in ways that have rarely been studied and are difficult to generalize.
In the absence of information on the nature of these choices, the following are
general observations on broadly defined options that developing countries may
be considering:
• A shift of resources from direct investment in child health toward adults
most probably would be inefficient and inequitable. This is particularly
likely if resources were simply to follow current patterns of investment.
Many interventions in child health are highly cost-effective, due both to
the nature of the relatively inexpensive and effective interventions and
the fact that they can be applied early in life with relatively immediate
benefits. Furthermore, income-related health differentials are greater
among children than adults and the poor tend to be younger because of
higher fertility rates, implying that investment in children is likely to
address inequalities more effectively.
• Communicable diseases of adults are generally more cost-effective to
treat than noncommunicable diseases. Many communicable diseases arc
readily cured with drugs (for example, dysentery, bacterial pneumonia,
and ascariasis). Noncommunicable diseases, conversely, are often difficult
to manage. Some, like lung cancer, are essentially untreatable or involve
SUMMARY
23
high treatment costs with extremely modest benefits in terms of extra
years of healthy life. Resources invested in noncommunicable diseases
will benefit the poor and probably the poor more than the rich since many
noncommunicable disease rates are higher among the poor, but invest
ment in communicable disease control will probably be even more rela
tively beneficial to the poor. Major shifts in government health services
from communicable to noncommunicable diseases, particularly while
diseases like tuberculosis remain important problems, therefore do not
seem appropriate. (Some important specific exceptions are discussed
below.)
° Cases of noncommunicable disease and injury in adults are increasing in
number and in relative importance and are an appropriate target of
concern for developing countries. Sizeable amounts of resources are
already devoted to the treatment of these diseases with often questionable
results. A redirection of some of these resources towards prevention is
justified. Not only are some of these preventive strategies demonstrably
more cost-effective than their therapeutic alternatives, but differences in
the economic characteristics of treatment and prevention suggest that the
private market in health is likely to underinvest (from a social perspec
tive) in preventive strategies.
• It is hard to judge the relative merits of tradeoffs outside the health sector
between economic development and health. A good case, however,
probably could be made for some redistribution of the substantial re
sources employed by many governments in agriculture, industry, and price
subsidies for the middle classes toward health and safety concerns.
• Finally, there is one transfer that is potentially efficient and dramatically
equitable: shifting resources from industrial countries to improve adult
health in developing countries. A shift of resources for health research is
similarly attractive.
Specifics for Action
Ten areas of action arc identified below. The first concerns the withdrawal
of resources from some adult health programs. The other nine are specific
interventions that merit more attention. All are cost-effective (less than
US$500 per discounted year of healthy life gained) and address problems of
importance in all developing countries (cancer, traffic injuries, maternal ill
health, sexually transmitted diseases, tuberculosis, and diabetes). Important
tropical diseases are excluded. Some, such as malaria, are not being con
trolled adequately, others, such as onchocerciasis are, and these diseases
already receive considerable attention in international and national health
programs.
24
THE IIEALTH OF ADULTS IN THE DEVELOPING WORLD
Withdraw Resources from Inefficient and Inequitable Government Health Services
for Adults
Anecdotal evidence supports the suspicion that much investment on adult
health in developing countries is inefficient and inequitable. Cancer treatment
is one example. An estimated two-thirds of cancers in developing countries arc
incurable when diagnosed. Technology offers little hope to those who contract
stomach, esophageal, liver, or lung cancer. Even in the United States, the
five-year survival rates of people who have these cancers are less than 15 per
cent, the survival rates of people with esophageal and liver cancers being only
2 to 3 percent. Overall, cancer treatment provides only small gains in life
expectancy, and such gains often are associated with great discomfort and
distress. Furthermore, cancer treatment is expensive. Cost-effectiveness esti
mates average more than US$50,000 per discounted year of healthy life gained.
Too often, the use of aggressive therapeutic attempts to achieve minor prolon
gation of the act of uncomfortable dying predominate over the concern for the
quality of death in a familiar environment. Governments should withdraw
resources from the nonpalliative treatment of most cancers. More appropriate
approaches (cancer pain relief, cervical cancer screening and treatment, to
bacco control, and hepatitis B vaccination) are discussed below.
Other medical interventions that are highly costly tn relation to adult health
returns in terms of discounted healthy years of life gained have been identified.
Medical management of hypertension (US$2000), medical management of
hypercholesterolemia (US$4000), antiviral therapy for acquired immunodefici
ency syndrome (aids) (US$5000), and coronary artery bypass surgery (US$5000)
are all immensely unattractive investments for public funds. Furthermore, these
four conditions can be effectively and economically reduced by primary pre
vention involving behavioral and dietary practices.
This is a short list of some of the more obvious examples of technologies for
which government spending should be discouraged. There are others. How
commonly employed they are in developing countries has not been the subject
of much attention. Health ministries should take a close look at the health
services they provide to adults. An honest appraisal of the way existing health
services meet the needs of adults is likely to reveal substantial room for
improvement in a variety of administrative, training, financing, and technical
areas. To constrain what would otherwise be a daunting task, the initial
approach should focus on technical areas and, in particular, on the few diseases
of adults for which substantial resources are invested in treatment, such as
injuries, cancer, cardiovascular diseases, and tuberculosis. How do current
services manage adult illnesses and injuries? What are the costs and effects and
the factors important in determining them? What are the alternatives, their
likely costs and effectiveness, and their effect on the poor? What are the
SUMMARY
25
implications of these findings for the broader health services issues of financing,
administration, and training?
Minimizing government support for treatments of highly doubtful value may
antagonize entrenched interests. For this reason, governments need to consider
carefully their policies that influence health care staffing. Unless medical
curricula, scholarships, specialty training, and salary structures all reflect iden
tified health care priorities, powerful medical lobbies may seek to apply thera
peutic advances in all areas without regard to cost-effectiveness. Policies toward
technology assessment and adoption need to be developed with great care and
determination. This is an area in which industrial-country governments are
only just beginning to make progress. Some, such as the United States have
already found they have essentially no means of putting a brake on the use of
excessively costly or ineffective technology.
Stop Smoking
Tobacco use, particularly cigarette smoking, plays an important role in
undermining the health of adults in the developing world. Tobacco use creates
a burden of smoking-related morbidity and mortality, the full effect of which
has yet to be felt. Recent estimates suggest a current worldwide annual toll of
three million tobacco-related deaths—a quarter of which occur in India
alone—rising to more than ten million by the 2020s. Most of this increase will
occur in developing countries. Fifty million Chinese alive today will die as a
result of tobacco use.
Industrial-country experience has clearly demonstrated that smoking habits
can be changed. Changing public opinion through combined legislative and
educational policies is promising. Legislation to require health warnings on
tobacco product packages and bans on advertising and on smoking in public
areas has been enacted in several industrial countries and appears to be effective.
Education through individual counseling (for example, by physicians) and
high-quality mass media campaigns have been shown to work in some coun
tries, although more for encouraging nonsmokers never to start smoking than
for helping smokers to stop. Education that targets children is especially
promising and needs strengthening in most countries.
Taxing cigarettes is one of the most effective public health tools governments
have for reducing cigarette smoking. Cigarette taxes deter nonsmokers from
taking up the habit and reduce smoking among the poor and the young. Price
increases of 10 percent are estimated to reduce consumption by 4 percent in
the United States and Western Europe. The first report from a developing
country showed that an increase in tobacco tax (not price) of 10 percent in
Papua New Guinea reduced demand for cigarettes by 7 percent. Simultaneous
increases in the cost of all tobacco products are necessary to discourage
26
THE HEALTH OF .ADULTS IN THE DEA ELOPING W ORLD
consumers from switching to cheaper (and perhaps even more hazardous)
products.
Others have analyzed the limited data available on the costs and effective
ness of strategies to reduce cigarette smoking and concluded that educational
interventions are highly cost-effective. They found costs of about US$25 per
discounted year of healthy life gained in countries with gross national products
(gnp) of US$1,500 per capita, and possibly having costs as low as US$15 if
cigarette taxes are increased. There are other costs not captured by these figures,
such as the discomfort suffered by individuals who give up smoking or the
temporary unemployment and loss of national income suffered by those coun
tries with large tobacco growing or cigarette manufacturing industries. But there
are also additional benefits including reductions in smoking-related domestic
fires and the saving of wood used for curing tobacco.
Demonstrating that the social benefits of reduced tobacco consumption
exceed the costs does not imply that reforms can be implemented easily. Groups
that have vested interests in maximizing cigarette consumption (cigarette
manufacturers, distributors, and advertisers) have considerable influence. Con
sumers in developing countries have relatively weak lobbying power, are
generally poorly informed, and do not currently face a major problem with
tobacco-related diseases. They are less likely to play the role that their indus
trial-country counterparts have in stimulating antitobacco activities. The
governments of developing countries, which almost universally benefit from
taxation applied to cigarettes, may be reluctant to adopt measures they fear will
harm this lucrative source of income. In fact, the demand-deterrent effect of
moderate increases in tobacco taxes is less than the price increase, and the net
effect is that a 10 percent increase in taxes is estimated to increase revenues by
some 5 to 8 percent. Some governments have understood this and have taken
firm action in the face of strong opposition from the tobacco industry.
The challenge is great. Each developing country should establish a national
agency to plan and coordinate efforts against tobacco use. Procrastination
cannot be justified. The control of tobacco use is one of the most, if not the
most, important public health issue facing the world.
Make Road Travel Safer
Injuries from motor vehicle collisions are a major cause of death for adults
in developing countries and have become increasingly important in the last
two decades: two- to threefold increases in mortality rates were common during
the 1970s. Crude death rates from motor vehicle collisions are higher in
developing than industrial countries, and when adjustments are made for the
number of vehicles, the difference is even more dramatic: the number of
fatalities per thousand motor vehicles is ten to twenty times greater in devel
SUMMARY
27
oping countries. These high death rates are accompanied by substantial levels
of serious morbidity and disability and destruction of property. Motor vehicle
collisions result in estimated economic losses of 1 to 2 percent of GNP in some
developing countries.
Two important features distinguish the developing-country picture: the high
percentage of people injured in motor vehicle collisions who are pedestrians,
and the variety of vehicles on the road—bicycles, animal-drawn carts, and
high-speed trucks—all jostle for space in narrow roads. Fatalism is the first
obstacle to overcome in reducing these deaths and injuries. Motor vehicle
collisions are not accidents. They have determinants that arc largely control
lable: dangerous road design (characterized by poor lighting and lack of traffic
segregation), dangerous driving (involving high speeds, young or inexperienced
drivers, and drivers under the influence of alcohol), and dangerous vehicles
(characterized by insufficient protection for drivers and passengers, poor main
tenance, and oversized loads). Legislation, pricing policies, direct investment,
and education arc all potentially effective.
Alcohol plays an important, though inadequately studied, role in motor
vehicle collisions in developing countries. Several strategics, including price
increases, have been successful in moderating general alcohol consumption and
in reducing motor vehicle related mortality, especially among young drivers.
Legislation, including penalties for drunk driving and limits placed on the hours
and conditions of alcohol sales, is another approach, though generally less
successful.
Unfortunately, there is little evidence of the cost-effectiveness of any of these
strategies in developing countries. Further investigations arc urgently needed.
The relative importance ofdifferent causes of traffic collisions varies in different
countries, and the variation that this implies for specific preventive strategies
suggests that governments should collect location-specific data as an essential
complement to their efforts to make road travel safer. In the meantime, it would
be highly prudent for governments to make traffic safety a high priority and
focus improving road design and modifying driver behavior. The latter could
be achieved through such measures as the enactment and enforcement of
legislation governing speed limits, seat-belt provision and use, the use of
helmets and headlights by motorcyclists, and improving road design. Special
attention should be given to reducing alcohol use—which has health effects
beyond motor vehicle collisions—improving pedestrian safety and accommo
dating slow and mixed traffic.
Vaccinate against Hepatitis B
Worldwide, more than 300 million people are carriers of hepatitis B. Of
these, 25 to 30 percent will die of hepatitis B-virus-induccd cirrhosis or liver
28
THE HEALTH OF ADULTS IN THE DEXTIOFING WORLD
cancer. Liver cancer is one of the most common cancers in southeast Asia and
the Pacific and is a common cancer in parts of Sub-Saharan Africa. It is
essentially untreatable. Up to 80 percent of liver cancers are attributed to
hepatitis B virus. The risk of developing liver cancer is 200 times greater for
hepatitis B carriers than noncarriers.
The cost of the hepatitis B vaccine recently fell as a result of technological
developments and competitive pricing (from more than US$100 to less than
US$3 for prophylaxis that is 75 to 95 percent effective in preventing the
hepatitis B carrier state). The vaccine, intended for administration to newborns
and infants, can be delivered through the infrastructure already in place for
other childhood vaccinations, thereby increasing the feasibility and reducing
the cost of delivery. Several developing countries, including the Gambia and
Taiwan (China), already have started national hepatitis B vaccination pro
grams, and Italy is considering compulsory hepatitis B vaccination for all
infants.
As with many preventive strategies, the financial attractiveness of vaccinat
ing for hepatitis B is modified by the delay between investment in the inter
vention and the realization ofbenefits (i.e., avoided cancers). Nevertheless, the
cost per discounted year of healthy life gained is likely to be in the range of
US$25 to US$50. This calculation takes into account all mortality related to
hepatitis B—principally liver cancer, but also cirrhosis of the liver and hepatitis
itself. Most developing countries will find hepatitis B vaccination a highly
worthwhile investment.
Make Motherhood Safe
Maternal health problems are widespread and should be priorities for inter
vention. The maternal mortality ratio (the number of maternal deaths per 100
thousand live births) is in the range of 100 to 2,000 in developing countries,
compared to less than 30 in most industrial countries. The lifetime risk of dying
of maternal causes (which combines maternal mortality ratios with fertility
rates) is one in twenty in much of Africa and one in ten thousand in northern
Europe. Three-quarters of all maternal deaths are caused by hemorrhage, sepsis,
or eclampsia, and a considerable proportion of the hemorrhage and sepsis is
attributable to abortion or obstructed labor.
The majority of these maternal deaths are preventable. Appropriate preven
tive activities vary from country to country, but developing-country govern
ments should consider the following: (a) screening to detect women at high
risk (including very young women and women with sexually transmitted
diseases and other reproductive tract infections); (b) referring women with
complicated pregnancies to higher-level care and encouraging them to deliver
in health facilities; and (c) providing tetanus toxoid immunizations, iron/folate
summahi'
29
supplements, and, where necessary, malaria prophylaxis. Other measures worth
serious consideration are monitoring of weight and blood pressure during
pregnancy, educating of pregnant women about signs of premature labor, and
measures to ensure that all pregnant women receive pelvic examinations. High
priorities for care at delivery include providing hygienic supplies, the training
of birth attendants (both traditional and health service staff), and the mainte
nance of referral systems for complications and emergencies. Programs that
improve general education and literacy also benefit maternal health, and
interventions that help women avoid unwanted pregnancies are highly costeffective.
Cost and effectiveness data for these measures are scarce. However, the
averting of maternal mortality through the combined effects of antenatal care,
safe delivery and emergency referral measures (i.e., the package described
above) are among the more cost-effective interventions for adults.
Because the risk factors for maternal morbidity and mortality are almost
identical to those for neonatal morbidity and mortality, these measures also
benefit newborns by increasing birthweights and neonatal survival. If the effect
on perinatal mortality is taken into account, the cost-effectiveness of this same
package becomes even more favorable.
Promote Safe Sex and Treat STDS
Sexually transmitted diseases (STDs), especially AIDS and syphilis, contribute
considerably to morbidity and mortality in many parts of the developing world.
AIDS, an incurable and fatal disease caused by infection with the human
immunodeficiency virus (hiv), is a growing problem and already the major cause
of productive days of life lost in parts of Africa.
A variety of strategics can be used to prevent the spread of HIV, which is
transmitted through sexual contact, intravenous drug use, blood transfusions,
and intrauterine transmission. Legislative measures are controversial, but pric
ing policies (c.g., reducing the cost of condoms, needles, and syringes; stopping
payment for blood donations), voluntary partner notification, and investment
in improved blood screening may be effective and worthy of more attention.
The success of educating individuals to have fewer sexual partners and use
condoms to prevent the spread of HIV has been mixed and not always well
evaluated. Education efforts arc most cost-effective when targeted at high-risk
groups. Developing-country governments should promote the use of condoms,
especially among the promiscuous, and should screen blood donors for HIV
antibodies. These interventions are cost-effective in reducing HIV transmission.
Depending on the prevalence of HIV infection, the cost-effectiveness per
discounted year of healthy life gained is US$7 to US$50 for condom promotion
and US$1 to US$250 for blood screening. If the benefit of condom use in the
30
THE HEALTH OF ADULTS IN THE DEtTLOFIX’G WORLD
prevention of other sexually transmitted diseases is taken into consideration,
the cost-effectiveness of this intervention is even greater.
aids has provoked a global response, and substantial funding is being
directed to AIDS research and prevention. All countries should exploit this
opportunity to develop institutional capacities and effective ways of using
health education to promote safe sex. The control and treatment of other
sexually transmitted diseases is also highly cost-effective. Such control and
treatment may also reduce HIV transmission, partly by the direct effect of
interventions, such as safe sex promotion, and partly because some of these
diseases are major risk factors for HIV transmission.
Improve Case Management for Tuberculosis
Tuberculosis is widespread throughout the developing world and one of the
major killers of adults. An estimated two million adults in developing countries
die annually from tuberculosis, representing nearly 20 percent of all adult
deaths and probably more than 25 percent of all avoidable adult deaths.
Tuberculosis is one of the most common opportunistic infections of people in
Africa who are HIV positive, and the prevalence of tuberculosis is increasing in
areas with epidemics of HIV infection and AIDS. Effective diagnostic tests and
chemotherapeutic agents exist, but their use has been undervalued in recent
years by much of the international health community. Vaccination with
bacillus Calmette-Guerin (BCG) is an additional and cost-effective approach to
control in some countries.
Treatment of tuberculosis has been demonstrated to give excellent results in
developing-country field conditions, even in large-scale, national interven
tions (such as in Tanzania) in which the challenge of achieving compliance for
the necessary six to eighteen months of treatment is great.
Treatment is highly effective (cure rates approach 90 percent; reductions in
transmission are parallel) and also inexpensive. Passive case detection (using
sputum microscopy) combined with short-course chemotherapy for sputum
positive cases appears to be the most cost-effective approach, having an
estimated cost of less than US$ 10 per discounted year of healthy life gained.
Developing-country health ministries should devote special energies to
reassessing their current approaches to tuberculosis control and to designing
and implementing new programs using short-course chemotherapy.
Screen far Cervical Cancer
Cervical cancer is the most common cancer in developing countries and
leads to substantial morbidity and mortality when it reaches an advanced
symptomatic stage. If detected early, however, it is almost 100 percent curable.
SUMMARY
31
The technology for early detection (cytological screening in the form of
Papanicolaou tests), is technically straightforward, sensitive, and relatively
inexpensive. Well-organized cervical screening programs (for example, in
Canada and Iceland) have reduced cervical cancer mortality by 50 to 60 per
cent, and cost-effectiveness calculations indicate that cervical cancer screening
and early treatment are worthwhile investments. Screenings every five years of
women aged thirty-five to sixty years are estimated to cost between US$75 and
US$400 per discounted year of healthy life gained (depending, among other
things, on the prevalence of cervical cancer and the ability to detect and treat
cervical cancer in its earliest stages) in a country where the average CNP per
capita is US$1,500.
Fewer than 5 percent of women in developing countries have been screened
for cervical cancer in the last five years, and the little screening that has been
done has tended to focus inappropriately on younger women who have lower
risk. Developing countries should consider investing more in cervical cancer
screening and treatment, especially for women aged thirty-five to sixty years.
Developing countries (e.g., Brazil and China) that have extensive health care
systems (including the ability to obtain pathology reviews, do surgical proce
dures, and avoid postoperative infections) are more likely to be able to identify
and treat cervical cancers cost-effectively than are countries with rudimentary
health care systems.
Relieve Cancer Pain
Cancer is one of the three leading causes of death in adults in developing
countries and will continue to be important even if the cancer prevention and
screening measures advocated in this chapter are adopted. An estimated 30 to
40 percent of people with early stages of cancer and 45 to 100 percent of people
with advanced stages of cancer experience moderate to severe pain. The
technology to alleviate this pain exists. The World Health Organization has
developed a method to relieve 80 to 90 percent of pain by administering drugs
on a schedule instead of on demand and moving from nonopiates to weak and
then strong opiates until the patient is free from pain. The average cost
(including the costs of drugs and outpatient services) is estimated at US$75 to
US$250 per discounted year of healthy life gained.
Despite cheap and effective means for relieving cancer pain, most cancer
patients in developing countries are not offered pain relief. For example, in
India, which has about 20 percent of the cancers in the developing world, only
about 5 percent of cancer patients are treated for pain at specialized treatment
centers; the rest are largely neglected. In many countries, misguided national
drug legislation limits the availability of pain-relieving drugs and poorly man
aged drug procurement and distribution systems further limit supplies. Among
32
THE HEALTH OF ADULTS IN THE DEVELOPING WORLD
health specialists, ignorance about appropriate drug strategies and misplaced
fears of creating addiction further constrain the use of these drugs.
Developing countries should pay serious attention to the options for making
cancer pain relief more widely available through appropriate legislative, logis
tic, and training arrangements. New legislation, training protocols, and retrain
ing programs for physicians, although not without cost, are likely to involve
relatively small one-time investments. Some controls on the use of addictive
drugs are clearly appropriate. The challenge is to design systems that achieve
this without penalizing the many people who, without access to these drugs,
will suffer unnecessarily painful deaths.
Treat Diabetes
Diabetes is a more serious problem for adults in developing countries than
generally acknowledged. In some countries, diabetes accounts for more than
5 percent of the mortality risk of adult women; in Trinidad and Tobago and
Nauru, it is as high as 15 percent. Diabetic persons may develop a variety of
serious complications—including blindness, renal disease, heart disease, and
peripheral nerve damage—and have a shorter than average life expectancy.
Treatment of complications imposes a substantial burden on health care
facilities in some countries.
Treatment of non-insulin-dependent diabetes with oral hypoglycemic drugs
may be a cost-effective proposition, at about US$330 per discounted year of
healthy life gained, and many of the dietary and behavioral changes recom
mended for prevention of cardiovascular disease are very likely to assist in the
prevention of diabetes.
Treatment of insulin-dependent diabetes may be even more worthwhile.
Characterized by lifetime dependence on daily insulin injections, without
which the patient dies, insulin-dependent diabetes frequently goes untreated
in developing countries. The basic costs for insulin and syringes are estimated
at about US$150 per discounted year of healthy life gained. Although this is an
underestimate of total costs, it suggests that insulin treatment is relatively
cost-effective, even if costs are doubled to allow for patient monitoring and
project administration.
Education programs for diabetic patients and their health care providers are
highly cost-effective in some developed countries (e.g., the United States).
Teaching diabetic patients proper foot care (i.e., how to bathe and dry feet,
how to clip toenails, what types of footwear to use) reduces the rate of foot and
leg infections and prevents amputations. Blindness can be prevented or delayed
by ophthalmologic screening (which relatively uneducated workers can be
trained to do) followed by laser repair of pathologic changes in the retina. The
relatively sophisticated technology is expensive, but so is the social and eco
SUMMARY
33
nomic cost of blindness. A trial program of retinal screening for persons with
diabetes should be done to determine the appropriateness of using this inter
vention in developing countries.
Policies toward diabetes in developing countries should be reviewed, and
consideration should be given to additional subsidies for treatment of insulin
dependent and non-insulin-dependent diabetes and for patient and health care
provider education.
Other Important Agenda Items
The interventions highlighted above are those that are both relatively
cost-effective and likely to have a substantial effect on morbidity and mortality
levels in most developing countries. These interventions are not an exhaustive
list of cost-effective options. Other interventions deserve close attention but
do not lend themselves to global recommendations at this time. Several of these
are mentioned below.
DIETARY INTERVENTIONS. Diet plays a major role in a variety of adult illnesses.
Specific dietary problems, however, differ markedly from one country to the
next. Furthermore, good evidence on the cost and effect of dietary interventions
is not available. Dietary interventions merit further research and experimental
implementation in some developing countries.
POLLUTION CONTROL. Much is known about the hazards of severe pollution
and specific toxic agents, the technology of pollution control, and government
actions that are effective in controlling pollution. Furthermore, pollution
control is an area in which market failure demands some response from
government. For some cities in the developing world, it would be foolish for
governments not to take steps to control pollution through appropriate regula
tions and pricing policies. The specific strategies required will vary depending
on the nature and extent of the pollution in these cities.
OCCUPATIONAL ILLNESS AND INJURY interventions. Occupational hazards are
an important cause of adult morbidity and mortality, and many arc preventable
at reasonable cost. While important and worthy of further research and inter
vention investment by developing countries, occupational hazards are too
varied and too location-specific for global recommendations to be appropriate.
Questions for Intervention-Related Research
The interventions highlighted in the previous section simultaneously serve as
proposals for action and provocations to research. They arc some of the best
34
THE HEALTH OF ADULTS IN THE DEVELOPING WORLD
bets given present knowledge, but the evidence for them is by no means cut
and dried.
Preventive programs as a whole arc poorly developed in many countries. This
is sometimes because determinants have not been identified or do not appear
readily amenable to modification. Often, however, it is simply that prevention
has been an unjustifiably low priority. Research is needed to evaluate how
worthwhile selected preventive strategies are and to determine how best to
implement such strategies. One way of accomplishing this is to conduct field
trials of promising interventions. The results of these field trials (which
should include an analysis of both costs and health consequences) should
be used to select strategies for widespread adoption, and the experience
gained in these field trials should be used to improve capacities for im
plementing these strategies.
Several issues remain to be clarified.
What are the spin-off effects for children and the elderly of investments to improve
the health of adults!
• For children, the potential benefits include those resulting from (a)
reduced exposure to risks such as passive smoking, (b) averting the death
or disability of parents, and (c) improvements in treatment programs such
as tuberculosis control. How much of an effect each of these has, has yet
to be clearly and widely demonstrated.
• Saving the lives of adults simply to have them spend a disabled and
unhappy old age is a questionable objective. Waiting until adults
become ill and then treating them is a strategy that might increase the
proportion of the elderly who are unwell. Preventing adult ill health
is probably an effective way to ensure a healthy old age. More evidence
is needed and uncertainty remains as to how the prevention of adult
mortality affects the number of years spent subsequently in a state of
frail health.
How best can equity objectives be served in meeting the health needs of adults!
• Equity considerations provide much of the rationale for the direct provi
sion of health care services and other government interventions in the
health sector. Yet the exact distributional consequences of different adult
health interventions remain unclear.
• Data on socioeconomic differentials and mortality rates in developing
countries show that the poor have higher rates of noncommunicablc
diseases than the rich. The equity effect, however, of additional govern-
SUMMARY
35
ment investment in the prevention of noncommunicable diseases in
adults is unclear. There are two dimensions of equity that need to be
distinguished: equity of health outcomes and equity of health care costs.
Whether equity of outcome is improved as a result of preventing noncom
municable diseases in adults depends on what other opportunities for
health improvement are forfeited. Shifting resources from children to
adults, or from communicable to noncommunicable disease control, may
reduce equity. Investing in prevention at the expense of treatment is more
likely to improve equity since therapeutic services are notoriously regres
sive, being demanded and consumed more by the wealthy than the poor.
The outcome equity of prevention strategies is influenced also by the
choice of media, style, geographic, or commodity focus. Televising edu
cational messages where few people own televisions and distributing
brochures where few people read are strategies that are likely to benefit
the rich.
’ Improvements in the equity of health outcomes arc sometimes accompa
nied by a deterioration in the equitable distribution of costs. For example,
taxes on cigarettes and alcohol will depress demand more among the poor,
bringing them greater health benefits than the rich. However, this may
well be achieved at a financial cost to the poor that is proportionally
greater than that to the rich, for whom cigarette purchases constitute a
relatively small share of total expenditure.
What are the appropriate sources of finance for the proposed adult health
interventions?
• In addition to the finances generated by withdrawing government funds
from inefficient and inequitable health care of adults, there are a number
of potential sources of funding for the strategies proposed above. Non
health sectors can be called on (for example, to improve road construc
tion) or fees can be charged for certain services. Several of the
recommended interventions actually have the potential to generate re
sources for the health sector: taxation of cigarettes, alcohol, gasoline, and
private vehicles could increase government resources while at the same
time reducing health risks, depending on the level of tax and the respon
siveness of demand to price. If extra funds are generated, health ministries
will be competing with other government bodies to secure these resources.
Health ministries will, therefore, need carefully prepared proposals for
taxation that stress the explicit objective of health improvement through
the combined use of both price increases and additional health-related
investments.
36
THE HEALTH OF ADULTS IN THE DEVELOPING WORLD
Beyond the provision of health services, what is the appropriate role for government
in improving adult health’
• Much of the health care of adults takes place outside government health
facilities. The government share in the health sector of developing
countries is generally less than 50 percent. Government can still influ
ence practices in the rest of the health sector through, for example,
governing medical training and certification and regulating the use of
medical technology and drugs. Given the importance of nongovernment
health services, these avenues of influence deserve attention.
• Many of the attractive options for improving adult health are preventive
and do not involve health services at all. Some take the form of direct
investment, for example, in safer roads or working environments. Others
imply a role for legislation and pricing policies. These tools have not been
studied adequately, and their appropriate use needs to be better defined
through careful analysis of costs and impacts.
An Agenda for Policy
The number of adults in developing countries is increasing rapidly—from 2.1
billion in 1988 to an estimated 3.8 billion in 2015, and the increase is most
rapid in the poorest countries. Adults are influential politically and likely to
demand increasing expenditure on sophisticated curative health services. As
the number of adults increases, developing countries cannot afford to delay the
articulation of adult health policy and action. They need to identify important
information gaps and fill them through the development of disease surveillance
and improved vital statistics systems and through action-oriented research.
They need to make strenuous efforts to reduce the prevalence of risk factors
through prevention and to improve the cost-effectiveness of therapy. Govern
ments must target specific modifiable determinants of adult ill health—such as
tobacco use, dangerous roads, and hepatitis B infection—and take systematic
action to reduce exposure to these risk factors. The cost-effectiveness of the
substantial resources already expended on treating ill and injured adults should
be examined carefully. Public funds should be spent on curative services that
offer good value for the money and not on expensive means to achieve minor
prolongation of life.
Policy formulation for adult health needs to start now. The longer it takes,
the more vulnerable health resources will be to pressures from adults for
high-cost, marginally effective technology, and the greater the adult health
problems of the future will be.
Contents of the Book
Foreword
Hiroshi Nakajima
Preface
Contributors
1.
Introducing Adult Health
Richard G. A. Feachem, Margaret A. Phillips,
and Rodolfo A. Bulatao
The Objective
The Scope
The Age Focus
The Disease and Mortality Focus
The Need
The Adult Health Policy Vacuum
The Importance of Adult Health
The Changing Picture of Adult Health—The Health Transition
The Book
Appendix
2.
Adult Mortality: Levels, Patterns, and Causes
Christopher J. L. Murray, Gonghuan Yang, and Xinjian Qiao
Measuring Adult Mortality
Overview of Adult Mortality in the Developing World
The Age Pattern of Mortality
Avoidable Mortality
Years of Potential Life Lost
45Q15 and Other Probabilities of Death
Empirical Patterns of Overall Adult Mortality
Historical Changes in Overall Adult Mortality
Current Overall Levels of Adult Mortality
37
38
THE HEALTH OF ADULTS IN THE DEVELOPING WORLD
Relationships between Probabilities of Death for Various Ages and Sexes
Child and Adult Mortality
Gender Differentials in Adult Mortality
Mortality in Younger and Older Adults
Reference Tables
Causes of Adult Death
Review of Previous Studies
Framework Used in this Analysis
Analysis of Empirical Data on Causes of Adult Death
The Relationship between Cause-Specific Adult Mortality and Total
Adult Mortality
Other Sources of Cause-of-Death Data for Asia and Sub-Saharan Africa
Causes of Death in China
Summary and Conclusions
Appendix
3.
Adult Morbidity: Limited Data and Methodological Uncertainty
Christopher J. L. Murray, Richard G. A. Feachem,
Margaret A. Phillips, and Carla Willis
Measures of Morbidity
Observed Measures of Morbidity
Self-Perceived Measures of Morbidity
Interpretation of Differences in Self-Perceived Morbidity
Selected Surveys of Observed Morbidity
Comparative Studies of Self-Perceived and Observed Morbidity
Selected Surveys of Self-Perceived Morbidity
Cross-Sectional Surveys of Self-Perceived Symptoms
Cross-Sectional Surveys of Self-Perceived Impairment
Egypt, Bahrain, and Sri Lanka
Prospective Studies of Self-Perceived Symptoms
Conclusions
4.
The Consequences of Adult 111 Health
Mead Over, Randall P. Ellis, Joyce H. Huber, and Orville Solon
Effects on the Health and Composition of the Household
Health of the Household
Composition of the Household
CONTENTS OF THE BOOK
Medical Costs of Treating Adult Illness
Costs of Adult Hospital Care
Cost of Primary Care for Adults
Effects on Production, Consumption, Investment, and Income
Effects of Adult Ill-Health on Individual Productivity and IncomeGenerating Potential
Reallocation of Labor Force
Change in Investment/Consumption Patterns
Income Distribution
Costs of Avoiding or Ameliorating the Effects of Adult III Health:
Informal and Formal Insurance Mechanisms
Informal Insurance Mechanisms
Investment and Savings
Formal Health Insurance
Conclusions
Current and Future Determinants of Adult Ill Health
Tord KjeIlstrom, Jeffrey P. Koplan, and
Richard B. Rothenberg
Introductory Issues
Identifying the Determinants: the Basis of Prevention
The Underlying Socioeconomic Factors: Poverty and Adult Ill Health
The Impact of Case Management
Assessing the Importance of Different Determinants
Major Determinants at Early Stages of Development
The Precarious Coexistence with Infectious Disease
Unfinished Business: Providing the Basic Necessities for
a Healthy Life
Hunger: A Persistent Threat
Giving Birth: A Frequent and High-Risk Activity
Being an Unhealthy Child
Other Traditional Health Hazards of Adults
Major Determinants Emerging with Economic Development
Developing Unhealthy Habits
AIDS: An Infectious Disease of New Dimensions
The Motorized Epidemic
Destroying the Environment
Safety Shortcuts and Dangerous Jobs
39
40
THE HEALTH OF ADULTS IN THE DEA ELOPING WORLD
Reducing the Impact of Determinants
Modes of Intervention
Examples of Successful Interventions
Conclusions
Appendix
6.
The Emerging Agenda for Adult Health
Margaret A. Phillips, RichardG. A. Feachem, and Jeffrey P. Kaplan
The Findings
An Agenda for Improving the Information Available for Decisionmaking
Levels and Causes of Adult 111 Health
Consequences of Adult III Health
Determinants of Adult Ill Health
An Agenda for Action
Principles and Provisos
Withdraw Resources from Inefficient and Inequitable Government
Health Services for Adults
Stop Smoking
Make Road Travel Safer
Vaccinate against Hepatitis B
Make Motherhood Safe
Promote Safe Sex and Treat STDs
Improve Case Management for Tuberculosis
Screen for Cervical Cancer
Relieve Cancer Pain
Treat Diabetes
Other Important Agenda Items
An Agenda for Intervention-Related Research
An Agenda for Policy
Appendix
Statistical Appendix
A-1 Country-specific estimates of child and adult mortality risk
A-2 Classification of causes of death in various ICD revisions
A-3 Cause-specific 45Q15 for women and men in countries with complete
recent vital registration data classified according to cause of death
A-4 Sample distributions of the 1982 Census and the 1988 Disease
Surveillance Points in China by type of area
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The World Bank
Half or more of health-sector resources in developing countries are con
sumed by the age group that supports society—adults between the
ages of fifteen and sixty. A substantial proportion of these resources
could be better allocated. To improve such allocation, we must first
improve our understanding of adult health. This book is an important
contribution to that process.
Some findings in this book were unexpected. In nearly all developing
countries, adult male mortality exceeds adult female mortality, even in
the reproductive age range. In all countries for which adequate data
exist, noncommunicable diseases are the leading causes of adult mor
tality, and death rates from noncommunicable diseases decline as a
country develops. Ignorance of such trends can only result in the
wasteful misallocation of resources.
Much ignorance about adult health remains, and the authors of this col
lection, identify important areas for further research.. Although compre
hensive policy prescriptions for adult health cannot be made, the
authors conclude by recommending actions that every developing
country should seriously consider. These include programs concerning
tobacco, tuberculosis, road safety, hepatitis B immunization, sexual
health, safe motherhood, certain cancers, and diabetes.
RICHARD G. A. FEACHEM is dean of the London School of Hygiene and
Tropical Medicine. At the time of this study he was the principal public
health specialist in the Population, Health, and Nutrition Division at
the World Bank. TORD KJELLSTROM is an epidemiologist and medical
officer in the Division of Environmental"Health at the World Health
Organization.- 'CHRISTOPHER J. L MURRAY is assistant professor of inter
national health economics in the Department of Population and
International Health, Harvard School of Public Health. MEAD OVER is
an economist in the Population, Health, and Nutrition Division at the
World Bank. MARGARET A. PHILLIPS is a health economist working in
Mexico. At the time of this study, she was a consultant at the World
Bank and a research fellow in the Department of Public Health and
Policy at the London School of Hygiene and Tropical Medicine.
ISBN 0-8213-2591-4
- Media
12158.pdf
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