Intended for healthcare professionals


Improving the health of the world's poor

BMJ 1997; 315 doi: (Published 30 August 1997) Cite this as: BMJ 1997;315:497

Communicable diseases among young people remain central

  1. Davidson R Gwatkin, Directora,
  2. Patrick Heuveline, Research associateb
  1. a International Health Policy Program, Washington, DC 20433, USA
  2. b Population Studies Center, University of Pennsylvania, Philadelphia PA 19104, USA

    Several prominent reports have recently called attention to the world's health transition,1 2 3 4 5 a process associated with reductions in fertility and improvements in overall health. As the transition progresses death and disability among infants and children from communicable diseases tend to decline in importance relative to problems resulting from non-communicable conditions at older ages.

    The transition has proceeded furthest in the developed countries, but it has also occurred in the developing world. Recognising this, many observers have begun thinking in terms of a double burden of disease in developing countries.6 7 The first is the “unfinished agenda” of communicable diseases in the young, which dominated professional thought in the decade after the World Health Organisation's 1978 Alma-Ata conference on primary health care. The second is the “emerging agenda” of non-communicable diseases at older ages resulting from the health transition. Such thought has recently resulted in calls for a shift in attention toward the emerging agenda.8 9

    In assessing these calls we need to be aware of their equity implications. The emerging agenda is unquestionably important for the world's poor. However, it is much less important for the poor than it is for the rich. It also continues to be less important for the poor than communicable diseases in infants and children, despite the gains that have been achieved. As a result, any shift in emphasis from the unfinished to the emerging agenda would move away from problems that are most important for the poor towards those that are more important for the better off.

    Non-communicable diseases were responsible for most (56%) deaths in the world in 1990.5 But a closer look at the figures shows that these deaths were unevenly distributed across social class. For example, non-communicable diseases caused a notably smaller percentage of deaths (34%) among the poorest 20% of the world's population and a much higher percentage (85%) among the richest 20%. The situation for communicable, maternal, and perinatal diseases was the reverse: they caused 33% of deaths overall but 56% among the poorest compared with only 8% among the richest.

    When these mortality figures are adjusted for disability the interclass differences increase, reflecting the fact that non-communicable diseases are far from alone in causing sickness as well as death. Similarly large differences also exist in age of death and disability, with the poor falling ill and dying at a much earlier age than the better off. Other research points to interclass differences within countries that are similar to the global variations.10

    In the world as a whole, certainly, non-communicable diseases have increased in importance. What is not clear is the extent to which the poor have shared or will share in the overall gains that have brought enormous improvements for the emerging middle and upper classes in many countries. Whatever the future brings, however, today's policies cannot avoid taking today's conditions into account. And for those concerned with the poor a central feature of today's conditions is the fact that the health problems of the poor differ significantly from those of the better off.

    These differences point to a need to move well beyond the aggregate figures that have thus far dominated discussions of disease burdens. If the poor are to benefit from the disease burden approach the approach will have to be used to identify the problems that are most important for them and that differentiate them from the rich. The packages of cost effective poverty oriented health interventions resulting from such an application will vary from setting to setting. In most places such packages will almost certainly include at least some components dealing with non-communicable diseases among poor adults and elderly people. Undoubtedly room also exists for further research to identify more effective, inexpensive interventions against such diseases. But, overall, governments and agencies using a burden of disease approach to improve the health of the poor, and to reduce rich-poor disparities, should expect to give a much more central place to further reducing infectious diseases among young people than is suggested by current assessments.


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