The Double Burden: Emerging Epidemics and Persistent Problems 13

2
THE DOUBLE BURDEN:

EMERGING EPIDEMICS
AND PERSISTENT PROBLEMS

T he 20th century revolution in health – and the consequent demographic transi-

tion – lead inexorably to major changes in the pattern of disease. This epidemio-
logical transition results in a major shift in causes of death and disability from infectious
diseases to noncommunicable diseases (1).
As a result of the epidemiological transition, to continue the example of Chile presented
in Chapter 1, the distribution of causes of death in 1999 differs markedly from the distribu-
tion of causes of death in 1909, as shown in Figure 2.1 (2). Not only have the major causes
of death changed, but the average age of death has been steadily rising. The resulting new
epidemics of noncommunicable disease and injuries challenge the finances and capacities
of health systems.
Despite the long list of successes in health achieved globally during the 20th century,
the balance sheet is indelibly stained by the avoidable burden of disease and malnutrition
that the world’s disadvantaged populations continue to bear. Some analysts have charac-
terized a world of incomplete epidemiological transition, in which epidemiologically polar-
ized sub-populations have been left behind (3). Reducing the burden of that inequality is a
priority in international health. Furthermore, it can be done – the means already exist.

Figure 2.1 Distribution of deaths by cause for two cohorts from Chile, 1909 and 1999

1909 Estimates for 1999

Respiratory infections Cancers
Other infectious
20.1% 22.8%
diseases
Other infectious diseases
11.5%
Diarrhoea 12.8%
4.8%
Cancers
Tuberculosis 1.9% Respiratory infections
8.9% 8.5%
Cardiovascular
diseases Diarrhoea
12.9% 0.3%
Injuries Tuberculosis
0.6% Cardiovascular
3.5%
Other diseases diseases
Other diseases
WHO 99086

Injuries 30.4%
35.1% 17.5% 8.5%

Sources: 1909 data: Preston SH, Keyfitz N, Schoen R. Causes of death: Life tables for national populations. New York and London, Seminar Press, 1972.
1999 data: Estimates based on data from the WHO Mortality Database.
14 The World Health Report 1999

Health policy-makers in the early decades of the 21st century will thus need to address
a double burden of disease: first, the emerging epidemics of noncommunicable diseases
and injuries, which are becoming more prevalent in industrialized and developing coun-
tries alike, and second, some major infectious diseases which survived the 20th century –
part of the unfinished health agenda. This chapter describes this double burden of disease.
It points to the availability of cost-effective interventions that make it possible to complete
substantially the unfinished agenda in the first decade of the 21st century. Health systems
development – discussed in the next chapter – must focus on delivering these interventions
for the poor.

EMERGING EPIDEMICS OF
NONCOMMUNICABLE DISEASES AND INJURIES
The next two decades will see dramatic changes in the health needs of the world’s
populations. In the developing regions, noncommunicable diseases such as depression
and heart disease are fast replacing the traditional enemies, in particular infectious diseases
and malnutrition, as the leading causes of disability and premature death. Injuries, both
intentional and unintentional, are also growing in importance and by 2020 could rival in-
fectious diseases worldwide as a source of ill-health (1). The rapidity of change will pose
serious challenges to health care systems and force difficult decisions about the allocation
of scarce resources.
To provide a valid basis for such difficult health policy decisions, there is a great need for
the development of reliable and consistent data on the health status of populations world-
wide. Further, as The world health report has argued before (4,5), a new approach to measur-
ing health status needs to be implemented, one that quantifies not merely the number of

Figure 2.2 The emerging challenges: DALYs attributable to noncommunicable diseases in low and middle income countries,
estimates for 1998

Alcohol dependence Other cardiovascular Lung

Bipolar depression 10% Inflammatory 23% Rheumatic Stomach 12%
11% Psychoses heart disease heart disease 11%
9% 8% 5%
Breast
Obsessive-compulsive
6%
Unipolar disorders
major depression 8% Other
Stroke Ischaemic Liver
38% cancers
29% heart disease 12%
53%
Other neuropsychiatric 35% Leukaemia
24% 6%
Cardiovascular
Neuropsychiatric diseases Cancers
conditions 10% 5%
10%

Injuries
16%
WHO 99088

Other diseases
59%

Source: Annex Table 3.

 The Double Burden: Emerging Epidemics and Persistent Problems 15

deaths but also the impact of premature death and disability on populations, and which
combines them into a single unit of measurement. Several such measures have been devel-
oped in different countries, many of them being variants of the so-called Quality-Adjusted
Life Year (QALY), which is principally used to measure gains from interventions. In con-
trast, the Disability-Adjusted Life Year (DALY) is a measure of the burden of disease.
DALYs express years of life lost to premature death and years lived with a disability,
adjusted for the severity of the disability. One DALY is one lost year of healthy life. A “prema-
ture” death is defined as one that occurs before the age to which the dying person could
have expected to survive if he or she was a member of a standardized model population
with a life expectancy at birth equal to that of the world’s longest-surviving population,
Japan. Disease burden is, in effect, the gap between a population’s actual health status and
some reference status.
The initial assessment of global disease burden using DALYs was prepared in 1993 for
the World Bank (6) in collaboration with WHO. Subsequently revisions and extensive docu-
mentation of disease burden for the year 1990 have been published (1). In this report,
disease burden has been quantified using “standard DALYs”, calculated according to the
methods described in earlier work on the burden of disease (1). This report provides new
estimates of disease burden for the year 1998.

NONCOMMUNICABLE DISEASES
In 1998, an estimated 43% of all DALYs globally were attributable to noncommunicable
diseases. In low and middle income countries the figure was 39%, while in high income
countries it was 81%. Among these diseases, the following took a particularly heavy toll
(see Figure 2.2):
• neuropsychiatric conditions, accounting for 10% of the burden of disease measured in
DALYs in low and middle income countries and 23% of DALYs in high income coun-
tries;
• cardiovascular diseases, responsible for 10% of DALYs in low and middle income coun-
tries and 18% of DALYs in high income countries;
• malignant neoplasms (cancers), which caused 5% of DALYs in low and middle income
countries and 15% in high income countries.

One of the most surprising results of using a measure of disease burden which incorpo-
rates time lived with disability is the magnitude it ascribes to the burden of neuropsychiat-
ric conditions. Because of the limited mortality consequences, this burden was previously
underestimated. As shown in Box 2.1, a large proportion of the burden of disease resulting
from neuropsychiatric conditions is attributable to unipolar major depression, which was
the leading cause of disability globally in 1990. The disease burden resulting from depres-
sion is estimated to be increasing both in developing and developed regions. Alcohol use is
also quantified as a major cause of disease burden, particularly for adult men. It is the
leading cause of disability for men in the developed regions and the fourth leading cause in
developing regions.
These findings also highlight the “hidden epidemic of cardiovascular disease” (7). Within
cardiovascular diseases (CVD), which collectively are responsible for about one in eight
DALYs globally, ischaemic heart disease and cerebrovascular disease (stroke) are the most
significant conditions. It has been estimated that ischaemic heart disease will be the largest
single cause of disease burden globally by the year 2020 (1). Box 2.2 discusses in more detail
the nature of cardiovascular diseases in the Eastern Mediterranean Region. Substantive
16 The World Health Report 1999

evidence suggests that current programmes for CVD risk factor prevention and low-cost
case management offer feasible, cost-effective ways to reduce CVD mortality and disability
in populations both in developed and developing countries (8). Implementation of such
programmes should be a priority for health policy-makers as the burden of CVD rises in all
socioeconomic groups and inflicts major human and economic costs on societies.
The third largest cause of disease burden within noncommunicable conditions is can-
cer. Cancers are responsible for a large proportion of years of life lost and years lived with
disability. Among cancers, the most significant cause of disease burden is lung cancer, which
is projected to become ever more prevalent over the next few decades, if current smoking
trends continue. Tobacco is a major risk factor for several other noncommunicable diseases
as well. As discussed in detail in Chapter 5, tobacco control is one of the major public health
priorities for the 21st century.
Noncommunicable diseases are expected to account for an increasing share of disease
burden, rising from 43% in 1998 to 73% by 2020, assuming a continuation of recent down-
ward trends in overall mortality (which have yet to be realized in China and elsewhere) (9).
The expected increase is likely to be particularly rapid in developing countries. In India,
deaths from noncommunicable causes are projected to almost double from about 4.5 mil-
lion in 1998 to about 8 million a year in 2020.
The steep projected increase in the burden of noncommunicable diseases worldwide –
the epidemiological transition – is largely driven by population ageing, augmented by the
rapidly increasing numbers of people who are at present exposed to tobacco and other risk
factors, such as obesity, physical inactivity and heavy alcohol consumption. This increase in
noncommunicable diseases induced by changes in age distribution poses significant prob-
lems. Health systems must adjust to deal effectively and efficiently with the globally chang-

Box 2.1 The rising burden of neuropsychiatric disorders

Disease priorities change dramati- Of the ten leading causes of disease of DALYs, both in high income and in the area of mental health.As shown
cally as measurement of disease bur- burden in young adults (in the 15–44 low and middle income countries. Al- in the table,neuropsychiatric condi-
den shifts from simple mortality year age group) four were neuropsy- cohol dependence, bipolar disorder, tions are among the leading causes
indicators to indicators that incorpo- chiatric conditions. More specifically, and schizophrenia were among the of disability and burden. Psychiatric
rate disability.Neuropsychiatric con- unipolar major depression was the leading causes of disease burden in disorders are frequently a consider-
ditions have been ignored for a long fourth leading cause of overall disease this age group in 1998. able drain on health resources as a
time as they are absent from cause burden in 1990, while in adults aged Great attention needs to be paid to consequence of being misunder-
of death lists.However,when disease 15–44 years it was the leading cause the growing needs of populations in stood, misdiagnosed or improperly
burden measurement includes time treated. With proper budgetary
Rank of selected conditions among all causes of disease burden,
lived with a disability, several of the planning and allocation of resources,
neuropsychiatric disorders become estimates for 1998 introducing an effective mental
leading causes of disease burden Rank in cause-list health programme into primary
worldwide. Disease or injury World High Low and health care can reduce overall health
income middle income
Annex Table 3 reports that 11% of countries countries
costs. Mental health care, unlike
the global burden of disease in 1998 many other areas of health,does not
was attributable to neuropsychiatric Unipolar major depression 4 2 4 generally demand costly technol-
Alcohol dependence 17 4 20
conditions;in high income countries, ogy; rather, it requires the sensitive
Bipolar disorder 18 14 19
one out of every four DALYs was lost Psychoses 22 12 24 deployment of personnel who have
to a neuropsychiatric condition, Obsessive-compulsive disorder 28 18 27 been properly trained in the use of
while in low and middle income Dementia 33 9 41 relatively inexpensive drugs and
countries this group of conditions Drug dependence 41 17 45 psychological support skills on an
was responsible for one out of ten Panic disorder 44 29 48 outpatient basis.
DALYs. Epilepsy 47 34 46
Source: Annex Table 3.
 The Double Burden: Emerging Epidemics and Persistent Problems 17

ing nature of illness, and health policy-makers will be challenged to find the most cost-
effective uses of their limited resources to control the rising epidemics of noncommunicable
diseases. In contrast to the limited number of conditions responsible for most of the excess
disease burden among the poor, policy-makers will need to develop systems capable of
responding to an enormous variety of conditions as the epidemiological transition ma-
tures.
At the same time, health policy-makers will need to respond to the unexpectedly per-
sistent inequalities in health status within countries. This is a problem that affects disadvan-
taged populations in developed and developing countries alike. Traditionally, the focus of
global health policy has been on the less developed nations. Recent studies have revealed
surprisingly large inequalities within developed nations, and they highlight the need for
policies that focus on disadvantaged populations throughout the world. Box 2.3 summa-
rizes some of the findings of national studies on inequalities in the USA and the UK.

INJURIES
Injuries, intentional and unintentional, are a large and neglected health problem in all
regions, accounting for 16% of the global burden of disease in 1998. Figure 2.3 shows the
major categories of injuries responsible for most of the burden. Road traffic accidents were
the ninth leading cause of disease burden globally in 1998, fifth in the high income coun-
tries and tenth in the low and middle income countries. For adult men aged 15–44, road
traffic accidents are the biggest cause of ill-health and premature death worldwide, and the
second biggest in developing countries. The burden from road traffic accidents is projected
to increase globally, and particularly in developing countries. In sub-Saharan Africa, partly
because of the projected reduction of the burden from infectious diseases, injuries (prima-
rily road traffic accidents, war and violence) are expected to account for a large proportion
of ill-health.
Recent figures for homicides, suicides and traffic accident deaths for countries in the
Americas show that these rank as the main causes of death and disability. Every year, close
to 120 000 people are killed, 55 000 commit suicide, and 126 000 die in traffic accidents
in the Americas (10). At least 12 countries have homicide rates above 10 per 100 000
inhabitants.

Box 2.2 Cardiovascular diseases in the Eastern Mediterranean

The countries of the Eastern Medi- cardiovascular diseases are more shows that coronary heart disease is fore working with countries to es-
terranean are going through an epi- prevalent than before. Diets have a increasing as a cause of hospital ad- tablish pilot projects to provide in-
demiological transition, leaving higher fat content; there are over 17 mission and is being seen at younger formation on risk factors and to
many of them with the double bur- million people with diabetes and a fur- ages than before. Hypertension has promote healthy lifestyles with re-
den of infectious and noncommuni- ther 17 million with impaired glucose been reported to affect more than gard to tobacco use, diet and physi-
cable diseases. The ageing of the tolerance; smoking is widespread es- 20% of adults, but it is estimated that cal activity. Special emphasis is
population, progressive urbaniza- pecially among younger people; and more than half of the cases are not di- placed on inculcating good habits in
tion, and changes in nutritional hab- physical activity is insufficient.Preven- agnosed. children and adolescents.Efforts are
its and lifestyles all contribute to the tion has the potential to reduce mor- Community-based intervention made to involve local groups and
occurrence of cardiovascular dis- tality further. programmes have been shown to be community decision-makers, so as
eases. Mortality data are inadequate in effective in promoting healthy life- to mobilize the community and en-
Although age-specific mortality many countries of the Eastern Medi- styles and reducing the incidence of sure that people are able to follow
rates are declining,the risk factors for terranean, but available information cardiovascular diseases.WHO is there- healthier lifestyles.
Contributed by the WHO Regional Office for the Eastern Mediterranean.
18 The World Health Report 1999

Violence and self-inflicted injuries (including suicide) are a major public health concern
because of their increasing significance within the global disease burden. Injuries primarily
affect the younger age groups and often result in disabling conditions. In higher income
countries, road traffic accidents and self-inflicted injuries were among the ten leading causes
of disease burden in 1998 as measured in DALYs. In less developed countries, road traffic
accidents were the most significant cause of injuries, ranking eleventh among the most
important causes of lost years of healthy life. War, violence and self-inflicted injuries were
all among the leading twenty causes of such loss in those countries. Intentional injuries
primarily affect young adults, with males in the age group of 15–34 years bearing a particu-
larly large proportion of the burden.
Domestic violence, especially against women, is not always reflected in physical injury
but may be apparent in psychological sequelae. Traditionally, violence has been classified as
intentional injury. While it is clearly important to recognize violence as a cause of injury,

Figure 2.3 The emerging challenges: DALYs attributable to injuries in low and middle income countries,
estimates for 1998

Cardiovascular diseases
Neuropsychiatric conditions 10% Road traffic
10% Cancers accidents
5% 16%
Other
injuries Self-inflicted
54% injuries
Injuries 9%
16%
Homicide
and violence
10%
Other diseases War

WHO 99081
59% 11%

Source: Annex Table 3.

Box 2.3 Health inequalities in the USA and the UK

The use of national life expectancy ancy between females in Stearns,Min- pared to the range in mortality ob- ish government reviewed the evi-
at birth as a measure of health and nesota and males in Bennett, Jackson, served between the established mar- dence on inequalities in health in
well-being of a population places Mellette, Shannon, Todd and ket economies and sub-Saharan Africa. England.The report published in No-
the United States among the better- Washabaugh counties, South Dakota, On the other hand, the USA has been vember 1998 states that although
off countries. National life expect- is 22.48 years. This range becomes much less successful in reducing in- average mortality rates have fallen
ancy has been rising steadily for both even wider – 41.3 years – when race- equalities in adult male and to a lesser in the last 50 years, unacceptable
men and women in the last half of specific life expectancy across counties but substantial extent adult female inequalities in health have persisted.
the century. National life expectancy is calculated. This difference of 41.3 mortality.While the focus of most pub- The report identified three crucial
is an aggregate measure and masks years corresponds to 90% of the glo- lic health analysis remains health con- approaches:all policies likely to have
the remarkable variation that is ob- bal range from the population with the ditions in children and the elderly, the an impact on health should be
served within the nation.The results lowest life expectancy (males in Sierra largest inequalities in the USA relative evaluated in terms of their impact
from the on-going study on the bur- Leone) to the population with the to the rest of the world are found in on health inequalities; a high prior-
den of disease and injury in the USA highest (females in Japan). adult male and adult female health ity should be given to the health of
have shown that at the county level, The USA has been reasonably suc- conditions. families with children; and further
the range in life expectancy is simi- cessful at reducing the inequalities in Large health inequalities have also steps should be taken to reduce in-
lar to the range observed across all absolute terms (not relative terms) in been reported in the UK. Last year an come inequalities and improve the
countries. The range in life expect- child and adolescent mortality as com- independent inquiry set up by the Brit- living standards of poor households.
Sources: Murray CJL et al. US patterns of mortality by county and race: 1965--1994. Cambridge MA, Harvard Center for Population and Development
Studies, 1998 (US Burden of Disease and Injury Monograph Series).
Report of the Independent Inquiry into Inequalities in Health. London, The Stationery Office, 1998.
 The Double Burden: Emerging Epidemics and Persistent Problems 19

particularly among women where the connection may not always be evident, the health
consequences also need to be understood. So too does the different nature of the violence
experienced by men, women and children.
Globally, injuries are responsible for one in six years lived with disability. Injuries have,
nevertheless, often been a neglected area of public health policy. More attention there-
fore needs to be focused on dealing with the growing problem of injuries – through more
comprehensive prevention, improved emergency and treatment services, and better
rehabilitation.

PERSISTENT PROBLEMS OF
INFECTIOUS DISEASES AND MATERNAL
AND CHILD DISABILITY AND MORTALITY
Despite the extraordinary advances of the 20th century, a significant component of the
burden of illness globally still remains attributable to infectious diseases, undernutrition
and complications of childbirth. These conditions are primarily concentrated in the poorest
countries, and within those countries they disproportionately afflict populations that are
living in poverty. The residual concentration of infectious diseases afflicting the poor is truly
an avoidable burden, because inexpensive and effective tools exist to deal with much of it.
In fact, it mostly results from relatively few conditions.
The disproportionate share of the burden of disease on the poor is demonstrated in
Table 2.1 and Figure 2.4, based on analyses reported in Annex Table 7. Within countries, the
disadvantaged fare much worse as measured by several health indicators than the better-
off. Those living in absolute poverty, compared with those who are not poor, are estimated
to have a five times higher probability of death between birth and the age of 5 years, and a
2.5 times higher probability of death between the ages of 15 and 59 years. Overall, the poor
fare worse than the better-off in society on all health indicators studied. Figure 2.4 demon-
strates the distinctly different distributions across countries of health indicators for the poor
and the non-poor. It clearly shows that the non-poor have a much higher overall health
level than the poor.
These data illustrate another critical point. Some countries attain far better health con-
ditions for their poor people than others. Poor children in China have less than a third of
the risk of dying before their fifth birthday than comparably poor children in the United

Table 2.1 Health status of the poor versus the non-poor in selected countries, around 1990
Country Percentage of Probability of dying per 1000 Prevalence of
population between birth between ages 15 tuberculosis
in absolute and age 5, females and 59, females
povertya Non-poor Poor:non-poor Non-poor Poor:non-poor Non-poor Poor:non-poor
ratio ratio ratio
Aggregate b 38 4.8 92 4.3 23 2.6
Chile 15 7 8.3 34 12.3 2 8.0
China 22 28 6.6 35 11.0 13 3.8
Ecuador 8 45 4.9 107 4.4 25 1.8
India 53 40 4.3 84 3.7 28 2.5
Kenya 50 41 3.8 131 3.8 20 2.6
Malaysia 6 10 15.0 99 5.1 13 3.2
a Poverty is defined as income per capita of less than or equal to $1 per day, expressed in dollars adjusted for purchasing power.
b The aggregate estimate refers to all countries listed in Annex Table 7.

See Explanatory Notes to the Statistical Annex for an explanation of the methods used to derive the estimates.
Source: Annex Table 7.
20 The World Health Report 1999

Republic of Tanzania. Poverty is not an insurmountable barrier to better health when poli-
cies are right. This further illustrates that much of the burden on the poor is unnecessary.

THE UNFINISHED AGENDA

The populations of developing countries and particularly the disadvantaged groups within
those countries remain in the early stages of the epidemiological transition, where infec-
tious diseases are still the major cause of death. Figure 2.5 depicts the distribution of deaths
in low and middle income countries in 1998. It illustrates the five major childhood condi-
tions which are responsible for 21% of all deaths in low and middle income countries:
diarrhoea, acute respiratory infections, malaria, measles and perinatal conditions. Almost
all DALYs from these five conditions occur in developing countries. Less than 1% are reg-
istered in high income countries. It is noteworthy that most of the DALYs among infants
and young children are attributable to a limited number of conditions for which either
preventive or curative interventions exist. This report will argue, in Chapter 3, that a priority
for health systems development is to achieve effective delivery of these interventions, which
are delineated below.
Immunization programmes have yielded the most significant changes in child health in
the last few decades. Although some vaccines represent the most cost-effective public health
intervention of all, the world does not use them enough. At least 2 million children still die
each year from diseases for which vaccines are available at low cost. Similarly, for diarrhoeal
disease, there exists a simple, inexpensive and effective intervention: oral rehydration therapy.
Diarrhoeal diseases and pneumonia together account for a high proportion of deaths of
children in developing countries. In several developing countries, therefore, diarrhoeal dis-
ease control programmes have been merged with a simplified approach, promoted by WHO,
to detecting acute respiratory infections (primarily pneumonia).
In adults, maternal conditions, HIV/AIDS and tuberculosis are the three major causes of
disease burden in developing regions, as depicted in Figure 2.5. Together, they accounted
for 7% of all DALYs in 1998. Among maternal conditions, obstructed labour, sepsis and
unsafe abortion were among the ten leading causes of death and disability among women
aged 15–44 years in developing countries in 1998. The burden of maternal conditions has
been hard to quantify because of the lack of reliable data. But it is a major public health
problem and represents a major and unnecessary burden for which policy-makers should
increasingly be held accountable.

Figure 2.4 Distribution of the probability of death, selected countries, around 1990
30

25
Number of countries

20

15

10
WHO 99084

0
0 10 20 30 40 50 60 70 80 90 100
Probability of death between ages 15 and 59, females
Source: Annex Table 7. Non-poor Poor
 The Double Burden: Emerging Epidemics and Persistent Problems 21

THE PERSISTING AND EVOLVING CHALLENGES

Despite the successful eradication of smallpox and the control of several infectious dis-
eases in the 20th century, there remain some significant threats that are particularly chal-
lenging because of the changing nature of the disease pattern and the ways it manifests
itself in populations. A clear example is malaria. Public health efforts in the last four dec-
ades have been remarkably effective in reducing the burden of malaria in South-East Asia
and Latin America. Despite this achievement, malaria remains a major public health prob-
lem, particularly in Africa (see Annex Table 8). Malaria has been named as one of WHO’s
top priorities. Chapter 4 provides a detailed overview of the problem and the WHO ap-
proach to it.
Malaria, along with HIV/AIDS and tuberculosis, can be classified among a group of
diseases for which control efforts are being jeopardized by microbial evolution. This prob-
lem is described in Box 2.4. Figure 2.5 demonstrates that a large proportion of the deaths
occurring between the ages of 15 and 59 years in low and middle income countries can be
attributed to HIV and tuberculosis. Effective and cost-effective strategies for controlling
tuberculosis exist; but standard treatment regimens require six or more months of chemo-
therapy and rely on well-organized services to achieve high rates of adherence. The inter-
action of HIV and tuberculosis is also an important public health matter, as individuals who
are infected with both are more likely to die from tuberculosis than from other infections.
During the period of active tuberculosis infection, they may transmit the infection to previ-
ously uninfected contacts. Because HIV infection is projected to increase over the coming
decade, the burden from tuberculosis may also increase unless there are energetic efforts to
extend the reach of existing control measures with proven effectiveness and cost-effective-

Figure 2.5 DALYs attributable to conditions in the unfinished agenda in low and middle income
countries, estimates for 1998

Tuberculosis Maternal Acute respiratory

conditions infections Perinatal
22%
25% 27% conditions
26%

Malaria
Measles
13%
10%
HIV/AIDS
54% Diarrhoea
24%
Major adult Major childhood
conditions conditions
10% 23%

All other conditions

WHO 99082

66%

Source: Annex Table 3.

22 The World Health Report 1999

ness, as well as to invest in the development of new tools for tuberculosis control. The
tuberculosis situation in the Western Pacific Region is described in Box 2.5.
The challenge posed by these persisting and evolving conditions is that tools to control
them have either not been developed or, if available, are not used effectively or, in some
cases, are becoming increasingly ineffective (11). As examined in more detail in Box 2.4,
antimicrobial resistance is a worrying phenomenon since it could have great adverse effects
on the control and treatment of diseases such as pneumonia, tuberculosis and malaria.
These conditions emphasize the need, as discussed further in Chapter 3, for health systems
to invest in research and development strategies to come up with cost-effective tools to
control the remaining threats from infectious diseases.
Increases in international air travel, trade – particularly the food trade – and tourism
mean that disease-producing organisms, the deadly as well as the commonplace, can be
transported rapidly from one continent to another (4). This trend may threaten interna-
tional public health security, although so far the consequences have remained quantita-
tively unimportant. To counter any such threat, the global surveillance of infectious diseases
is being improved through an international information network. This should make it pos-
sible to recognize outbreaks faster.

THE AVOIDABLE BURDEN OF DISEASE

The most significant fact about the unnecessary burden is that it is concentrated on a
few conditions, most of which are avoidable. There are many vaccines, drugs and clinical
algorithms that if employed globally would lead to a dramatic reduction in the burden of
infectious diseases. Figure 2.6 illustrates the links between infant mortality rates and per
capita income in some of the most populous low and middle income countries. The coun-
tries that are above the curve in 1990 are low and middle income countries which had a
higher infant mortality rate than expected, given their average income per capita. Their
distance above the curve indicates potential reductions in mortality, i.e. the gains that would

Box 2.4 Microbial evolution – the continually changing threat of infectious disease
Resistance of disease-causing or- that favour overgrowth of bacteria compliance with treatment have led In the USA, antibiotic-resistant bac-
ganisms to antimicrobial drugs and carrying a gene that confers resist- to the development of strains of teria generate costs of a minimum
other agents has become a great ance.The continuous use of antimi- Mycobacterium tuberculosis which are of $4 billion to $5 billion yearly; these
public health concern worldwide. It crobial agents encourages the resistant to the available drugs.Malaria costs are likely to be much higher in
is having a deadly impact on the multiplication and spread of resist- presents a double resistance problem: developing countries.
control of diseases such as tubercu- ant strains. resistance of the Plasmodium parasites, Answering questions concerning
losis, malaria,cholera, dysentery and The result is that drugs which cost which cause the disease,to antimalar- the use of antibiotics in food produc-
pneumonia. tens of millions of dollars to produce, ial drugs; and resistance of the Anoph- tion, emphasizing ways to prolong
Antimicrobial resistance is not a and take perhaps 10 years to reach eles mosquitoes, the vectors of the the effectiveness of existing antibi-
new, nor a surprising problem, but it the market, are only effective for a disease, to insecticides. Pneumococci otics, pursuing key areas of basic
has worsened in the last decade. All limited time period.Examples of dis- and Haemophilus influenzae, the most research and seeking incentives
bacteria possess an inherent flexibil- eases whose agents have demon- common bacteria causing acute res- for developing new antibiotics, and
ity that enables them,sooner or later, strated drug resistance include piratory infections in children, are be- exploring legal and regulatory
to evolve genes that render them tuberculosis, malaria, gonorrhoea coming more resistant to drugs. More mechanisms in key areas of need are
resistant to any antimicrobial.By kill- and typhoid fever. than 90% of Staphylococcus aureus priorities that need to be addressed
ing susceptible bacteria, an antimi- In the case of tuberculosis, poor strains and about 40% of pneumo- by policy-makers.
crobial provides selective pressures prescribing practices or poor patient cocci strains are resistant to penicillin.
Source: Harrison PF, Lederberg J (eds). Antimicrobial resistance: Issues and options. Institute of Medicine. Washington DC, National Academy Press, 1998.
 The Double Burden: Emerging Epidemics and Persistent Problems 23

result from their joining the curve. That the infant mortality rate in low and middle income
countries is higher in the most populous countries suggests the importance of focused
international assistance. Health systems need to provide the existing, cost-effective inter-
ventions to these populations so that the countries that are currently lagging behind can
join the curve.
Immunization is the greatest public health success story in history (12).The basic vaccines
are available to combat the six major diseases in children (measles, tetanus, pertussis, tu-
berculosis, poliomyelitis and diphtheria). Immunization coverage falls far short of 100%,
and it is the world’s poorest and most vulnerable children who remain unreached.
Poliomyelitis is an example of a disease for which eradication is possible. The only rea-
son for the existence of remaining cases is insufficient coverage. WHO is committed to

Figure 2.6 Infant mortality rate related to income

100
Bangladesh
Nigeria
Pakistan IMR in the most highly
populous countries far
India
Infant mortality rate (IMR) in 1990

75 exceeds predicted levels.

Indonesia
(per thousand)

Turkey
50 Brazil
China
Islamic Mexico
Republic
25 of Iran

WHO 99085
0
0 1 000 2 000 3 000 4 000 5 000 6 000 7 000 8 000 9 000 10 000
GDP per capita, adjusted for purchasing power
(in 1985 international dollars)
Note: For explanation of the curve ralating IMR to income, see note to Figure 1.4.

Box 2.5 Tuberculosis in the Western Pacific

The notified cases of tuberculosis veillance of HIV infection among tu- urban population: 39% of them were cess to the strategy. In China, a DOTS
in the Western Pacific Region in 1996 berculosis patients in Cambodia, Ma- infected with the disease. programme supported by the World
represented 25% of the global total, laysia, and Viet Nam. Tuberculosis ignores national Bank is being implemented with
mainly because expansion of the Data from 21 countries and areas in boundaries. In Australia, Hong Kong WHO collaboration in 13 provinces.
WHO tuberculosis control strategy, the Region show that the majority of (China), Malaysia and Singapore, the The programme has so far achieved
particularly in China, improved case cases occurred during the productive numbers of tuberculosis cases have a cure rate of over 90% and is acces-
management and brought many years of life. Delayed diagnosis or par- not decreased for several years be- sible to 560 million people. In Cam-
more cases under treatment. There tial treatment often lead to long- cause of the increased or continued bodia, more than 90% of district
were 2.16 million estimated new standing lung disability and job loss, detection of new tuberculosis patients health facilities are using DOTS as a
cases in 1997, and the average case causing socioeconomic hardship. Un- among immigrants. routine strategy. In the Philippines,
fatality rate was 20%. Coinfection treated or inadequately treated tuber- The directly observed treatment, a new approach using DOTS began
with HIV is still low in the Region as culosis patients spread the infection to short course (DOTS) strategy was in- in three provinces in 1996, in col-
a whole, but those who are coinfec- others, especially in crowded and poor troduced in the Western Pacific in the laboration with WHO, raising the
ted with tuberculosis and HIV may communities.Children aged 5–9 years early 1990s and is now used in 28 cure rate from 60% to 80%. DOTS
reach 26 per 100 000 population by living in urban slums in the Philippines countries and areas; 35% of tubercu- will be accessible to more than half
2000. WHO has been collaborating showed more than twice the preva- losis cases are treated with DOTS, and of the total population in the coun-
closely in the establishment of sur- lence rate of infection for the general 55% of the total population have ac- try by the end of 1999.
Contributed by the WHO Regional Office for the Western Pacific.
24 The World Health Report 1999

eliminating poliomyelitis cases by the year 2000. As is shown in Figure 2.7, there have been
remarkable reductions in the geographical spread of the disease since 1988. The last case
caused by wild poliovirus in the Western hemisphere occurred in Junin, Peru, on 23 August
1991. The last case in WHO’s Western Pacific Region was recorded in March 1997 near
Phnom Penh in Cambodia. WHO has just initiated a “final stretch” effort with the goal of
stopping transmission globally by December 2000, of certifying this achievement by 2005
and of stopping immunization by 2010. The eradication effort illustrates two important
points. First, partnerships with nongovernmental organizations can be very productive:
Rotary International has made major commitments to polio eradication and its influence
with local leaders plus financial contributions (about US$ 500 million) have been critical to
success. Second, properly designed, highly goal-oriented programmes can contribute im-
portantly to health systems development.
WHO is also involved with the provision of interventions against several other infec-
tious diseases. The Integrated Management of Childhood Illness is a group of preventive
and curative interventions. The strategy focuses on pneumonia, diarrhoea, measles, ma-
laria and malnutrition, as these account for 70% of all childhood deaths globally, but it also
addresses other serious infections (for example, meningitis), other causes of febrile disease
(for example, dengue) and other associated problems (such as eye problems associated
with measles or vitamin A deficiency, and ear infections). Preventive interventions includ-
ing immunization, support for breastfeeding and other nutrition counselling are also em-
phasized.
Other similar initiatives are in different stages of development and implementation. For
tuberculosis, the “directly observed treatment, short course” (DOTS) intervention has been

Figure 2.7␣ ␣ Reductions in wild poliovirus transmission between 1988 and 1998

Free of wild poliovirus transmission by 1988

Free of wild poliovirus transmission by 1998
Known or probable wild poliovirus transmission in 1998
No data available WHO 99083
 The Double Burden: Emerging Epidemics and Persistent Problems 25

shown to be highly cost-effective (see Box 2.6). Tuberculosis is highly concentrated in poor
subgroups of populations, as indicated in Table 2.1. Prevalence of tuberculosis is estimated
to be almost four times higher in populations living below the poverty line than in the
better-off. The adult lung health initiative has grown out of the tuberculosis control activi-
ties of WHO, recognizing that only a small proportion of adults presenting with a cough
have tuberculosis and that adequate treatment or advice should be provided to individuals
with other lung diseases. The initiative offers an integrated approach to detecting and treating
tuberculosis, asthma and chronic obstructive lung disease.
Maternal mortality risks, which are highly concentrated in developing countries, are
also to a large extent preventable and avoidable. The mother–baby package aims to reduce
mortality and disability associated with maternal reproductive health, the risks of delivery
for both mother and child, and the first weeks of life.
At the end of the 20th century, it is unacceptable that women continue to suffer and die
as a result of complications related to pregnancy and childbirth. The enormous disparities
in levels of maternal mortality and morbidity between rich and poor are a continuing af-
front. The evidence of what works to reduce maternal mortality already exists. The inter-
ventions needed are cost-effective. Expanding health system coverage is required: women
must have access to skilled assistance during pregnancy and childbirth, and they must be
able to reach a functioning health care facility when complications arise.

Box 2.6 Tuberculosis and the “Stop TB” Initiative

Tuberculosis was one of the chief where resources are generally suffi- the high burden countries which ac- preparations of anti-tuberculosis
causes of death in northern Europe cient,their poor allocation and ineffec- count for 80% of the global epidemic, drugs and to ensure coordinated
and the Americas until about 1900. tive use often result in treatment the International Union against Tuber- international arrangements for
Mortality rates gradually fell because which fails to cure almost all patients. culosis and Lung Disease, the Royal their financing, procurement and
of improved living conditions and These conditions explain the evolution Netherlands Tuberculosis Association, supply, quality control and distri-
the advent of effective chemo- of multidrug-resistant strains of tuber- the American Lung Association, the bution.
therapy, but the disease persisted in culosis. American Thoracic Society, the US • A global research agenda to ad-
developing countries, where it Since 1989, WHO has encapsulated Centers for Disease Control and Pre- dress short-term operational con-
causes some 25% of preventable current best practice for tuberculosis vention, the World Bank and WHO. straints and the development of
mortality among young people. It is case-finding and treatment into the WHO aims to expand significantly this new diagnostic agents, drugs and
still a leading killer of young women DOTS (directly observed treatment, global coalition and to increase invest- vaccines. It will facilitate collabo-
worldwide. About 1.8 billion people short course) strategy and, together ment in tuberculosis control, in order ration on research capacity
are infected with the tuberculosis with the World Bank and Harvard Uni- to attain the Stop TB goal of reducing strengthening in low income,high
bacillus,and the tuberculosis burden versity, has shown it to be one of the the tuberculosis disease burden. prevalence countries; expansion
will grow with an expanding global most cost-effective health interven- The Stop TB initiative will focus on of appropriate policy-relevant
population. Inappropriate or inad- tions available.Over 100 countries now four products to accomplish its objec- health systems research; control
equate tuberculosis treatment fur- accept DOTS as a standard approach, tives. and treatment of multidrug-
ther increases transmission. So do and over 1 million patients have been • A global action plan to guide and resistant tuberculosis; and the
such assaults on the health of the treated with it since 1990. Global accelerate coordinated responses to development of new tools.
poor as hunger, civil disturbances surveillance systems have been estab- tuberculosis control internationally, • A global charter for advocacy and
and, most importantly, HIV which lished and the spread of drug resist- regionally and nationally. It will commitment to enable endemic
alone will account for some 14% of ance is being charted. offer an analytical framework and countries and their partners to
global cases by the year 2000. But progress is too slow, mainly be- recommendations for immediate declare renewed commitment
Because tuberculosis predomi- cause of the lack of political will and action in high burden countries and and agreement on specific steps
nantly hits young adults, its social commitment within a number of high particular settings, such as areas to be taken. It will generate in-
and economic consequences are prevalence countries to broaden the significantly affected by multidrug- creased international attention to
among the greatest of any infectious deployment of the strategy to all who resistant strains of tuberculosis. tuberculosis.Specific performance
disease.Almost all cases are in coun- need it. The “Stop TB” initiative arose • A global tuberculosis drug facility to targets will enable the monitoring
tries least able financially to mount from discussion of these constraints provide universal access to high and reporting of progress.
an effective response. In countries between representatives of several of quality Fixed Dose Combination
26 The World Health Report 1999

Syndromic treatment of sexually transmitted infections is another example of defining

best practices in the face of resource constraints. Box 2.7 describes successful interventions
to stop HIV transmission in Thailand and elsewhere in South-East Asia.
Rationalization of drug use and development of drug supply systems can similarly be
aided by clearly defined standard guidelines where first and second line drugs for each
level are specified. Revision of the regulations on who can use which drugs is often needed.
For example, an injection of quinine for severe malaria or chloramphenicol for severe pneu-
monia, prior to referral to a higher level in the health system, may be life saving. But health
staff at first-level facilities may not be authorized to use injectable drugs or the drugs may
be supplied regularly only to hospitals. Policies may need to be changed to accommodate
broader use of certain drugs for defined purposes.
In addition to the disease-specific interventions and control programmes which are
available, there is also a need to deal with a significant risk factor for disease, malnutrition,
which is primarily concentrated in the world’s poorest and most disadvantaged populations.
Malnutrition is estimated to be the single most important risk factor for disease, being
responsible for 16% of the global burden in 1995, measured in DALYs (1). Malnutrition,
either in the form of protein-energy malnutrition or micronutrient malnutrition, primarily
of iron, vitamin A and iodine, often contributes to premature death, poor health, blindness,
growth stunting, mental retardation, learning disabilities and low work capacity (13,14).
Protein-energy malnutrition, as indicated by slow or incomplete physical growth is, how-
ever, as much a consequence of disease as a cause. Infection may, in many environments,
contribute more to malnutrition than dietary inadequacy. Hence disease control is impor-
tant for reducing the malnutrition burden.

Box 2.7 HIV/AIDS control in South-East Asia: the challenge of expanding successful programmes
The human immunodeficiency vi- from high-risk groups to the general • Needle exchange programmes and ing of primary care workers, manag-
rus (HIV) was slower to emerge in population. community-based treatment ap- ers and private practitioners. WHO
South-East Asia than in other parts National authorities in the Region proaches for injecting drug users in and UNAIDS provide support to gov-
of the world, but it is now a serious are responding to the pandemic with Myanmar and Nepal have been ef- ernments in order to monitor the
public health problem and a threat urgency. They have developed strate- fective in bringing about behav- trends of the HIV/AIDS pandemic
to development. The first patient gic plans and are implementing a va- ioural change and reducing HIV through surveillance, to promote
with AIDS was reported in 1984 from riety of control measures, as the infection rates. research, to ensure safe blood trans-
Thailand, since when a total of following examples show. fusions, and to strengthen labora-
92␣ 391 cases of the disease have • Thailand’s 100% condom use pro- WHO continues to provide techni- tory diagnostic services. Other
been reported up to 1 July 1997, gramme has received worldwide cal, material and logistical support to priority interventions include case
mostly from Thailand, India and attention. Its effectiveness can be national programmes for AIDS preven- management capacity building,
Myanmar. However, because of un- assessed by the declining HIV inci- tion and the control of sexually trans- health promotion and education,
der-reporting and under-diagnosis dence among military recruits: from mitted diseases, through the Regional and the planning of comprehensive
the reported cases only reflect a pro- 3.6% in 1993 to 2.1% in 1995. At the Office in New Delhi and in selected care and counselling for people with
portion of the true problem.UNAIDS same time, sexually transmitted dis- countries. WHO collaborates with the AIDS or infected with HIV.
and WHO estimate that there are eases are at a lower rate than ever World Bank and with UNAIDS – of Evidence shows that intervention
currently more than 5.5 million peo- before. which it is a cosponsor – in assisting can succeed. Augmented political,
ple in WHO’s South-East Asia Region • In Calcutta, India, the Sonagachi national programmes and in carrying financial and technical support is
(which includes India) who are in- health care and education project out intercountry and regional activi- required to make sure that interven-
fected with HIV – 18% of the global among sex workers has become a ties. tions are delivered where they are
total. In 1998 alone there were esti- model for successful peer education; The integration of care of sexually needed.
mated to be 1.2 million new infec- HIV prevalence remains low and transmitted diseases into the general
tions in the Region. Heterosexual sexually transmitted diseases are health services is considered a priority
transmission may spread the virus declining. in the region, necessitating the train-
Contributed by the WHO Regional Office for South-East Asia.
 The Double Burden: Emerging Epidemics and Persistent Problems 27

Interventions to reduce micronutrient malnutrition are likely to prove particularly cost-

effective. Programmes can include four strategies – supplementation, fortification, food-
based approaches leading to dietary diversification, and complementary public health control
measures – to the degree appropriate and feasible (13). The long-term goal of intervention
should be to shift emphasis away from supplementation towards a combination of food
fortification – universal salt iodization or iron-fortified flour, for example – and dietary di-
versification.
In conclusion, the double burden of disease defines the complexity of the problems
health systems must address. The two elements of the double burden differ markedly in
their implications for policy. The unfinished agenda deals with a limited number of condi-
tions, highly concentrated on the poor and for most of which extremely cost-effective inter-
ventions are available. This burden on the poor is, indeed, an unnecessary one that targeted
programmes can alleviate. Epidemiological transition, on the other hand, generates epide-
miological diversity. This aspect of the double burden involves large numbers of conditions
potentially affecting everyone, although here again the poor suffer more. Interventions –
whether preventive or curative – are less likely to be decisive, although there are important
exceptions, such as tobacco control discussed in Chapter 5. Health systems must be able to
respond flexibly to this diversity.

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