[Alma Mata] The maladies of affluence

[Tiago Villanueva]

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*Globalisation and health*

*The maladies of affluence*
Aug 9th 2007
>From The Economist print edition


    AFP [image: AFP]

**

*The poor world is getting the rich world's diseases*

IN 1619 an English captain sailing past Cape Cod reported that the
Massachusetts shore was "utterly void". The Indians "died in heapes as they
lay in their houses" confirmed an English merchant. By killing much of the
population of the Wampanoag confederacy, the epidemic that raged from
1616-19 made possible the first permanent European settlement in north
America, that of the Pilgrim Fathers in 1620. The Indians had caught the
illness, thought to have been viral hepatitis, from prior contact with
Europeans, probably captured French sailors.

Europeans have been exporting their maladies throughout history. They seem
to be doing it again, but in a new way. In the past, the problem was
infection. Now, illnesses associated with Western living standards are the
fastest growing killers in poor and middle-income countries. Chronic disease
has become the poor world's greatest health problem.

For many in the West, diseases are a bit like birds: everyone gets them but
poor countries have more exotic species. Rich-country maladies are things
like heart disease, cancer and diabetes: "chronic" conditions often
resulting from diet or physical inactivity. Developing countries suffer more
lurid and acute infections: malaria, tuberculosis, measles, cholera.
HIV/AIDS is unusual in that it affects rich and poor alike. But otherwise,
poor countries are presumed to have their own health problems. The sixth of
the United Nations' millennium development goals (a sort of ten commandments
of poverty reduction adopted in 2000) is concerned with infections only—the
ailments of poverty. The progress report issued last month half way through
the millennium programme's 15-year course tracks HIV/AIDS, malaria and
tuberculosis. Combating chronic disease is not part of what the UN calls its
"universal framework for development".

**

Yet the distinction between illnesses of affluence and illnesses of poverty
is misleading as a description of the world and doubtful as a guide to
policy. Heart disease—supposedly an illness of affluence—is by far and away
the biggest cause of global mortality. It was responsible for 17.5m deaths
worldwide in 2005. Next comes cancer, another non-infectious sickness, which
caused more deaths than HIV/AIDS, tuberculosis and malaria put together (see
chart 1). Chronic conditions such as heart disease took the lives of 35m
people in 2005, according to the World Health Organisation (WHO)—twice as
many as all infectious diseases.

If you look at lower-middle income countries, such as China, or upper-middle
income ones, like Argentina, you find that what kills people there is the
same as in the West (see chart 2). Four-fifths of all deaths in China are
from chronic sicknesses. That is also true of countries as varied as Egypt,
Jamaica and Sri Lanka.

The main difference between these countries and rich ones is that chronic
illnesses are more deadly there. Five times as many people die of heart
disease in Brazil as in Britain, though Brazil is not five times as
populous. Rich countries have become better at dealing with chronic
conditions: death rates from heart disease among men over 30 have fallen by
more than half in the past generation, from 600-800 per 100,000 in 1970 to
200-300 per 100,000 now.

**

This has not happened in middle-income countries. In 1980 the death rate for
Brazilian men was below the rich-country average (300 compared with
500-600). Its death rate has not changed—and is now higher than all but a
few rich countries. Russia is worse off. In 1980 its death rate was 750 per
100,000. Now it is 900, about four times as high as most rich countries.

It may not seem surprising that upper-middle income places such as Russia
suffer from "Western" ailments. But chronic diseases are mass killers in the
poorest nations, too. Indeed, the only unusual thing about these countries
is that they suffer from infections as well as chronic disease: a double
burden. Chronic diseases were responsible for over 12m deaths in countries
with annual incomes below $750 a head in 2005—almost as many as were caused
by communicable ones. Africa is the only continent where infectious
illnesses cause more deaths than the non-communicable kinds.

Chronic diseases are becoming deadlier and more burdensome to the poor. By
2015, says the World Bank, these ailments will be the leading cause of death
in low-income countries. They already account for almost half of all
illnesses there and impose substantial economic costs.

People in poor countries get chronic diseases younger than in the West.
There, chronic conditions bear heavily upon the old. Not so in poor and
middle-income nations. Death rates for those between 30 and 69 years of age
in India, Russia and Brazil are two or three times higher than in Canada and
Britain. Almost half of deaths from chronic problems in developing countries
occur in people below 70.

As a result, the poor suffer from chronic illnesses longer and are more
likely to die of them. The death rate from chronic disease in poor countries
is obviously higher than in rich countries; more surprisingly, it is often
higher than the death rate from infections. India, Pakistan, Nigeria and
Tanzania all have roughly the same death rate for cardiovascular disease:
400 per 100,000. That is at least twice as high as the Western norm and, at
least in India and Pakistan, more than four times the average death rate
from infections (in Nigeria and Tanzania, HIV/AIDS, malaria and tuberculosis
are still deadlier).

Chronic disease bears down especially hard on working adults, imposing a
heavy economic burden. Families in poor countries are much more likely than
in the West to spend their savings looking after a chronically ill relative,
or to pull children out of school to act as nursemaids.

In short, developing countries suffer more from "rich world maladies" than
the rich world itself. Overall in 2005, only a fifth of deaths attributable
to "illnesses of affluence" (chronic conditions) actually took place in the
most affluent nations. Three-quarters happened in poor or
lower-middle-income ones.

*Death eaters*

Why are poor countries so vulnerable to the diseases of the rich? And why
does public attention and aid money ignore them and focus on infections?

The simplest explanation for chronic diseases' increasing importance is that
people in poor countries now live long enough to suffer them. Thanks to
better sanitation, more food and improved public health, average life
expectancy in low and middle-income countries has risen from 50 in 1965 to
65 in 2005. The increase in the poorest countries was proportionately
greater: from 47 to 63. There are now more old people around to be
vulnerable to chronic maladies.

At the same time, because of increased health spending and safer water,
infectious diseases have declined relative to chronic ones. International
financing for malaria control has increased more than tenfold in the past
decade. The Bill and Melinda Gates Foundation, with its $33 billion
endowment, concentrates largely on infections. As a result, the incidence of
tuberculosis, measured by the number of new cases per 100,000, has fallen
slightly. In Africa fatal malaria cases among children under five (the main
victims) fell between 1960 and 1995, though the decline has since levelled
off. The WHO reckons that deaths from infections will decline by 3% over the
next ten years. So more people in poor places will survive infections in
their dangerous childhoods to reach an age when they are susceptible to
heart attacks and cancer.

Since chronic disease among the poor is not the preserve of old age, another
part of the explanation for its increasing importance must lie in the
harmful things middle-aged folk do. Of these, smoking and unhealthy eating
are most important.

Around 300m Chinese men smoke. In China, Egypt, Indonesia and Russia, people
spend 5-6% of their household income on cigarettes—far more than the share
in rich countries. Smoking and its associated ailments are still rising in
poor countries, even while they fall in rich ones.

Middle-income countries are also experiencing extraordinary levels of
obesity. According to one study, half of all households in Brazil contain at
least one obese person; the share is three-quarters in Russia. According to
another, Mexico is the second fattest nation among the 30 (mostly rich)
countries of the Organisation for Economic Co-operation and Development,
after America. It has the highest rate of diabetes among large countries,
with 6.5m diabetics in a population of 100m. Not coincidentally, Mexicans
are among the biggest swiggers of fizzy drinks in the world. Coke and tacos,
anyone?

Obesity affects rich countries, of course: it is a symptom of affluence and
urbanisation. But it is occurring much earlier than anyone had expected in
middle-income places. Obesity among children there used to be unheard of.
Last year China's vice-minister for health, Wang Longde, said more than a
fifth of Chinese children between seven and 17 who live in cities are
overweight—a proportion that presumably reflects not only the wealth of
China's urban elite but the amount of money they lavish on their "little
emperors" (the single children they are limited to by China's one-child
policy).

Yet despite all the evidence that chronic disease is the world's biggest
health problem, most poor countries focus on infectious disease and their
health policies are usually based on the idea that infections should be
controlled before chronic conditions. These choices no doubt partly reflect
bureaucratic inertia at health ministries and investment in fighting
infections by medical charities and drugs firms.

*Not just statistics*

It is true that there are better reasons why poor countries might want to
concentrate on infections despite the growth of chronic disease. Infectious
illnesses are usually simpler to deal with than chronic ones, requiring
inoculation campaigns rather than long-term care, changes of lifestyle and
the uphill work of public education. Moreover, if you inoculate a child
against malaria, you considerably reduce his or her chances of dying from
that disease, since most deaths from malaria occur among children under ten.
If you lower someone's risk of getting a heart condition at 50, you might
well find they get it at 60. The disease can only be managed.

Still, it can be managed better: the contrast between death rates from heart
attacks (falling in the West, rising elsewhere) shows that. Stalin said a
single death is a tragedy, a million deaths, a statistic. But millions of
avoidable deaths are millions of tragedies. Chronic disease is already the
biggest problem for poor and middle-income countries. To concentrate so much
on infections is to add to the health burden of the next generation in what
are already the world's poorest, unhealthiest places.


-- 
Tiago Villanueva

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