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Try out PMC Labs and tell us what you think. Learn More. The mortality s and rates of chronic disease are rising faster in developing than in developed countries. This article compares prevailing explanations of population chronic disease trends with theoretical and empirical models of population chronic disease epidemiology and assesses some economic consequences of the growth of chronic diseases in developing countries based on the experiences of developed countries. Four decades of male mortality rates of cardiovascular and chronic noncommunicable diseases were regressed on changes in and levels of country income per capita, market integration, foreign direct investment, urbanization rates, and population aging in fifty-six countries for which comparative data were available.

Neoclassical economic growth models were used to estimate the effect of the mortality rates of chronic noncommunicable diseases on economic growth in high-income OECD countries. Processes of economic growth, market integration, foreign direct investment, and urbanization were ificant determinants of long-term changes in mortality rates of heart disease and chronic noncommunicable disease, and the observed relationships with these social and economic factors were roughly three times stronger than the relationships with the population's aging.

In low-income countries, higher levels of country income per capita, population urbanization, foreign direct investment, and market integration were associated with greater mortality rates of heart disease and chronic noncommunicable disease, less increased or sometimes reduced rates in middle-income countries, and decreased rates in high-income countries.

Each 10 percent increase in the working-age mortality rates of chronic noncommunicable disease decreased economic growth rates by close to a half percent. Macrosocial and macroeconomic forces are major determinants of population rises in chronic disease mortality, and some prevailing demographic explanations, such as population aging, are incomplete on methodological, empirical, and policy grounds. Rising chronic disease mortality rates will ificantly reduce economic growth in developing countries and further widen the health and economic gap between the developed and developing world.

Inmore than 31 million people will die from four leading chronic, noncommunicable diseases: heart disease, cancer, respiratory disease, and diabetes. Close to half of these deaths are estimated to be premature WHO Nearly 80 percent will occur in low- and middle-income countries, where these chronic diseases claim around 80 percent more lives than do the total of all infectious causes. The outlook for chronic diseases is no better. Inchronic diseases were responsible for 46 percent of all deaths in developing countries, a figure that will grow to 59 percent byor to more than 37 million lives a year a 64 percent increase.

In all regions of the world, even in low-income countries, the leading chronic diseases are projected to be the major killers. In East Asia and the Pacific countries, for example, the expected rise in chronic disease mortality rates will be more than five times the expected drop in infectious disease mortality rates. More generally, infectious diseases are falling and chronic diseases are growing at a much faster pace in low- and middle-income countries than in high-income countries.

Sources: Author's calculations. Infectious diseases classification is based on WHO's type 1 burden of disease cluster. Chronic diseases classification is based on cardiovascular disease, cancers, respiratory disease, and diabetes mellitus sub of WHO's type 2 burden of disease cluster. Appendix 1 further describes the data sources, disease classifications, and calculations. Notes: Infectious disease classification is based on WHO's type 1 burden of disease cluster.

Chronic disease classification is based on cardiovascular disease, cancers, respiratory disease, and diabetes mellitus sub of WHO's type 2 burden of disease cluster. This simple taxonomic division between infectious and chronic diseases, originally institutionalized by the World Health Organization WHO as types 1 and 2 burden of disease note the implicit policy ordering, type 1 as first-order and type 2 as second-orderhas become increasingly problematic for epidemiologists and health policymakers. Diseases can be acute or chronic and infectious communicable or noninfectious noncommunicablewith considerable overlap among these for a comprehensive discussion on medical problems associated with developing a disease taxonomy, see Nolte and McKee and appendix 1.

An epidemiologic justification for focusing on the four leading chronic diseases is that more than four-fifths of all deaths and two-fifths of all disabilities due to chronic noncommunicable diseases are derived from them. Although other important chronic noncommunicable diseases, such as neuropsychiatric disorders and sensory organ diseases, have high morbidity rates, they have comparably lower mortality rates. Another pragmatic policy motivation for concentrating on this subset of chronic noncommunicable diseases pertains to their similar set of determinants: of the many chronic noncommunicable diseases, these four in particular are related to three modifiable risks: 1 tobacco use, 2 alcohol consumption, and 3 unhealthy diet and physical inactivity.

Although this does not mean that the other chronic noncommunicable diseases are not important, if the risks of contracting the leading chronic diseases were lowered, the outcome of many of the high-burden, low-probability chronic noncommunicable diseases would be improved as well. With these foreseeable consequences of chronic diseases and given the potential for their prevention, we might expect that key health organizations, such as the World Health Organization and national health ministries, and also development institutions that focus on poverty, such as the World Bank and the United Nations Development Program, would be aggressively trying to combat the rising tide of chronic diseases in developing countries.

But this is, unfortunately, not the case. Inofficial development assistance for chronic noncommunicable diseases represented just under 0. Moreover, a survey of national health ministries found that nearly two-thirds did not have a budget line for chronic noncommunicable diseases WHO ; Yach et al. I begin my analysis by introducing a basic transition model of chronic disease epidemiology, which I then test against a series of comparative epidemiologic facts about chronic diseases to ascertain some key drivers of population chronic disease growth.

Next I evaluate these determinants in the context of globalization and provide some empirical tests of these hypotheses with respect to prevailing explanations. I then draw on this evidence base to forecast some of the global consequences of chronic disease growth for health and economic development in rich and poor countries. I conclude with some implications for global health policy and recommendations for controlling chronic diseases. Chronic diseases have a common set of clinical risk factors—hypercholesterolemia, hypertension, and obesity—and their associated behavioral risk factors—tobacco, physical inactivity, and unhealthy diets.

Figure 2 shows a standard model of chronic disease epidemiology, in which a member of the population transitions 1 from being healthy to acquiring a behavioral risk factor, at a probability modified by the effectiveness of primary prevention and a set of social determinants P 1and then 2 from having a behavioral risk factor to having a clinical risk factor at a probability modified by the effectiveness of secondary prevention as well as other modifiers such as age, coexisting risks, and social determinants P 2and so forth.

Exposures to risk factors act synergistically and cumulatively over the life course, speeding up the progression from being healthy to future chronic disease morbidity and mortality. As chronic diseases move from one state to the next, the health and economic burdens increase. With low probability, a person's movement toward chronic disease morbidity and mortality can be reversed, but with successful intervention, the progression of chronic disease can be stopped. Notes: P is a population probability, and for each state healthy, behavioral risk, clinical risk, morbidity, and mortality refers to the probability that an individual transitions from one chronic disease state to the next.

For example, P 1 refers to an individual's transition from being healthy to acquiring a behavioral risk, such as initiating tobacco or being sedentary. Sitting above P 1 in the model is the effectiveness of primary prevention and a set of social determinants, which are shown to modify this population transition probability both positively and negatively. The model is based upon a Markov process modeling framework, which is increasingly being used to model comparatively the effectiveness of population interventions at various stages of the transitions from health to chronic disease mortality.

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What does this model tell us about chronic disease trends? I use three comparative epidemiologic facts about the population distributions of chronic diseases to identify the key drivers of chronic disease growth:. Persons in poor countries tend to die at younger ages from chronic diseases than do persons in rich countries. The rate of chronic diseases is growing faster in poor countries than in rich countries. Fact 1, depicted in table 4implies that people in poorer countries either are moving through the transitions from being healthy to dying more rapidly than people in rich countries are or are accumulating behavioral risks at younger ages.

There is evidence for both these possibilities: 1 health systems in resource-poor settings are less effective at stopping chronic disease progression, and 2 the use of alcohol and tobacco is begun at younger ages in poor countries, and coexisting risks, such as micronutrient deficiencies and stunting, lead to greater risks for childhood obesity and early-onset diabetes.

In regard to fact 2, that poor countries have higher morbidity rates of chronic disease than rich countries do about 31 percent more disability-adjusted life years perpopulationtogether with fact 3, that the rate of chronic disease is growing faster in poor countries, suggests that health care is unlikely to be a crucial driver. Health care might possibly for fact 2 although a higher P 4 would compress morbidity in poor countries; see appendix 1but health systems alone cannot explain the rise in chronic disease incidence.

Indeed, P 3the probability of a transition from clinical risk to chronic disease morbidity, has likely been decreasing across the world as health systems have become stronger. What about population aging? Several studies cite it as the principal driver of the rise in population chronic disease rates Marks and McQueen ; Mathers and Loncar ; Murray and Lopez ; Roglic and Unwin ; WB But this conclusion is often a spurious feature of a commonly used method to decompose population mortality forecasts into demographic and epidemiologic change components for a methodological critique, see appendix 1.

The aging of a population cannot independently for the global differences in the growth of the mortality rate: the percentage of the population over age sixty-five is rising faster in developed than in developing countries, even though the absolute s of persons aging is much higher in developing countries CDC ; Murray and Lopez In sub-Saharan Africa, the proportion of persons over sixty-five will increase from 3.

At the same time, mortality s are projected to roughly double from 1. Perhaps the set of behavioral risk factors is responsible. Together, they are estimated to for 30 to 60 percent of chronic diseases, and their burden is growing. Some of the behavioral risks are global vices, such as tobacco, for which the risk always increases as exposure rises. Other behavioral factors, however, can be favorable to chronic disease, such as healthy dietary intake and greater physical activity.

What the behavioral risks have in common is that they operate at the individual level. These occupy the space in the model at P 1or the probability that a population member starts smoking, drinking, not exercising, or eating unhealthy foods. To explain cross-national patterns of chronic disease using these individual risk factors thus begs the question: Why are people all over the world today making worse personal choices than before, and at a rate much higher in developing countries than in developed countries?

Clearly, this is only a partial explanation of chronic disease growth, and a large residual risk remains to be ed for. Putting too much emphasis on the individual perspective suffers exactly the opposite bias of ecologic fallacy: whereas an ecological fallacy distorts individual causes through population associations, an individual fallacy distorts population causes through individual associations.

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To fully understand what is driving such sweeping individual changes—that is, population changes—we must look to the social forces that are transforming risk factors acting at both the individual and societal levels. Globalization provides the best theoretical framework for understanding today's rising risk of chronic disease and for thinking about what will happen in the future.

Next I outline three structural aspects of globalization: economic flows, economic growth, and technological change, which are shifting the entire healthy population's risk distribution to the right or increasing P 1 much faster in poor than in rich countries. Many of these products flow from the global North to the global South and, in so doing, tap existing local markets and often create new ones.

Most of these flows as they relate to behavioral risks favor items that can be easily transported, such as processed and prepackaged items like sodas and cigarettes. Since supply chains and technology are more advanced in the global North, many of these products outcompete more expensive products generated by local suppliers. As a result of transnational companies' ificant market advantages, the large-scale entry of Western foods and beverages and tobacco companies into emerging markets will continue Gilmore and McKee Countries often wish to encourage such investment by foreign sources foreign direct investment, or FDI as a way to boost their economic growth.

FDI offers expertise and resources that are typically unavailable at home. In order to enhance the potential for these flows, countries seek to integrate themselves more fully into the global marketplace by liberalizing trade restrictions and transferring the ownership of large state-owned monopolies to the private sector.

Much of this is to the good. When markets work well, people are better off.

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More competition brings lower prices and more efficiently delivers goods to populations. Conversely, in the presence of market failures 4 relating to the increased risk of chronic disease Suhrcke et al. From a chronic disease control perspective, strategies such as liberalizing trade restrictions break down for global vices like tobacco but can improve access to nutritious fruits and vegetables.

Many critics, however, believe that the current market environment in poor countries, where regulatory regimes are often underdeveloped and where global companies may be able to undermine efforts to strengthen regulation Gilmore, Collin, and McKeeprivileges risky rather than healthy products on foreign direct investment's differential effects on diets in developed and developing countries, see Hawkes andand for evidence in relation to tobacco, see Gilmore and McKee ; also Beaglehole and Yach ; Pang and Guindon ; Popkin ; Rayner et al.

How this might be the case can be better understood by examining the interaction between these prevailing economic growth strategies and co-occurring social transformations. As a population's income level increases, people's habits and consumption patterns change. Rapid growth creates many opportunities to modify a population's risk just as people's lifestyles catch up to their newfound wealth.

This is particularly true for rapidly developing countries such as India and China, which have registered record economic growth rates of more than 5 percent on average over the past decade but have also experienced a rapid rise in the risk of chronic disease Reddy et al. Unlike in Western countries, where people buy more healthy foods and spend more time exercising as their income levels rise, in developing countries the opposite seems to happen Cutler, Glaeser, and Shapiro ; Drewnowski and Darmon ; Popkin et al.

Why might this be the case? First, transnational companies have aggressively engaged in information campaigns in developing countries using advanced marketing strategies proven in Western countries. In less competitive information environments, such as those in developing countries, marketing is even more powerful than persons in the West can appreciate. One particularly effective strategy has been to confer social status or prestige on eating in restaurants, often by associating restaurant consumption with cosmopolitan Western habits for a discussion, see Yum!

Growth is only part of the story. Technological changes driving growth also are relevant. As societies advance technologically, labor shifts from agrarian to intellectual production, and workplaces become increasingly sedentary. Work becomes more centralized as tech and service industries grow think of the call centers in Indiaand these work opportunities in turn drive people en masse from rural to urban settings.

In urban settings, food production can be concentrated and take advantage of economies of scale, leading to lower prices and further encouraging people to eat outside the home. Urban settings in developing countries also commonly have few opportunities for physical activity.

As more women begin to enter the workforce—a possibility encouraged by technological advance—they face greater time constraints for the household production of food, and this reduction of time also acts to move food consumption away from the home. Because of the market structure and incentives just described, the net effect on society is a greater consumption of unhealthy products, especially energy-dense foods, and increasingly sedentary behavior.

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In sum, economic flows have improved the accessibility of behavioral risks; the social changes accompanying economic growth have encouraged their adoption; and technological change has created incentives for people to exercise less and eat out more.

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