Patrick Heuveline

The burden of disease among the global poor

BACKGROUND Global and regional estimates show that non-communicable diseases in old age are rising in importance relative to other causes of ill health as populations age, and as progress continues against communicable diseases among infants and children. However, these estimates, which cover population groups at all income levels, do not accurately reflect conditions that prevail among the poor. We estimated the burden of disease among the 20% of the global population living in countries with the lowest per capita incomes, compared with the 20% of the worlds people living in the richest countries. METHODS Estimates for the global poorest and richest 20% were prepared for 1990 for deaths and disability-adjusted life years (DALYs), by a procedure used in a prominent recent study of the global disease burden. Projected mortality rates in the year 2020 were established for the worlds poorest and richest 20% under various assumptions about the future rate of decline in communicable and non-communicable diseases. FINDINGS In 1990, communicable diseases caused 59% of death and disability among the worlds poorest 20%. Among the worlds richest 20%, on the other hand, non-communicable diseases caused 85% of death and disability. A raised baseline rate of communicable disease decline between 1990 and 2020 would increase life-expectancy among the worlds poorest 20% around ten times as much as it would the richest 20% (4.1 vs 0.4 years). However, the poorest 20% would gain only around a quarter to a third as much as the richest 20% from a similar increase in non-communicable diseases (1.4 vs 5.3 years). As a result, a faster decline in communicable diseases would decease the poor-rich gap in 2020, but under an accelerated rate of overall decline in non-communicable diseases, the poor-rich gap would widen. INTERPRETATION Our estimates are crude, but despite their limitations, they give a more accurate picture of changes in attributable mortality among the worlds poor than do the global averages in current use.

Health-seeking behaviour for child illness in Guatemala.

Summary Relying on data from the 1995 Guatemalan Survey of Family Health (EGSF), we analyse the relationship between child illness and health‐seeking behaviour. Information on illness was collected for 3193 children. This analysis is based on 870 of these who became ill with diarrhoeal or respiratory disease during a 13‐day period prior to interview. Estimates are derived from logistic models of the probability of seeing any or a specific type of health care provider as a function of characteristics of the illness on a given day and the child. The results indicate that modern medical care plays a major role in the treatment of infectious illness among children in rural Guatemala, with visits to pharmacists, doctors and the staff at government health facilities occurring much more frequently than visits to curers and other traditional practitioners. In general, families are much more likely to seek out a health care provider when a child experiences fever and gastrointestinal symptoms than when suffering from respiratory and other symptoms, and when a mother perceives the illness to be serious. The results also indicate that infants, low parity children, and children assessed as having generally been in good health are more likely to visit health care providers than other children. However, the particular associations often vary by type of health care provider.

Impact of the HIV epidemic on population and household structure: the dynamics and evidence to date

Background: HIV is contracted most frequently at birth and during early adulthood. The epidemic may thus impact the demographic structure and the household structure of affected populations. Methods: This paper reviews earlier evidence of such an impact, uses demographic theory to anticipate its changes over time, and reviews the most recent evidence for indications of these changes. Results: Modest increases in the male : female ratio are beginning to show within certain age groups only (approximately 15% among 25–34 year olds). Similarly sized increases in the proportion of 15–29 year olds relative to 30–54 year olds are observed in some age pyramids. These ‘youth bulges’ are expected to fade out, whereas an aging effect phases in with the fertility impact of the epidemic. In the longer run, the size of all age groups will be reduced, but relatively less so for middle-aged adults. Proportions of orphans and widows have increased in the most affected countries. Fewer remarriage probabilities for widows were observed. Resulting increases in the proportion of female-headed households should only be temporary, as female mortality is catching up with male mortality. The number of double orphans is beginning to increase, but overall, orphans continue to live predominantly with a family member, most often the grandparents if not with the surviving parent. Conclusion: To date, the epidemics impact on the population and household structure has been limited by demographic (aging) and social (adaptive movements of kin across households) processes that contribute to diffuse the epidemic throughout the entire population and all households.

The Phoenix Population: Demographic Crisis and Rebound in Cambodia

The study of mortality crises provides an unusual and valuable perspective on the relationship between mortality and fertility changes, a relationship that has puzzled demographers for decades. In this article, we combine nationally representative survey and demographic-surveillance system data to study fertility trends around the time of the Khmer Rouge (KR) regime, under which 25% of the Cambodian population died. We present the first quantitative evidence to date that attests to a one-third decline of fertility during this regime, followed by a substantial “baby boom” after the fall of the KR. Further analyses reveal that the fertility rebound was produced not only by a two-year marriage bubble but also by a surge in marital fertility that remained for nearly a decade above its precrisis level. Our results illustrate the potential influence of mortality on fertility, which may be more difficult to identify for more gradual mortality declines. To the extent that until recently, Cambodian fertility appears to fit natural fertility patterns, our findings also reinforce recent qualifications about the meaning of this core paradigm of demographic analysis

Adolescent and Young Adult Mortality by Cause: Age, Gender, and Country, 1955 to 1994

PURPOSE To compare mortality rates from motor vehicle accidents (MVA), homicide, and suicide across countries, age groups, and time. METHODS The World Health Organization Mortality Database was used to construct age- and gender-specific rates in 26 countries for individuals aged 15 to 34 years during the period 1955 to 1994. The rates were adjusted for differences among countries in the age-and-gender distributions of their populations. Cause-specific rates were compared by country, 4-year age groups, 8-year time blocks, and male/female ratios. RESULTS The proportion of deaths in 15-34-year-olds owing to MVA, homicide, and suicide increased from 26% to 43% over the 40-year study period. Mortality rates differ by country more than time block, peak at ages 15-29 years, and are higher in males than females. Compared to the United States, 24 countries had lower homicide rates and 23 had lower MVA-death rates. CONCLUSIONS Despite declining rates of death from other causes, the rates of adolescent and young adult death from MVA, homicide, and suicide remain high in countries throughout the world. The proportion of deaths attributable to these causes increased steadily during the latter half of the 20th century. Fatal risk behaviors begin to increase during adolescence but do not peak until age 30 years, suggesting that the target population for prevention extends well beyond the teenage years.

The International Child Poverty Gap: Does Demography Matter?

According to the Luxembourg Income Study data, the U.S. child poverty rate is the second highest among 15 high-income nations. The present work reveals that 55% of all American children living in a household headed by a single female with no other adult present live in poverty—the highest rate for any of the five living arrangements in the 15 countries examined in this study. While previous analyses have focused on market forces and governmental redistribution across households, we question the contribution of demographic factors that place children in family structures with different poverty risks relative to other factors such as differential market opportunities and governmental benefits for adults caring for children in various living arrangements. Applying a classic demographic decomposition technique to the overall poverty gap, we find that the distributional effect of demographic behavior contributes little to the U.S. poverty gap with other nations (and none with respect to the United Kingdom). Overall differences in labor markets and welfare schemes best explain the U.S. child poverty gap, although for some countries, the gap is accentuated by the gradient of governmental transfers, and for most countries, by the gradient of market earnings across living arrangements.

A description of child illness and treatment behavior in Guatemala

This paper uses a new calendar design implemented in the Guatemalan Survey of Family Health to analyze diarrheal and respiratory illness among children. The calendar provides a much richer description of child illness and treatment behavior than do conventional data typically collected in health interview surveys. The resulting estimates reveal that Guatemalan children experience high rates of diarrheal and respiratory illness and that these illnesses often involve multiple symptoms that only partially overlap one another. In addition, estimates from the calendar demonstrate that the measurement of illness frequency is fairly complex and that classification of illness into distinct categories may not always be feasible or meaningful. Results regarding treatment behavior indicate that the vast majority of illnesses are treated and that mothers almost always receive advice regarding their childrens illnesses from relatives. On the other hand, health providers are sought for advice and treatment in only about one-third of illnesses. When families do seek providers, they are more likely to rely on biomedical ones - especially pharmacists, doctors and personnel at health posts and centers - than traditional practitioners. By far, the most common form of treatment - recommended by both relatives and providers - consists of readily available Western medicines. In contrast, the use of traditional remedies appears to be relatively low.

HIV and Population Dynamics: A General Model and Maximum-Likelihood Standards for East Africa

In high-prevalence populations, the HIV epidemic undermines the validity of past empirical models and related demographic techniques. A parsimonious model of HIV and population dynamics is presented here and fit to 46,000 observations, gathered from 11 East African populations. The fitted model simulates HIV and population dynamics with standard demographic inputs and only two additional parameters for the onset and scale of the epidemic. The underestimation of the general prevalence of HIV in samples of pregnant women and the fertility impact of HIV are examples of the dynamic interactions that demographic models must reproduce and are shown here to increase over time even with constant prevalence levels. As a result, the impact of HIV on population growth appears to have been underestimated by current population projections that ignore this dynamic.

Improving the health of the world's poor

Several prominent reports have recently called attention to the worlds 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 Organisations 1978 Alma-Ata conference on primary health care. The second is the “emerging agenda” of non-communicable …

Do marriages forget their past? Marital stability in post-Khmer Rouge Cambodia.

This paper assesses the impact of three main destabilizing factors on marital stability in Cambodia: the radical reformation of marriage under the Khmers Rouges (KR); the imbalanced gender ratio among marriageable adults resulting from gendered mortality during the KR regime; and, after decades of isolation from the West, a period of rapid social change. Although there is evidence of declining marital stability in the most recent period, marriages contracted under the KR appear as stable as adjacent marriage cohorts. These findings suggest that the conditions under which spouses were initially paired matter less for marital stability than does their contemporaneous environment.