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Introduction

BACKGROUND

Among the poorest and least developed regions in the world, sub-Saharan Africa has long faced a heavy burden of disease, with malaria, tuberculosis, and, more recently, HIV being among the most prominent contributors to that burden. Yet in most parts of Africa—and especially in those areas with the greatest health care needs—the data available to health planners to better understand and address these problems are extremely limited. The vast majority of Africans are born and will die without being recorded in any document or appearing in official statistics (Setel et al., 2007). With few exceptions, African countries have no civil registration systems in place and hence are unable to continuously generate vital statistics or to provide systematic information on patterns of cause of death, relying instead on periodic household-level surveys or intense and continuous monitoring of small demographic surveillance sites to provide a (partial) epidemiological and demographic profile of the population. Complicating matters further, large parts of Africa still operate a dual health care system with large numbers of traditional healers operating alongside modern hospitals and clinics. It is not surprising, therefore, that good medical recordkeeping exists for only a tiny percentage of the population concentrated in a few areas and that even major disease registries and tracking systems either are not comprehensive or are lacking altogether.

Given the difficulties of constructing a comprehensive picture of the current epidemiological situation at a national or even sub-national level, let alone understanding how the epidemiological situation is changing over time, any attempts to predict how demographic and epidemiological changes will play out in the future must be somewhat speculative and be accompanied by an acknowledgment of significant uncertainty.

In 1991 the Committee on Population of the National Academy of Sciences organized a workshop on the epidemiological transition in developing countries. The workshop brought together medical experts, epidemiologists, demographers, and other social scientists involved in research on the epidemiological transition in developing countries to discuss the nature of the ongoing transition, identify the most important contributors to the overall burden of disease, and discuss how such information could be used to assist policy makers in those countries to establish priorities with respect to the prevention and management of the main causes of ill health.

The workshop, which resulted in the publication of The Epidemiological Transition: Policy and Planning Implications for Developing Countries (National Research Council, 1993), was timely because it provided an opportunity to review



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. 1 Introduction BACKGROUND Among the poorest and least developed regions in the world, sub-Saharan Africa has long faced a heavy burden of disease, with malaria, tuberculosis, and, more recently, HIV being among the most prominent contributors to that burden. Yet in most parts of Africa--and especially in those areas with the greatest health care needs--the data available to health planners to better understand and address these problems are extremely limited. The vast majority of Africans are born and will die without being recorded in any document or appearing in official statistics (Setel et al., 2007). With few exceptions, African countries have no civil registration systems in place and hence are unable to continuously generate vital statistics or to provide systematic information on patterns of cause of death, relying instead on periodic household-level surveys or intense and continuous monitoring of small demographic surveillance sites to provide a (partial) epidemiological and demographic profile of the population. Complicating matters further, large parts of Africa still operate a dual health care system with large numbers of traditional healers operating alongside modern hospitals and clinics. It is not surprising, therefore, that good medical recordkeeping exists for only a tiny percentage of the population concentrated in a few areas and that even major disease registries and tracking systems either are not comprehensive or are lacking altogether. Given the difficulties of constructing a comprehensive picture of the current epidemiological situation at a national or even sub-national level, let alone understanding how the epidemiological situation is changing over time, any attempts to predict how demographic and epidemiological changes will play out in the future must be somewhat speculative and be accompanied by an acknowledgment of significant uncertainty. In 1991 the Committee on Population of the National Academy of Sciences organized a workshop on the epidemiological transition in developing countries. The workshop brought together medical experts, epidemiologists, demographers, and other social scientists involved in research on the epidemiological transition in developing countries to discuss the nature of the ongoing transition, identify the most important contributors to the overall burden of disease, and discuss how such information could be used to assist policy makers in those countries to establish priorities with respect to the prevention and management of the main causes of ill health. The workshop, which resulted in the publication of The Epidemiological Transition: Policy and Planning Implications for Developing Countries (National Research Council, 1993), was timely because it provided an opportunity to review 1

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progress at the midpoint towards the goal, set forth in the 1978 Alma Ata Declaration, of achieving "Health for All by the Year 2000." Given the paucity of resources available for health services in many developing countries, most public health programs up to the time of the 1991 workshop were focused more on eradication or at least control of preventable childhood infectious diseases, such as measles and diarrhea, than they were on treatment of chronic diseases or responding to the health-care needs of the elderly (National Research Council, 2006). This was not surprising given the extremely high rates of infant and child mortality in some parts of the developing world, particularly Africa, where the majority of such deaths were preventable with low-cost interventions such as oral rehydration salts or vaccinations. The 1991 workshop coincided with the development and rapid acceptance of new measures of healthy years of life lost to various diseases as the basis for making comparisons of the cost-effectiveness of alternative health programs; this approach would get even more support in the years following the workshop, with the publication of the seminal 1993 report Investing in Health (World Bank, 1993) and the publication of the first edition of the World Health Organization's Global Burden of Disease study (Murray and Lopez, 1996a; 1996b) that elevated the science of assessing mortality and disability from diseases, injuries, and risk factors to a new level. The workshop also took place at a time of mounting concern about how the human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), then a fairly new and geographically limited disease, would affect patterns of health and development (Merli and Palloni, 2006). ORGANIZATION OF THE WORKSHOP Recognizing the need to continuously monitor how mortality patterns are changing in sub-Saharan Africa over time, the National Institute of Aging asked the Committee on Population of the National Academy of Sciences to convene a workshop to review a number of issues related to the epidemiological transition in sub-Saharan Africa. Statement of Task An ad hoc committee will plan, organize and commission papers for a public workshop on the epidemiological transition in sub-Saharan Africa. Papers may be commissioned either to develop the workshop or to be presented at the workshop. Following the workshop, a rapporteur will summarize the presentations and workshop discussions. The workshop will feature invited presentations and discussion. Among the issues to be considered are the following: A review of the changes that have taken place in the past 15 years in this rapidly moving area of inquiry. An update of trends and their implications for health policy. The coordination of data analysis across demographic surveillance sites and from new surveys and other sources. Methodological challenges for dealing with data from demographic surveillance sites. 2

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New theoretical perspectives on demographic modeling and their application to modeling the epidemiological transition. To address the statement of task, the National Academy of Sciences appointed an ad hoc panel of experts in epidemiology, demography, and public health from Africa, Australia, Europe, and North America. Biographical sketches for the panel members are provided in Appendix C. The panel, chaired by Barthlmy Kuate Defo, had a dual charge: 1. to develop a two-day workshop wherein leading scientists from relevant disciplines could come together to discuss the nature of the ongoing transition, to identify the most important contributors to the overall burden of disease, and to discuss how such information could be used to better assist policy makers in those countries establish priorities with respect to the prevention and management of the main causes of ill health as well as to plan for the likely demand for certain types of health care in the future; and 2. to build on the workshop discussions by developing a research agenda focused on novel analyses and data collection strategies that would afford policy makers a better understanding of current and emerging health-related needs and enhance their assessment of the potential impact of policy options. The public workshop was held in Johannesburg, South Africa, on October 2122, 2011. The workshop reviewed the changes that have taken place in the past 15 years in this rapidly moving area of inquiry, updated trends and their implications for health policy, coordinated data analysis across demographic surveillance sites and from new surveys and other sources, considered methodological challenges related to dealing with data from demographic surveillance sites, and explored new theoretical perspectives on demographic modeling and their application to modeling the epidemiological transition. The agenda for the October 2011 Johannesburg workshop is found in Appendix A and a list of the workshop participants is offered in Appendix B. In advance of the workshop the panel commissioned a set of background papers from prominent researchers in order to summarize extant research findings and further the goals of the meeting. These papers covered a range of research topics related to the epidemiological transition in sub-Saharan Africa, including changing patterns of child and adult mortality and causes of death in Africa (Masquelier, Reniers, and Pison), the uniqueness of the sub-Saharan Africa context (Defo), the role of migration in epidemiological transitions (Collinson et al.), risk exposures and comparative risk assessment (Ezzati), comparisons between the emerging epidemiological transition in Africa and Asia (Tollman et al.), the economic implications of the epidemiological transition (Elovainio and Evans), and the state of data collection (Byass, de Savigny, and Lopez). These commissioned papers became the basis for the presentations. They will be published separately in an appropriate journal. 3