A Workshop Summary

Thomas J. Plewes and Kevin Kinsella, Rapporteurs

Committee on Population

Division of Behavioral and Social Sciences and Education


Washington D.C.

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. THE CONTINUING EPIDEMIOLOGICAL TRANSITION IN SUB-SAHARAN AFRICA A Workshop Summary Thomas J. Plewes and Kevin Kinsella, Rapporteurs Committee on Population Division of Behavioral and Social Sciences and Education i

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the Steering Committee for the workshop were chosen for their special competences and with regard for appropriate balance. This study was supported by the National Institutes of Health Award N01-OD-4-2139, Task Order 227 to the National Academy of Sciences. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. International Standard Book Number-13: 978-0-309-26648-2 International Standard Book Number-10: 0-309-26648-3 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; Copyright 2012 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Research Council. (2012). The Continuing Epidemiological Transition in sub- Saharan Africa: A Workshop Summary. Thomas J. Plewes and Kevin Kinsella, Rapporteurs. Committee on National Population, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press. ii

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. . iii

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STEERING COMMITTEE ON THE CONTINUING EPIDEMIOLOGICAL TRANSITION IN SUB-SAHARAN AFRICA BARTHLMY KUATE DEFO (Chair), University of Montreal AYAGA A. BAWAH, INDEPTH Network, Accra, Ghana LISA F. BERKMAN, Harvard University School of Public Health ALAN D. LOPEZ, School of Population Health, University of Queensland, Australia JANE MENKEN, Institute of Behavioral Science, University of Colorado JULIE KNOLL RAJARATNAM, Institute for Health Metrics and Evaluation, University of Washington STEPHEN TOLLMAN, University of the Witwatersrand, Johannesburg, Republic of South Africa STIG WALL, Ume University, Ume, Sweden v

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COMMITTEE ON POPULATION LINDA J. WAITE (Chair), The University of Chicago CHRISTINE BACHRACH, Duke University JERE R. BEHRMAN, University of Pennsylvania PETER J. DONALDSON, The Population Council KATHLEEN MULLAN HARRIS, The University of North Carolina at Chapel Hill MARK D. HAYWARD, University of Texas at Austin CHARLES HIRSCHMAN, University of Washington WOLFGANG LUTZ, International Institute for Applied Systems Analysis ROBERT D. MARE, University of California, Los Angeles SARA S. McLANAHAN, Princeton University BARBARA BOYLE TORREY, Independent Consultant MAXINE WEINSTEIN, Georgetown University DAVID R. WEIR, University of Michigan JOHN R. WILMOTH, University of California, Berkeley Staff BARNEY COHEN, Director (until August 15, 2012) THOMAS J. PLEWES, Interim Director KEVIN KINSELLA, Senior Program Officer BARBARA BOYD, Administrative Associate vi

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Contents Acknowledgments 1 Introduction 1 2 The Changing Context of the Transition in sub-Saharan Africa 4 3 Mortality and Causes of Death 6 4 Risk Factor Transitions: Exposures and Comparative Risk Assessment 8 5 The Role of Migration 10 6 Health Financing in sub-Saharan Africa 12 7 Data Collection and Validation in Resource-Poor Settings 14 8 The Epidemiological Transition in Africa: Are There Lessons from Asia? 17 9 Future Research Directions 19 References 22 Appendixes A Workshop Agenda 25 B Participant List 30 C Biographical Sketches of Steering Committee Members and Presenters 34 vii

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Acknowledgments This report summarizes the presentations and discussions from a workshop convened in October 2011 that featured invited speakers on the topic of epidemiological transition in sub-Saharan Africa. The workshop was organized by a National Research Council (NRC) panel of experts in various aspects of the study of epidemiological transition and of sub-Saharan data sources. The panel provided invaluable guidance in developing the workshop, in securing expert presentations, and in conducting the workshop. Although the panel members played a central role in designing and conducting the workshop, they did not actively participate in writing this workshop summary. A special acknowledgement is owed to Richard Suzman, director of the Division of Behavioral and Social Research of the U.S. National Institute on Aging, who not only played an important role in developing and refining the workshop but also actively participated in discussions that helped frame the issues and enhance the general understanding of the subject matter. The staff of the University of Witwatersrand, which hosted the conference, played an important role in preparing for and conducting the workshop. In particular we would like to acknowledge Stephen Tollman both for his work during workshop preparations and for his contributions during the workshop itself, when the information and comments he offered greatly enhanced the value of the event. The task of describing the overall changing context for these issues was taken on by the chair of the panel, Barthlmy Kuate Defo. Dr. Defo and the other presenters played a critical role in the workshop, identifying the key issues in the area and laying the basis for the robust discussions that were to follow; these discussions were also facilitated by a series of discussants. Peter Byass, Mark Collinson, Riku Elovainio, Majid Ezzati, Gilles Pison, and Stephen Tollman served as presenters, and their presentations were ably discussed by Ayaga Bawah, Hosen Coovadia, Karen Hofman, Alan Lopez, Moffat Nyirenda, Thomas Rehle, and Eric Udjo. The panel also acknowledges the excellent work of the staff of the Committee on Population (CPOP) and the NRC for support in developing and organizing the workshop and providing rapporteur services for this report. The workshop was carried out under the direction of Barney Cohen, who served as director of the Committee on Population until August 2012. Tom Plewes and Kevin Kinsella served as rapporteurs. The panel was ably assisted by Barbara Boyd, who handled much of the administrative load in organizing the meeting and Danielle Johnson, who prepared the report for final production. This workshop summary was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the Report Review Committee of the NRC. The purpose of this independent review is to provide candid and critical comments that assist the institution in making its report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. The panel thanks the following individuals for their review of this report: Chodziwadziwa Whiteson Kabudula, MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), South Africa, and W. Henry Mosley, Department ix

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of Population (emeritus), Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health. Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Mark D. Hayward, Population Research Center, University of Texas at Austin. Appointed by the NRC, he was responsible for making certain that the independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. The purpose of this report is to serve as a factual summary of what occurred at the workshop. The steering committee's role was limited to planning and convening the workshop. The views contained in this report are those of individual workshop participants and do not necessarily represent the views of all workshop participants, the committee, or the NRC. Responsibility for the final content of the report rests entirely with the rapporteurs and the NRC. x