The Health of Adults in Developing Countries

Feachem, RGA, T Kjellstrom, CJL Murray, M Over, and MA Phillips, eds. 1992. The Health of Adults in the Developing World. New York: Oxford University Press. No new data were collected for this document. Existing mortality data were reworked extensively, several unpublished data sources were brought together to illuminate current understanding of morbidity in adults, and disparate strands of evidence were compiled to help quantify the consequences of adult ill health for families, communities, and societies. The authors acknowledge that future research may modify some of their conclusions. The book was intended for a broad readership, including researchers and health policy makers in developing country governments and development agencies. Material on underlying relationships and patterns, of most interest to the research community, is presented together with practical guidance about future directions for action for consideration by developing country governments, but the book does not provide fully justified prescriptions for action. Its definition of adult ill health embraces all major health problems of adults communicable and noncommunicable diseases, injuries, childhood exposures to risk factors for adult diseaseand is not restricted by gender, residence, or socioeconomic status. The international, multidisciplinary team that prepared this book was aided by a panel of anonymous reviewers and a number of specialists supporting its work with various contributions.

OBJECTIVES
  • To document the nature, determinants, extent, and patterns of adult mortality and morbidity in developing countries and their social and economic consequences.

  • To suggest priority research areas and potential avenues for analysis, policy development, and action for consideration by national and international researchers and health policy makers.



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Global Health in Transition: A Synthesis: Perspectives from International Organizations The Health of Adults in Developing Countries Feachem, RGA, T Kjellstrom, CJL Murray, M Over, and MA Phillips, eds. 1992. The Health of Adults in the Developing World. New York: Oxford University Press. No new data were collected for this document. Existing mortality data were reworked extensively, several unpublished data sources were brought together to illuminate current understanding of morbidity in adults, and disparate strands of evidence were compiled to help quantify the consequences of adult ill health for families, communities, and societies. The authors acknowledge that future research may modify some of their conclusions. The book was intended for a broad readership, including researchers and health policy makers in developing country governments and development agencies. Material on underlying relationships and patterns, of most interest to the research community, is presented together with practical guidance about future directions for action for consideration by developing country governments, but the book does not provide fully justified prescriptions for action. Its definition of adult ill health embraces all major health problems of adults communicable and noncommunicable diseases, injuries, childhood exposures to risk factors for adult diseaseand is not restricted by gender, residence, or socioeconomic status. The international, multidisciplinary team that prepared this book was aided by a panel of anonymous reviewers and a number of specialists supporting its work with various contributions. OBJECTIVES To document the nature, determinants, extent, and patterns of adult mortality and morbidity in developing countries and their social and economic consequences. To suggest priority research areas and potential avenues for analysis, policy development, and action for consideration by national and international researchers and health policy makers.

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Global Health in Transition: A Synthesis: Perspectives from International Organizations CONCLUSIONS In the past 30 years, there has been appropriate, effective emphasis in research and action on tropical diseases, the health of children, the communicable diseases of childhood, and maternal health. Surviving childhood is not the only hurdle, however: 27 percent of all deaths in developing countries occur among adults ages 15 to 59; 72 percent of those deaths are avoidable. The nature, distribution, and trends of adult mortality in developing countries challenge preconceptions: noncommunicable diseases and injuries are the leading causes of death among adults in most developing countries. Deaths from noncommunicable diseases among adults are increasing both in absolute numbers and in relative importance. These high mortality rates are accompanied by substantial (and costly) levels of morbidity. The noncommunicable diseases, commonly thought of as diseases of the rich, actually cause higher death rates among individuals in poorer populations. Poor adults suffer more often from severe ill health, are more likely to depend on regular physical work, and have fewer resources with which to cope. Consequently, they are more heavily penalized by ill health, which also has major impacts on children, family, and society, so that the health risks that they take may have direct or indirect deleterious effects on the health of individuals in other age groups. Since adults make up the majority of the labor force, their ill health or death also tends to have negative effects on productivity and may be related to the slow pace of development in some countries. Sick adults consume substantial proportions (often more than half) of health sector resources in developing countries. Yet, because adult ill health involves more noncommunicable disease, more long-term morbidity and disability, and more lifestyle risk factors, policy makers cannot reduce the numbers of adults with ill health simply by expanding policies that have been successful in improving child health. There are large gaps in knowledge about the levels, causes, distribution, and determinants of sickness and death among adultscancer, cardiovascular disease, chronic obstructive lung disease, diabetes, injuries, sexually transmitted diseases (including human immunodeficiency virus infection and AIDS), and tuberculosis. Because morbidity is poorly understood and hard to measure, policy in both the curative and preventive subsectors is rudimentary, and there is imbalance between current resource allocations and reality. Absent better data, understanding, and policies, expenditures on sick adults will grow rapidly and sometimes inappropriately, as in the developed

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Global Health in Transition: A Synthesis: Perspectives from International Organizations world, even though there are alternative investments that would produce greater benefits to public health at lower cost. The demographic and epidemiologic transitions and the resulting “health transition” do not occur at the same pace or take the same form everywhere. Thus, countries are not locked into an inevitable experience of the health transition and can take steps to anticipate and avoid some of its undesirable manifestations. Many determinants of adult ill health in developing countries are behavioral, and the presence of some important risk factors is increasing. It is crucial to understand the factors that contribute to the transitionchanging patterns of mortality, demography, and lifestylesso that effective health promotion can be pursued. RECOMMENDATIONS FOR POLICY AND ACTION Development of appropriate, effective health policies and programs should be based on relevant data obtained by routine collection and analysis of health statistics and research focused on practical questions. The information needed for good decision making and research can be obtained, at reasonable cost, principally in developing countries themselves, and will require the establishment of appropriate institutional and financing mechanisms to expand the relevant research capacities. Much knowledge about the basic pathogenesis and pathophysiology of adult disease can be extrapolated from research in developed countries. Thus, these aspects need to be studied in developing country contexts only when there is some significant difference or objective, for example, distinctive environmental or genetic factors or special advocacy needs, and they subsequently need to be adapted to those needs. Priority research areas are the levels, causes, and determinants of adult ill health; inexpensive, innovative, easy-to-use methods of collecting and analyzing data on adult mortality; methods for clarifying the kinds of morbidity data that are useful and how to interpret them; collection and use of good data on health services utilization, the kinds of morbidity that prompt people to seek care, and the demands placed on private and public health care systems; consequences of different kinds of adult ill health and of ill

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Global Health in Transition: A Synthesis: Perspectives from International Organizations health experienced at different ages, in different economic circumstances, or by men and women; and achievements and costs of alternative approaches to improving adult health. Countries need to formulate at least interim policy agendas. In the short and medium terms, resources that are known to be inefficient may be withdrawn from government health services for adults to free resources for interventions known to be cost-effective, many of which are neglected interventions, such as stopping smoking, making road travel safer, vaccinating against hepatitis B virus, making motherhood safe, promoting safe sex and treating sexually transmitted diseases, improving case management of tuberculosis, screening for cervical cancer and relieving cancer pain, and treating diabetes. Other interventions for policy consideration for the longer terms would include dietary interventions, pollution control, and control and management of occupational illness and injury. COMMENTARY This book advances understanding of a critical area of health development in which the necessary steps for dealing with underlying problems are just beginning and are occurring only in a halting way. The authors describe adult health as “a research and policy vacuum.” Given the epidemiologic transition from infectious and deficiency diseases to noncommunicable diseases, the rising incidence of injuries, and the demographic momentum associated with the growing population of adults, there is no turning away from the urgency of dealing with this set of problems. Nonetheless, there will remain variable reluctance to accept the health of adults as of priority importance in the face of the still unfinished agendas of maternal and child health and tropical infectious diseases. Although this is surely a policy di

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Global Health in Transition: A Synthesis: Perspectives from International Organizations lemma, ways must be found now to begin grappling with the issues, at least in a preparatory way. The first step is to characterize the incidence, prevalence, determinants, and interventions in the area of adult diseases in local terms. There is a potential trap here, however. These diseases are so well known in developed countries that it will be tempting to simply transfer the understandings of and interventions for these diseases to developing country settings. That could be an epidemiologic mistake, since the character and determinants of those diseases could vary dramatically. It could also be impractical from an intervention perspective, since the diagnostic and therapeutic approaches used in developed country settings may surpass the resources of developing countries. Clearly, existing knowledge about diseases of adults in developed countries must be interpreted, applied, and extended carefully in developing country settings, an obvious area for close collaboration between the research and health system development communities of all countries. The directions of action that are called for are similar to those noted in connection with Disease Control Priorities in Developing Countries: assisting those countries in building their capacities in research, policy making, health system development, and development of human resources for all levels of the health care system.