The Epidemiologic Transition: Changing Patterns of Mortality and Population Dynamics
Robert E. McKeown, PhD, FACE
American Journal of Lifestyle Medicine - vol. 3 • suppl. 1- July • Aug 2009- p p 19S -26S
Abstract:
The epidemiologic transition describes changing patterns of population age distributions, mortality, fertility, life expectancy, and causes of death. A number of critiques of the theory have revealed limitations, including an insufficient account of the role of poverty in determining disease risk and mortality, a failure to distinguish adequately the risk of dying from a given cause or set of causes from the relative contributions of various causes of death to overall mortality, and oversimplification of the transition patterns, which do not fit neatly into either historical periods or geographic locations. Recent developments in epidemiologic methods reveal other limitations. A life course perspective prompts examination of changes in causal pathways across the life span when considering shifts in the age distribution of a population, as described by the epidemiologic transition theory. The ecological model assumes multiple levels of determinants acting in complex and interrelated ways, with higher level determinants exhibiting emergent properties. Development, testing, and implementation of innovative approaches to reduce the risks associated with the sedentary lifestyle and hypernutrition in developed countries should not overshadow the continuing threat from infectious diseases, especially resistant strains or newly encountered agents. Interventions must fit populations and the threats to health they experience while anticipating changes that will emerge with success in some areas. This will require new ways of thinking that go beyond the epidemiologic transition theory.
Keywords: epidemiologic transition; epidemiologic methods; mortality
Implications for Epidemiologic Methods and Conclusion
The theory of epidemiologic transition has been useful in laying out an overarching perspective on changing demographic patterns. The various criticisms of the theory suggest it is most relevant as a way of looking at and understanding the relation among disease, mortality patterns, and population rather than as a definitive explanation or prediction. Among the major critiques of the theory is that the overemphasis on mortality rather than disease causality and morbidity misses critical pieces of complex phenomena. The focus on mortality and life expectancy gives insufficient attention to disability and quality of life. Furthermore, our understanding of and approach to causal inference have matured in the nearly 4 decades since Omran’s original article appeared. The importance of the ecological model and what has been called eco-epidemiology has enriched our thinking and our methods and enhanced our understanding of differential patterns of morbidity and mortality within and across populations and different segments of populations. Although it is true that the burden from infectious diseases has been surpassed in many countries by the burden from chronic disease and mental disorder, it is still the case in many countries and in many populations within countries that morbidity and mortality from infectious disease, poor nutrition, and perinatal complications dominate, with poverty being the most evident shared characteristic. We cannot assume that the evidence of the epidemiologic transition means we can redirect our attention and resources away from those determinants of death and disease that still threaten the lives and well-being of a large portion of the world’s population. But we must also recognize that those same populations will be victims of the obesity, CVD, hypertension, and diabetes epidemics that now characterize the United States. Even as we continue to develop, test, and implement innovative approaches to reduce the risks associated with the sedentary lifestyle and hypernutrition in developed countries, we must also recognize the continuing threat from infectious diseases, especially resistant strains or agents that are newly encountered. The relative protection we have enjoyed from many infectious diseases is no longer a foregone conclusion. At the same time, we need to address multiple fronts in developing countries: historical threats from infectious agents, malnutrition, and perinatal complications, as well as emerging threats of the same sort we now see from resistant strains of infectious agents and contact with new agents, as well as the looming emergence and increasing importance of the chronic and degenerative diseases that are likely to follow successful programs to increase education and reduce poverty. One of the lessons of the epidemiologic transition is that interventions must fit the population and the threats to health it currently experiences while we anticipate the changes that success in one area are likely to bring out and the new challenges that will emerge. This will require new ways of thinking that go beyond .
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