Chapter One Global Health today's challenges Reviewing the latest global health trends, this chapter finds disturbing evidence of widening gaps in health worldwide. In 2002, while life expectancy at birth reached 78 years for women in developed countries, it fell back to less than 46 years for men in sub-Saharan Africa, largely because of the HIVIAIDS epidemic For millions of children today, particularly in Africa, the biggest health challenge is to survive until their fifth birthday, and their chances of doing so are less than they vere a decade ago. This is a result of the continuing impact of communicable diseases. However, a global increase in noncommunicable diseases is simultaneously occurring. adding to the daunting challenges already facing many developing countries 血GN
Global Health: today’s challenges 1 Chapter One Global Health: today’s challenges Reviewing the latest global health trends, this chapter finds disturbing evidence of widening gaps in health worldwide. In 2002, while life expectancy at birth reached 78 years for women in developed countries, it fell back to less than 46 years for men in sub-Saharan Africa, largely because of the HIV/AIDS epidemic. For millions of children today, particularly in Africa, the biggest health challenge is to survive until their fifth birthday, and their chances of doing so are less than they were a decade ago. This is a result of the continuing impact of communicable diseases. However, a global increase in noncommunicable diseases is simultaneously occurring, adding to the daunting challenges already facing many developing countries
Global health today's challenges Although this report is global in scope, the findings irresistibly draw the main focus to the increasingly fragile health of sub-Saharan Africa. It is here, where scores of millions of people scrape a living from the dust of poverty, that the price of being poor can be most starkly seen Almost an entire continent is being left behind Overall, 35% of Africa's children are at higher risk of death than they were 10 years ago. Every hour. more than 500 African mothers lose a small child. In 2002. more than four million African children died. Those who do make it past childhood are confronted with adult death rates that exceed those of 30 years ago. Life expectancy, always shorter here than almost anywhere else, is shrinking. In some African countries, it has been cut by 20 years and life expectancy for men is less than 46 years. Mostly, death comes in familiar garb. The main causes among children are depressingly rec- ognizable: the perinatal conditions closely associated with poverty; diarrhoeal diseases; pneu monia and other lower respiratory tract conditions; and malaria. Becoming more familiar by the day, HIV/AIDS, now the world,'s leading cause of death in adults aged 15-59 years, is killing almost 5000 men and women in this age group, and almost 1000 of their children very 24 hours in sub-Saharan Africa. The main components of Africa's tragedy are shared by many of the poorest people every where and include the agonizingly slow progress towards the Millennium Development Goals of reduced maternal and child mortality; the HIV/AIDS pandemic; and the double burden of communicable diseases plus noncommunicable diseases, including the tobacco epidemic and the avoidable deaths from road traffic crashes. Subsequent chapters of this report will exam- ne each of these components and show how they can and must be reshaped for a better future The global picture Life expectancy improves-but not for all Over the past 50 years, average life expectancy at birth has increased globally by almost 20 years, from 46.5 years in 1950-1955 to 65. 2 years in 2002. This represents a global average increase in life expectancy of 4 months per year across this period. On average, the gain in life expectancy was 9 years in developed countries(including Australia, European countries Japan, New Zealand and North America), 17 years in the high-mortality developing coun tries(with high child and adult mortality levels), including most African countries and poorer
Global Health: today’s challenges 3 1 Global Health: today’s challenges Although this report is global in scope, the findings irresistibly draw the main focus to the increasingly fragile health of sub-Saharan Africa. It is here, where scores of millions of people scrape a living from the dust of poverty, that the price of being poor can be most starkly seen. Almost an entire continent is being left behind. Overall, 35% of Africa’s children are at higher risk of death than they were 10 years ago. Every hour, more than 500 African mothers lose a small child. In 2002, more than four million African children died. Those who do make it past childhood are confronted with adult death rates that exceed those of 30 years ago. Life expectancy, always shorter here than almost anywhere else, is shrinking. In some African countries, it has been cut by 20 years and life expectancy for men is less than 46 years. Mostly, death comes in familiar garb. The main causes among children are depressingly recognizable: the perinatal conditions closely associated with poverty; diarrhoeal diseases; pneumonia and other lower respiratory tract conditions; and malaria. Becoming more familiar by the day, HIV/AIDS, now the world’s leading cause of death in adults aged 15–59 years, is killing almost 5000 men and women in this age group, and almost 1000 of their children, every 24 hours in sub-Saharan Africa. The main components of Africa’s tragedy are shared by many of the poorest people everywhere and include the agonizingly slow progress towards the Millennium Development Goals of reduced maternal and child mortality; the HIV/AIDS pandemic; and the double burden of communicable diseases plus noncommunicable diseases, including the tobacco epidemic and the avoidable deaths from road traffic crashes. Subsequent chapters of this report will examine each of these components and show how they can and must be reshaped for a better future. The global picture Life expectancy improves – but not for all Over the past 50 years, average life expectancy at birth has increased globally by almost 20 years, from 46.5 years in 1950–1955 to 65.2 years in 2002. This represents a global average increase in life expectancy of 4 months per year across this period. On average, the gain in life expectancy was 9 years in developed countries (including Australia, European countries, Japan, New Zealand and North America), 17 years in the high-mortality developing countries (with high child and adult mortality levels), including most African countries and poorer
The World Health Report 2003 countries in Asia, the Eastern Mediterranean Region and Latin America; and 26 years in the low-mortality developing countries. As shown in Figure 1.1, the large life expectancy gap between the developed and developing countries in the 1950s has changed to a large gap between the high-mortality developing countries and others Life expectancy at birth in 2002 ranged from 78 years for women in developed countries to less than 46 years for men in sub-Saharan Africa, a 1.7-fold difference in total life expectancy. Exceptions to the life expectancy increases in most regions of the world in the last 50 years are Africa and countries of eastern Europe formerly in the Soviet Union. In the latter case, male and female life expectancies at birth declined, by 2.9 years and I year, respectively, over the period 1990 to 2000. Estimated life expectancies for males and females for 2002 are given in Annex Table I for all Member States of the World Health Organization(WHO) The increases in life expectancy that occurred in the first half of the 20th century in devel oped countries were the result of rapid declines in mortality, particularly infant and maternal mortality, and that caused by infectious diseases in childhood and early adulthood. Access to better housing, sanitation and education, a trend to smaller families, growing incomes, and public health measures such as immunization against infectious diseases all contributed greatly to this epidemiological transition. In many developed countries, this shift started approxi- mately 100 to 150 years ago. In a number of countries, such as Japan, the transition started later but proceeded much more quickly. In many developing countries, the transition started even later and has not yet been completed. In developed countries, improvements in life xpectancy now come mainly from reductions in death rates among adults. Global mortality patterns Almost 57 million people died in 2002, 10.5 million(or nearly 20%)of whom were children of less than 5 years of age(see Figure 1. 2). Of these child deaths, 98% occurred in developing Figure 1.1 Life expectancy at birth: developed and developing countries, 1955-2002 ≌ g 20 Developing- low mortality Developing-high mortality 940 1960 020 Note: The term developed countries indudes Australia, Canada, European es. former Soviet Japan, New Zealand and the developing countries indude those in sub-Saharan Africa, and countries with I Central and South America and the Eastern Mediterranean. Other developing countries are refered to as'developing-low mortality
4 The World Health Report 2003 countries in Asia, the Eastern Mediterranean Region and Latin America; and 26 years in the low-mortality developing countries. As shown in Figure 1.1, the large life expectancy gap between the developed and developing countries in the 1950s has changed to a large gap between the high-mortality developing countries and others. Life expectancy at birth in 2002 ranged from 78 years for women in developed countries to less than 46 years for men in sub-Saharan Africa, a 1.7-fold difference in total life expectancy. Exceptions to the life expectancy increases in most regions of the world in the last 50 years are Africa and countries of eastern Europe formerly in the Soviet Union. In the latter case, male and female life expectancies at birth declined, by 2.9 years and 1 year, respectively, over the period 1990 to 2000. Estimated life expectancies for males and females for 2002 are given in Annex Table 1 for all Member States of the World Health Organization (WHO). The increases in life expectancy that occurred in the first half of the 20th century in developed countries were the result of rapid declines in mortality, particularly infant and maternal mortality, and that caused by infectious diseases in childhood and early adulthood. Access to better housing, sanitation and education, a trend to smaller families, growing incomes, and public health measures such as immunization against infectious diseases all contributed greatly to this epidemiological transition. In many developed countries, this shift started approximately 100 to 150 years ago. In a number of countries, such as Japan, the transition started later but proceeded much more quickly. In many developing countries, the transition started even later and has not yet been completed. In developed countries, improvements in life expectancy now come mainly from reductions in death rates among adults. Global mortality patterns Almost 57 million people died in 2002, 10.5 million (or nearly 20%) of whom were children of less than 5 years of age (see Figure 1.2). Of these child deaths, 98% occurred in developing 0 10 20 30 40 50 60 70 80 1940 1960 1980 2000 2020 Year Life expectancy at birth (years) Note: The term developed countries includes Australia, Canada, European countries, former Soviet countries, Japan, New Zealand and the USA. High-mortality developing countries include those in sub-Saharan Africa, and countries with high child and adult mortality in Asia, Central and South America and the Eastern Mediterranean. Other developing countries are referred to as “developing – low mortality”. Developed Developing – low mortality Developing – high mortality Figure 1.1 Life expectancy at birth: developed and developing countries, 1955–2002
Global Health: todays challenges igure 1.2 Age distribution of global mortality: developed and developing countries. 2002 50 40000 s20000 10000 eveloped W-mortality High-mortality World countries. Over 60% of deaths in developed countries occur beyond age 70, compared with about 30% in developing countries. A key point is the comparatively high number of deaths in developing countries at younger adult ages(15-59 years). Just over 30% of all deaths in developing countries occur at these ages, compared with 20% in richer regions. This vast premature adult mortality in developing countries is a major public health concern Developing countries themselves are a very heterogeneous group in terms of mortality (Fig ure 1.1). A contrast between low-mortality developing countries such as China(with more than one-sixth of the world s population)and high-mortality countries in Africa(with one tenth of the global population) illustrates the extreme diversity in health conditions among developing countries. Less than 10% of deaths in China occur below 5 years of age compared with 40% in Africa. Conversely, 48% of deaths in China occur beyond age 70, compared with Although risk of death is the simplest comparable measure of health status for populations, there has been increasing interest in describing, measuring and comparing health states of populations. Mortality statistics, in particular, substantially underestimate the burden from noncommunicable adult disease because they exclude non-fatal health outcomes such as de- pression and visual impairment. A useful method of formulating a composite summary of isease burden is to calculate disability-adjusted life years(DALYs), which combine years of DALY can be thought of as one lost year of " healthy " life and the measured disease burden is the gap between a population,s health status and that of a normative global reference popula tion with high life expectancy lived in full health. In terms of DALYs, 36% of total lost years of healthy life for the world in 2002 were a result of disease and injury in children aged less than 15 years, and almost 50% as a result of disease and injury in adults aged 15-59 years(see Fis I Estimated deaths by cause, age group and sex for 2002 are available on the WHO web site for the six WHo regionsandforthe14epidemiologicalsubregions(www.who.int/evidence/bod) LYs by cause, age group and sex for 2002 are available on the WHO web site for the six wHO regionsandforthe14epidemiologicalsubregions(www.who.int/evidence/bod)
Global Health: today’s challenges 5 countries. Over 60% of deaths in developed countries occur beyond age 70, compared with about 30% in developing countries. A key point is the comparatively high number of deaths in developing countries at younger adult ages (15–59 years). Just over 30% of all deaths in developing countries occur at these ages, compared with 20% in richer regions. This vast premature adult mortality in developing countries is a major public health concern. Developing countries themselves are a very heterogeneous group in terms of mortality (Figure 1.1). A contrast between low-mortality developing countries such as China (with more than one-sixth of the world’s population) and high-mortality countries in Africa (with onetenth of the global population) illustrates the extreme diversity in health conditions among developing countries. Less than 10% of deaths in China occur below 5 years of age compared with 40% in Africa. Conversely, 48% of deaths in China occur beyond age 70, compared with only 10% in Africa.1 Although risk of death is the simplest comparable measure of health status for populations, there has been increasing interest in describing, measuring and comparing health states of populations. Mortality statistics, in particular, substantially underestimate the burden from noncommunicable adult disease because they exclude non-fatal health outcomes such as depression and visual impairment. A useful method of formulating a composite summary of disease burden is to calculate disability-adjusted life years (DALYs), which combine years of life lost (YLLs) through premature death with years lived with disability (YLDs) (1). One DALY can be thought of as one lost year of “healthy” life and the measured disease burden is the gap between a population’s health status and that of a normative global reference population with high life expectancy lived in full health. In terms of DALYs, 36% of total lost years of healthy life for the world in 2002 were a result of disease and injury in children aged less than 15 years, and almost 50% as a result of disease and injury in adults aged 15–59 years (see Figure 1.3).2 1 Estimated deaths by cause, age group and sex for 2002 are available on the WHO web site for the six WHO regions and for the 14 epidemiological subregions (www.who.int/evidence/bod). 2 Estimated DALYs by cause, age group and sex for 2002 are available on the WHO web site for the six WHO regions and for the 14 epidemiological subregions (www.who.int/evidence/bod). 0 10 000 20 000 30 000 40 000 50 000 60 000 Developed Low-mortality developing High-mortality developing World Number of deaths (000) 0–4 5–14 15–59 60+ Figure 1.2 Age distribution of global mortality: developed and developing countries, 2002
The World Health Report 2003 gure 1.3 Distribution of disease burden(DALYs) by age group and region, 2002 rld loped regio 60+ 5-14 15% 33% 5-14 15-59 15-59 49% Low-mortality developing regions High-mortality developing regions 18% 5-14 57% 15-59 43% 5-14 9% As Figure 1.3 illustrates, child survival continues to be a major focus of the international health agenda for developing countries(2 ). Because nearly 90% of global deaths under age 15 occur before the age of 5, the following sections focus on child deaths under 5 years In con trast, the international effort to understand the magnitude of challenges to adult health in developing countries is still in its early stages. Even at present, there remains a perception that adult health is of great concern only in wealthy countries, where premature mortality among children has been substantially reduced. However, Figures 1. 2 and 1.3 also illustrate the high proportion of burden of disease and injury suffered by adults in developing countries, a grov ing burden that requires urgent action by the global public health community. This chapte therefore first examines trends and issues in child health, focusing on ages 0-4, then among dults aged 15-59 years and among adults aged 60 years and over. Unfortunately, complete cause-specific death registration data are routinely available for only a minority of the world s countries(see Chapter 7 and the Explanatory Notes in the Statisti al Annex). However, complete or incomplete vital registration data(see Box 1.1)together
6 The World Health Report 2003 As Figure 1.3 illustrates, child survival continues to be a major focus of the international health agenda for developing countries (2). Because nearly 90% of global deaths under age 15 occur before the age of 5, the following sections focus on child deaths under 5 years. In contrast, the international effort to understand the magnitude of challenges to adult health in developing countries is still in its early stages. Even at present, there remains a perception that adult health is of great concern only in wealthy countries, where premature mortality among children has been substantially reduced. However, Figures 1.2 and 1.3 also illustrate the high proportion of burden of disease and injury suffered by adults in developing countries, a growing burden that requires urgent action by the global public health community. This chapter therefore first examines trends and issues in child health, focusing on ages 0–4, then among adults aged 15–59 years and among adults aged 60 years and over. Unfortunately, complete cause-specific death registration data are routinely available for only a minority of the world’s countries (see Chapter 7 and the Explanatory Notes in the Statistical Annex). However, complete or incomplete vital registration data (see Box 1.1) together 0–4 29% 5–14 15–59 7% 49% 60+ 15% 0–4 6% 5–14 4% 15–59 57% 60+ 33% 0–4 40% 5–14 9% 15–59 43% 60+ 8% 0–4 18% 5–14 6% 15–59 57% 60+ 19% World Developed regions Low-mortality developing regions High-mortality developing regions Figure 1.3 Distribution of disease burden (DALYs) by age group and region, 2002