The maladies of affluence

Aug 9th 2007 From The Economist print edition
The poor world is getting the rich world's diseases
IN 1619 an English captain sailing past Cape Cod reported that the Massachusetts shore was “utterly void”. The Indians “died in heapes as they lay in their houses” confirmed an English merchant. By killing much of the population of the Wampanoag confederacy, the epidemic that raged from 1616-19 made possible the first permanent European settlement in north America, that of the Pilgrim Fathers in 1620. The Indians had caught the illness, thought to have been viral hepatitis, from prior contact with Europeans, probably captured French sailors.
Europeans have been exporting their maladies throughout history. They seem to be doing it again, but in a new way. In the past, the problem was infection. Now, illnesses associated with Western living standards are the fastest growing killers in poor and middle-income countries. Chronic disease has become the poor world's greatest health problem.
For many in the West, diseases are a bit like birds: everyone gets them but poor countries have more exotic species. Rich-country maladies are things like heart disease, cancer and diabetes: “chronic” conditions often resulting from diet or physical inactivity. Developing countries suffer more lurid and acute infections: malaria, tuberculosis, measles, cholera. HIV/AIDS is unusual in that it affects rich and poor alike. But otherwise, poor countries are presumed to have their own health problems. The sixth of the United Nations' millennium development goals (a sort of ten commandments of poverty reduction adopted in 2000) is concerned with infections only—the ailments of poverty. The progress report issued last month half way through the millennium programme's 15-year course tracks HIV/AIDS, malaria and tuberculosis. Combating chronic disease is not part of what the UN calls its “universal framework for development”.
Yet the distinction between illnesses of affluence and illnesses of poverty is misleading as a description of the world and doubtful as a guide to policy. Heart disease—supposedly an illness of affluence—is by far and away the biggest cause of global mortality. It was responsible for 17.5m deaths worldwide in 2005. Next comes cancer, another non-infectious sickness, which caused more deaths than HIV/AIDS, tuberculosis and malaria put together (see chart 1). Chronic conditions such as heart disease took the lives of 35m people in 2005, according to the World Health Organisation (WHO)—twice as many as all infectious diseases.
If you look at lower-middle income countries, such as China, or upper-middle income ones, like Argentina, you find that what kills people there is the same as in the West (see chart 2). Four-fifths of all deaths in China are from chronic sicknesses. That is also true of countries as varied as Egypt, Jamaica and Sri Lanka.
The main difference between these countries and rich ones is that chronic illnesses are more deadly there. Five times as many people die of heart disease in Brazil as in Britain, though Brazil is not five times as populous. Rich countries have become better at dealing with chronic conditions: death rates from heart disease among men over 30 have fallen by more than half in the past generation, from 600-800 per 100,000 in 1970 to 200-300 per 100,000 now.
This has not happened in middle-income countries. In 1980 the death rate for Brazilian men was below the rich-country average (300 compared with 500-600). Its death rate has not changed—and is now higher than all but a few rich countries. Russia is worse off. In 1980 its death rate was 750 per 100,000. Now it is 900, about four times as high as most rich countries.
It may not seem surprising that upper-middle income places such as Russia suffer from “Western” ailments. But chronic diseases are mass killers in the poorest nations, too. Indeed, the only unusual thing about these countries is that they suffer from infections as well as chronic disease: a double burden. Chronic diseases were responsible for over 12m deaths in countries with annual incomes below $750 a head in 2005—almost as many as were caused by communicable ones. Africa is the only continent where infectious illnesses cause more deaths than the non-communicable kinds.
Chronic diseases are becoming deadlier and more burdensome to the poor. By 2015, says the World Bank, these ailments will be the leading cause of death in low-income countries. They already account for almost half of all illnesses there and impose substantial economic costs.
People in poor countries get chronic diseases younger than in the West. There, chronic conditions bear heavily upon the old. Not so in poor and middle-income nations. Death rates for those between 30 and 69 years of age in India, Russia and Brazil are two or three times higher than in Canada and Britain. Almost half of deaths from chronic problems in developing countries occur in people below 70.
As a result, the poor suffer from chronic illnesses longer and are more likely to die of them. The death rate from chronic disease in poor countries is obviously higher than in rich countries; more surprisingly, it is often higher than the death rate from infections. India, Pakistan, Nigeria and Tanzania all have roughly the same death rate for cardiovascular disease: 400 per 100,000. That is at least twice as high as the Western norm and, at least in India and Pakistan, more than four times the average death rate from infections (in Nigeria and Tanzania, HIV/AIDS, malaria and tuberculosis are still deadlier).
Chronic disease bears down especially hard on working adults, imposing a heavy economic burden. Families in poor countries are much more likely than in the West to spend their savings looking after a chronically ill relative, or to pull children out of school to act as nursemaids.
In short, developing countries suffer more from “rich world maladies” than the rich world itself. Overall in 2005, only a fifth of deaths attributable to “illnesses of affluence” (chronic conditions) actually took place in the most affluent nations. Three-quarters happened in poor or lower-middle-income ones.
Death eaters
Why are poor countries so vulnerable to the diseases of the rich? And why does public attention and aid money ignore them and focus on infections?
The simplest explanation for chronic diseases' increasing importance is that people in poor countries now live long enough to suffer them. Thanks to better sanitation, more food and improved public health, average life expectancy in low and middle-income countries has risen from 50 in 1965 to 65 in 2005. The increase in the poorest countries was proportionately greater: from 47 to 63. There are now more old people around to be vulnerable to chronic maladies.
At the same time, because of increased health spending and safer water, infectious diseases have declined relative to chronic ones. International financing for malaria control has increased more than tenfold in the past decade. The Bill and Melinda Gates Foundation, with its $33 billion endowment, concentrates largely on infections. As a result, the incidence of tuberculosis, measured by the number of new cases per 100,000, has fallen slightly. In Africa fatal malaria cases among children under five (the main victims) fell between 1960 and 1995, though the decline has since levelled off. The WHO reckons that deaths from infections will decline by 3% over the next ten years. So more people in poor places will survive infections in their dangerous childhoods to reach an age when they are susceptible to heart attacks and cancer.
Since chronic disease among the poor is not the preserve of old age, another part of the explanation for its increasing importance must lie in the harmful things middle-aged folk do. Of these, smoking and unhealthy eating are most important.
Around 300m Chinese men smoke. In China, Egypt, Indonesia and Russia, people spend 5-6% of their household income on cigarettes—far more than the share in rich countries. Smoking and its associated ailments are still rising in poor countries, even while they fall in rich ones.
Middle-income countries are also experiencing extraordinary levels of obesity. According to one study, half of all households in Brazil contain at least one obese person; the share is three-quarters in Russia. According to another, Mexico is the second fattest nation among the 30 (mostly rich) countries of the Organisation for Economic Co-operation and Development, after America. It has the highest rate of diabetes among large countries, with 6.5m diabetics in a population of 100m. Not coincidentally, Mexicans are among the biggest swiggers of fizzy drinks in the world. Coke and tacos, anyone?
Obesity affects rich countries, of course: it is a symptom of affluence and urbanisation. But it is occurring much earlier than anyone had expected in middle-income places. Obesity among children there used to be unheard of. Last year China's vice-minister for health, Wang Longde, said more than a fifth of Chinese children between seven and 17 who live in cities are overweight—a proportion that presumably reflects not only the wealth of China's urban elite but the amount of money they lavish on their “little emperors” (the single children they are limited to by China's one-child policy).
Yet despite all the evidence that chronic disease is the world's biggest health problem, most poor countries focus on infectious disease and their health policies are usually based on the idea that infections should be controlled before chronic conditions. These choices no doubt partly reflect bureaucratic inertia at health ministries and investment in fighting infections by medical charities and drugs firms.
Not just statistics
It is true that there are better reasons why poor countries might want to concentrate on infections despite the growth of chronic disease. Infectious illnesses are usually simpler to deal with than chronic ones, requiring inoculation campaigns rather than long-term care, changes of lifestyle and the uphill work of public education. Moreover, if you inoculate a child against malaria, you considerably reduce his or her chances of dying from that disease, since most deaths from malaria occur among children under ten. If you lower someone's risk of getting a heart condition at 50, you might well find they get it at 60. The disease can only be managed.
Still, it can be managed better: the contrast between death rates from heart attacks (falling in the West, rising elsewhere) shows that. Stalin said a single death is a tragedy, a million deaths, a statistic. But millions of avoidable deaths are millions of tragedies. Chronic disease is already the biggest problem for poor and middle-income countries. To concentrate so much on infections is to add to the health burden of the next generation in what are already the world's poorest, unhealthiest places.
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