SPECIAL COVERAGE
By David R. Hill, MD
Each year, millions of people travel from developed areas of the world to developing countries. Understandably, most travelers tend to focus on the sights, sounds, and tastes that they hope to experience. The travel health professional focuses on providing the appropriate vaccines and counseling about safe food and water and the avoidance of malaria-transmitting mosquitoes. The health conditions of the countries of destination are frequently placed in the background.
A series of four pivotal articles that appeared in a recent issue of The Lancet bring attention to these health conditions.1-4 They should be required reading for travel medicine specialists and those interested in international health. In these articles, Christopher Murray of the Harvard School of Public Health and Alan Lopez of the World Health Organization (WHO) report on the Global Burden of Disease Study (GBD) initiated in 1992 by the World Bank in collaboration with WHO. Preliminary results have been reported in monograph form.5 The objectives of the study were: to develop estimates of mortality by cause, age, sex, and geographic region; to estimate the contribution to disability and mortality by sequelae of the major causes of death; to assess the most important risk factors for disability and mortality; and to project future disease burden. The information generated from this analysis would hopefully form the basis for debate on health interventions and priorities.
In 1990, there were 50.5 million deaths worldwide.1 Ninety-eight percent of all deaths in children younger than 15 years occurred in developing regions of the world. The burden of this for a region like sub-Saharan Africa is astounding: 53% of all deaths in this region occurred between the ages of 0 and 4 years, and there was a probability of 22% that a child would die before the age of 15. This compares with about a 1% probability of death in countries of the developed world. There were differences between developing regions; China and Latin America, as examples, had probabilities of 5-10%. As might be expected, the predominant causes of death for children in developing regions are respiratory and diarrheal disease, other infections and parasites, and perinatal complications. The risk factors contributing most to these causes are malnutrition and the inability to obtain clean water and live in sanitary conditions.3
In examining overall mortality figures, communicable, maternal, perinatal, and nutritional diseases (generally associated with conditions of poverty) accounted for one in three deaths, non-communicable diseases such as cardiovascular, pulmonary, and neoplastic disorders, for more than one in two deaths, and injuries for one in 10 deaths. The 15 leading causes are listed in the Table. Regional differences were seen againnearly all of the deaths from diarrhea occurred in developing areas. For example, 17% of deaths in China were due to cancer, and 9% of all deaths in developing regions were due to malignancy. Cardiovascular disorders accounted for 23% of deaths in developing regions.
Table
Worldwide Causes of Death1990 with Predictions for 2020
Cause of Death Deaths (´ 10-3)1990 Ranking2020
Cerebrovascular disease 4381 2
Lower respiratory infectio4299 4
Cancer of trachea, bronchus, and lung 945 5
Self-inflicted injuries 786 10
Others (ranking in 1990) Violence 563 (17) 14 War injuries 502 (21) 15 Liver cancer 501 (22) 13 HIV 312 (30) 9
Data from: Murray CJL, Lopez AD. Lancet 1997;349:1269-1276; Murray CJL, Lopez AD. Lancet 1997;349:1498-1504.
Injuries are another important and often neglected cause of morbidity and mortality. One in 10 deaths throughout the world, and 15% of all disabilities3 were caused by intentional (acts of war, homicide, or suicide) or unintentional injuries (accidents, drownings, or disasters). In China, suicide is estimated to account for almost one-fourth of deaths in women between the ages of 15 and 44. For young adult travelers, accidents and injuries are the leading cause of significant morbidity and mortality.6,7
The GBD study also makes projections to the year 2020 (see Table).4 Communicable and perinatal diseases are expected to decline, as socioeconomic development and vaccine and treatment programs continue. However, morbidity and mortality from heart and respiratory disease, and accidents and injuries will markedly increase. And, the HIV pandemic will have increasing impact if not controlled through the practice of safe sex.
What can we say about this information? Despite efforts to provide improved health conditions, five of the 10 leading causes of death and nearly 30% of all causes, are communicable or perinatal disorders. Most of these affect the children of the world. However, non-communicable disorders such as ischemic heart disease, chronic obstructive pulmonary disease (COPD), and cancer are universally prevalent, and future projections (2020) suggest that the majority of these disorders will occur in developing regions. An important cause of many non-communicable diseases, particularly lung cancer and respiratory illness, can be attributed to the sale and promotion of tobacco products throughout the developing world8,9 and the inability to control pollution in sprawling urban areas. Finally, injury prevention measuresfrom safe roads and vehicles to suicide and homicide preventionwill have to be emphasized.
As we strive to live in a world that provides health for all people, governmental and non-governmental agencies need to assess this information to establish and perhaps change their priorities. The developed world, which uses more than 90% of all health resources but has only 12% of the burden of disease,3 has to share its wealth to bring these figures into balance. This will not be easy.
As travel health professionals, we should make our traveling patients aware of the health conditions of the countries they are visiting and the burden of disease placed on indigenous populations. Thus, when decisions are being made about health priorities and allocating resources, we and our patients, as informed individuals and members of a global community, can contribute positively to the debate.
References
1. Murray CJL, Lopez AD. Mortality by cause for eight regions of the world: Global Burden of Disease study. Lancet 1997;349:1269-1276.
2. Murray CJL, Lopez AD. Regional patterns of disability-free life expectancy and disability-adjusted life expectancy: Global Burden of Disease study. Lancet 1997;349:1347-1352.
3. Murray CJL, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease study. Lancet 1997;349:1436-1442.
4. Murray CJL, Lopez AD. Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease study. Lancet 1997;349:1498-1504.
5. The World Bank. World Development Report 1993. Investing in Health. New York: Oxford University Press, Inc.; 1993:329.
6. Hargarten SW, Baker SP. Fatalities in the Peace Corps: A retrospective study: 1962 through 1983. JAMA 1985;254:1326-1329.
7. Paixao MLTDA, et al. What do Scots die of when abroad? Scot Med J 1991;36:114-116.
8. Barry M. The influence of the U.S. tobacco industry on the health, economy, and environment of developing countries. N Engl J Med 1991;324:917-920.
9. Jenkins CNH, et al. Tobacco use in Vietnam. Prevalence, predictors, and the roles of the transnational tobacco corporations. JAMA 1997;277:1726-1731.
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