Forget the Epidemiological Transition, Its All About Rate of Change

Dear Young Professionals,

We all know about the epidemiological transition. The term ‘transition’ implies the act of passing from one state to the next. I think this is not helpful in today’s NCD climate. There is an overlap now as we all know, the so-called ‘double burden’.


The main phenomenon that concerns me is rate of change. It took 200 years for the ‘West’ to develop, yet developing countries are doing it in decades. This rate of change can itself be harmful – as in the macro-economic field in which countries that adopted neo-liberal markets without adequate infrastructure teetered on the brink of collapse. Witness the drastic public health situation with the rapid economic collapse of the Soviet Union. A rapid curve uptake of lifestyle factors that predispose to CVD without adequate public knowledge, public health controls and secondary care is surely analogous to this.


The rate of increase of non-communicable diseases are much higher in developing countries now– this is due to a number of factors (which we could talk endlessly on) but broadly is down to the fact that countries are industrialising more quickly, partly as a result of the forces of globalisation - we live in an ever-faster society.  However, what we should also consider is that the rate of decline of communicable disease is slower – hence there is an overlap that is markedly different to that of the developed world chart 100 years ago. I’m no mathematician, but I m sure that an ‘area under the curve' could measure what I allude to.


We can ruminate over why the rates differ – but why is it that communicable diseases are only slowly declining in the developing world? Could it be that it was the developed world that invented the cures and properly installed sanitation measures, hence resulting in their own rapid decline of communicable disease whilst the developing world cannot afford these products of the ‘rich’ world? Market forces? Goes into the issue with cost of anti-retrovirals for instance…

As for NCDs, the practical issue would be rather than trying to ‘stem’ an epidemic of non-communicable disease, we need to slow uptake of lifestyles that encourage it – as I think sadly we will never truly be able to stem it. I believe in part that Japan’s low rate of coronary disease is due to their slow uptake of Western diets and smoking – I think however that their epidemic is still to come. Note however if Japan (rather than the US) had been the leading influence on global diet – then would we all have a much higher cancer rate, and more hypertensive disease?


Last year I taught cardiology for 2 weeks in Nigeria (Lagos). The drivers on the roads there are nuts! I said to them they have a problem in that they have embraced Western ideas but not the infrastructure. The West took 100 years to develop their road system, learning from their mistakes (and deaths) along the way. In that time, they learnt about road rules, traffic control, law and legislation. To a Westerner, the way people drive in the developing world is crazy. In the West, the vast majority of drivers stop at red lights, stick to their lanes, do not over speed, and are courteous to others. Much of this is because our laws are clear and strong, but importantly they are enforced strictly through thorough policing and technology (eg speed cameras).


The same analogy can be had of CVD. The West took 50-100 years to get fat and unhealthy. In that time we built up health care systems to deal with the problems we created. The problem of the developing world is that due to globalisation, it is embracing change too quickly, and without the infrastructure (in both roads and public health and in other areas like environmental protection) that the West built over half a century.


'Rome was not built in a day'


Those in communicable and non-communicable disease must work together to change policy. Rather than competing, the rate of decline of communicable disease must be quicker in parallel to control of measures for NCDs. We need to shift those curves.



Dr Justin Zaman BSc MBBS MRCP MSc PhD

Consultant Cardiologist, James Paget University Hospital, Great Yarmouth, UK

Honorary Senior Lecturer, University of East Anglia, Norwich, UK

Founder member, Young Professionals Chronic Disease Network

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Tags: Change

Comment by Ekaterina Bogatyreva on May 13, 2014 at 22:16

Hi Justin,

I agree with you, that the rate of change of 'westernisation' is associated with a lot of disease (increase and lack of decline). However, I would not narrow it down to individual behavioural patterns, such as uptake or embracing of a lifestyle without knowledge/education/adaptation, despite it being a definite factor, and not even the lack of system integration, i.e. the health systems not adapt to dealing with non-acute diseases, as many western-lifestyle-related NCDs are.

There are also immense industrial pressures and commercial interests at play. Western lifestyles are SOLD, rather than introduced. If those curves are to be shifted, the cause under the cause are the corporate giants who have vested interests in billions dollars of profits. The hundreds of years that it took for America to get fat was the building of the food industry 'empire' (if I can call it that). After that, McDonalds are merely maximising their profits. I won't go into the silence of the media, who have a responsibility to inform the general public...

Comment by Justin Zaman on June 4, 2014 at 17:04

I did not narrow it down to individual behavioural patterns. Read my blog again, carefully.

Comment by Ekaterina Bogatyreva on June 4, 2014 at 20:13
Perhaps I phrased that incorrectly and sorry if I missed something (no need for passice aggression, I read your article very carefully), but my point remains.
I don't believe that the west has infrastructure to deal with the problems they created. It took them 100 years to get fat and 100 years to build a medical system incapable of dealing with it and a few decades to build a public health system, which has trouble communicating health messages to the obese population.
In light of heavy pressure from giant industries, 'changing policy' (together with communicable or alone) is difficult without considering your profiting enemy.
So without getting defensive, would you like to read carefully what I addressed in my comments and respond? If you like, of course.
Comment by Ekaterina Bogatyreva on June 4, 2014 at 20:14

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