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The Epidemiologic Transition Model: Accomplishments and Challenges

MANNING FEINLEIB, MD, DRPH, FACE

Changes in population size and structure are determined by basic processes that can be summarized by the demographic equation (Fig. 1). While demographers and those concerned with population growth tend to emphasize fertility trends, and immigration policy is very much on the current political agenda, epidemiologists tend to concentrate their efforts studying the factors associated with the third part of the equation. Late in the nineteenth century, demographers, following Malthusian principles, developed several theories to describe how populations change over long periods of time. Dudley Kirk (1) points out that, in 1929, Warren Thompson categorized populations on the basis of fertility and mortality (2), followed in 1934 by the first use of the term ‘‘transition’’ by Adolphe Landry (3). But it is Frank Notestein who is given credit for the first full statement of the demographic transition model in 1945 (4). This model was expanded by Abdel Omran in a seminal article in 1971 in which he renamed the model the epidemiologic transition model (5). Whereas earlier demographers were concerned primarily with changes in fertility, Omran emphasized the mortality aspects. Omran renamed the four stages of the demographers’ transition model for population evolution to emphasize some epidemiologic aspects (Fig. 2): Stage 1, which demographers called pre-modern, he labeled the stage of pestilence and famine characterized by high death rates and high birth rates with low population size. Stage 2durbanizing and industrializingdhe described as the stage of receding pandemics resulting from a gradual conquest of disease primarily through better sanitation and nutrition and resulting in a reduction of mortality, especially child mortality, and a concomitant gradual increase in population size. Stage 3dmature industrialdhe called the stage of declining births with a peaking of the size of the population. Stage 4dpostindustrialdwas characterized as the stage of degenerative and man-made disease with a balance between birth and death rates, both at low levels, and a leveling off of the population size. It should be pointed out that the model is an idealized summary of the stages in a population’s development. It fits fairly well the demographic changes which occurred in Western Europe and the English-speaking countries during

Address correspondence to: Dr. Manning Feinleib, Johns Hopkins Bloomberg School of Public Health, Epidemiology, Bloomberg E6153, Baltimore, MD. Tel: (410) 614-0146. Fax: (410) 955-0863. E-mail: mfeinlei@jhsph.edu. Ó 2008 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010

the late eighteenth century through the mid-twentieth century, and there is evidence that the pattern is being followed by many developing countries, although the pace of the transitions varies greatly. My aim in this short essay is not to discuss the details of the various stages of the epidemiologic transition model but to use it as a platform to mention some of the major accomplishments of epidemiology in the past and to highlight the challenges and opportunities that lay ahead (Fig. 3). I view epidemiology as the provider of the evidential basis for public health action and for many clinical practices. Thus the accomplishments of epidemiology in preventing and controlling disease and enhancing longevity are intricately dependent on the implementation of its findings at the individual patient level and through community public health programs. During the pre-modern stage, epidemiology contributed little other than to emphasize the periodic increases in mortality resulting from epidemics, famine, and other hardships. But during stage 2, as epidemiologic and medical knowledge and public health applications increased, there was a gradual diminution of infectious diseases generally and some curtailment of epidemics. Infant mortality especially improved while the birth rate remained high so that populations gradually increased in size. The third stage is characterized in this model by a reduction in the birth rate. The reasons for this decline are complex, involving many societal, cultural, and economic factors (1), but some of the epidemiologic and public health influences were the improved survival of children and, more recently, the availability of effective birth control methods. This period also saw improvements in nutrition and greater concern with the health and safety of the labor force. With both mortality and birth rates at low levels the growth of the population leveled off and the concerns of epidemiologists and public health workers shifted to chronic diseases and their prevention. Many personal risk factors related to lifestyle and individual behaviors were identified. A greater awareness of environmental hazards grew and many regulatory and educational policies were instituted to reduce environmental risks. Omran dubbed this stage the age of degenerative and man-made disease (5). I would like to propose that we should now recognize a fifth stage in the epidemiologic model. This stage is characterized by birth rates below the population replacement level, an aging population with many more elderly dependent on a diminishing working population for their
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it is difficult to assess the magnitude of health problems.Aging and shrinking population Time CDR CBR Population FIGURE 2. epidemiologists can contribute to improving health by advocating for basic improvements in sanitation and wider immunization of children. immunology. Although great progress has been made in controlling infectious diseases in virtually all developed nations. What can we look forward to in the twenty-first century? I think that there is still much that epidemiologists and public health workers in general can contribute at every stage of the epidemiologic transition model (see Fig. lower panel). Many developed nations are already well into this phase.Degenerative & man-made disease 5 . Better city planning. In mature industrial societies epidemiologists will devote most of their efforts to preventing chronic diseases.Receding pandemics 3 . In those societies that are at the pre-modern stage. Combating these diseases will engage epidemiologists for decades to come. and diagnostics to better define and detect illnesses. They can also urge the development of basic epidemiologic toolsdvital registration and health statistics systems. identify vulnerable subgroups. emotional.Pestilence and famine 2 . exemplified by HIV/AIDS. greater dependence on advanced technological devices and procedures to diagnose and treat diseases. including physical. These activities will merge with evolving progress in the fields of genomics. 3.Declining births 4 . will necessitate expanded information about their physical. Broader aspects of the well-being of older persons. There is also the opportunity for epidemiologists to guide planners and policy makers in developing countries in avoiding some of the hazards that urbanized communities have experienced. and psychologic environments. The demographic equation. This newly proposed stage we may call that of aging and shrinking populations. 18. assessing early detection and treatment programs. Lacking accurate and complete data. 50 45 40 35 30 25 20 15 10 5 0 Epidemiologic Transition Model 1 2 3 4 5 1 . No. or measure the impact of public health programs. children will become increasingly precious. are a major problem in urbanizing/industrializing areas. safe work environments. physiologic. and improving the availability. economic and healthcare support. educating the public about healthy lifestyles. The epidemiologic transition model. There will be ever-increasing devotion to the salubrious development of children in all aspects. medically. and cognitive functioning. not only their biologic. accessibility. epidemiologists will become increasingly involved with the health conditions that prevail at both extremes of the age distribution. provision of adequate transportation systems. As the birth rates decrease. especially the ‘‘oldest old’’. and utilization of health services. and modern educational systems would go far to preventing future health problems as well as many other social ills. Epidemiologists will broaden their involvement in ‘‘social diseases. and. social. where disease levels are high and famine is still a constant threat. As we enter the fifth stage of the epidemiologic transition model. economic. avoidance of overcrowding. They will also be major players in understanding and ameliorating subgroup disparities in health and longevity. . emerging infections. Providing for the health needs of older patients will encumber greater proportions of communities’ resources.’’ including substance abuse and violence. 11 November 2008: 865–867 The Demographic Equation ∆P = Births ± Migration . and societal.866 Feinleib EPIDEMIOLOGIC TRANSITION AEP Vol. mental.Deaths Family Values Fecundity Gender roles Contraception Economics Politics Persecution Opportunities Disease Famine War Senescence Suicide Risky behavior FIGURE 1.

.50:361– 387. Population.49:509–538. social. ed. psychologic. violence Elder care – physical. Health services Injuries. Future immunization. 1945. 1971. The American College of Epidemiology has played an important role in encouraging and recognizing epidemiologists in their endeavors and will continue to provide leadership. In: Schultz T. Notestein F. emerging infections. p. La revolution demographique. 18. Population Studies. Chicago: University of Chicago Press. Education to modify life styles. Vital registration & Health Statistics FIGURE 3. 1996. 5. . occupational health. No. Kirk D. Omran AR. Impact of epidemiology. Demographic transition theory. Thompson WS.AEP Vol.34:959–975. Paris. 36–57. Am J Sociol. Landry A. fixes environmental risks Genomics. city planning 3 Mature industrial 4 Post Industrial 5 Past Nil Birth control. It has been a pleasure and an honor for me personally to have been a participant in these activities. 4. 1929. Child development Sanitation. 3. Smoking & other technological riskfactors. REFERENCES 1. 2. economic. The epidemiologic transition: a theory of the epidemiology of population change. 11 November 2008: 865–867 Feinleib EPIDEMIOLOGIC TRANSITION 867 Impact of Epidemiology Stage 1 Premodern 2 Urbanizing/ Industrializing Reduced infectious diseases & infant mortality HIV/AIDS. 1934. Population: the long view. nutrition Prevention of chronic diseases. This has been a wide view of the accomplishments of epidemiology and some of the challenges we will encounter in coming decades. guidance. Food for the world. substance abuse. Milbank Mem Fund Q. and stimulation in the future.