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Proposed Activities of the Committee on Emerging Health Threats 2000-2004
by Vladimir Shkolnikov

Working Programme

Background

Our understanding of major trends in mortality and health is largely based on the classic works of the 1970s by Omran, Preston, Coale and Demeny, and McKeown. These key studies have established a well-justified system of views on the nature of mortality transition observed in the 20th century and its major determinants. In general, they have created a notion of continuous reduction of premature death with economic development through a progressive sequence of mortality structures, defined in terms of ages and causes of death. This "grand theory" of mortality transition is still valued today because it continues to explain a core part of changes and international differences observed in mortality. However, some of the positive changes predicted in the 1970s on the basis of the historical experience of Europe and North America have not been observed over the last decades. In the 1970s it was expected that less developed countries would follow the historical pathway of the West and that this would result in a global mortality convergence. In fact, during the last three decades many countries and population groups within national populations experienced diverging trends, substantially deviating from the major route of mortality transition. CEHT’s attention is focused on demographic and inter-disciplinary studies devoted to unfavourable health trends and unexpected health challenges in the modern world.

The Topics

Mortality reversals in industrialised countries with a special focus on Central and Eastern Europe. Since the 1960s, almost no progress in life expectancy has been achieved in Eastern Europe. In the countries of the former Soviet union, a continuous deterioration of population health was observed during the last 30 years. This unfavourable pattern was mostly due to increasing mortality rates from cardiovascular disease, injuries and violence, alcohol-related conditions, and lung cancer among young and middle-age adults, especially among men. Since the 1960s, the East-West gap in life expectancy has widened dramatically. In the East of Europe during the 1970s and 1980s mortality rates were increasing or stagnating along with relatively slow, but significant improvements in material life standards in terms of housing, nutrition, consumption of goods and services (including medical services) etc. until now the reasons for such an unusual situation have not been fully understood.

During the first years of market transformations in the late 1980s and the early 1990s, significant mortality increases occurred in many countries of the region. A dramatic mortality increase occurred in the 1990s in Russia and other parts of the former Soviet union. In countries of Central Europe (former GDR, Poland, Czech RePUBLIC, Slovakia, Slovenia) these unfavourable patterns, however, have been changed for the better due to significant reductions in mortality. Whereas, in the former Soviet union, Romania and Bulgaria these unfavourable patterns are still persisting. In some western countries with low mortality the progress has slowed down considerably over the last two decades (Denmark), while in Spain, Scotland and some other countries worrying signs of mortality increase among young adults emerged.

Social inequalities in health

Between the beginning of the 20th century and the 1970s social inequalities in mortality and health have mostly diminished due to the reduction of absolute poverty and to the real improvements in the sanitary standards of poor households. However, since the 1970s the trend has slowed down or even reversed. It is well documented now that during the 1980s-1990s mortality rates in disadvantaged population groups (poor, manual workers, people with low education) in industrialised countries were remaining high. Their decrease with time was significantly slower, compared to the equivalent rates in more privileged socio-demographic groups (upper non-manual classes or people with higher education). In many industrialised countries the gap in mortality and other health indicators between better-off and worse-off has increased or stabilised at a high level. In particular, the gap in life expectancy between white and black Americans was increasing during the 1980s. In the second half of the 1980s, even an absolute decrease in the life expectancy of African Americans was recorded.

HIV/AIDS and resurgent infectious diseases.

The HIV/AIDS epidemic has emerged as an unexpected challenge to mankind. It has induced significant negative effects in mortality patterns and trends in industrialised countries. However, it seems that the worst scenarios of the epidemic has been avoided in Western Europe and North America. At the same time, in Africa, a continuous deterioration was observed and almost no progress was achieved. At present, AIDS has the potential to reduce life expectancy in African countries to values around 30 years from its present level of 50-60 years. In some parts of Southern Africa, HIV affects as many as one in three pregnant women. The incidence of AIDS is also high in certain population groups in countries of SouthEast Asia. In the former Soviet union the registered incidence is relatively low today, but its dynamics and the rapid spread of other sexually-transmitted infections suggest that a significant increase in AIDS is highly probable in the future. Certainly, the activities of the IUSSP on this topic should not be stopped after the mandate of the Committee on AIDS finishes.

Besides HIV/AIDS, an unusually large number of new and newly discovered infectious diseases has been recorded during the last two decades. Namely, the rotavirus, legionellosis, the Ebola virus, hepatitis C and others. This apparent increase in the spectrum and incidence of infectious diseases most probably reflects the rapid changes in today’s globalising world with increasing number of contacts between people from different parts of the world due to an increase of travel and trade, rapid urbanisation, increasing consumption of different medical products, especially of antibiotics. "Old" infectious diseases, such as TB or malaria, which seemed to be under firm control at least in developed countries and were rapidly declining in developing countries in the 1970s, have re-emerged as a threatening PUBLIC health problem. In many cases infectious diseases can not be treated effectively now by antibiotics which have been effective for curing the same diseases in the past (drug-resistant infectious diseases).

Environmental health

The population of the modern world is living in a changing environment due to persisting man-made as well as natural influences. The consequences of these changes are not easily predictable in most cases. Traditionally in industrialised countries, the concern has focused on chemical contaminants entering the air, water, soil and food, as well as on non-chemical substances such as ionising radiation and urban noise. In less developed countries the focus is on microbial quality of drinking water and food, the physical safety of housing and work and dangerous roads.

In rich countries concentrations of traditional industrial air pollutants such as sulphur dioxide and respirable particulates have fallen markedly. However, as traffic has increased, the concentrations of nitrogen oxides, carbon monoxide and very fine particulates have risen. Meanwhile, urban environments in the Third World and, partly, in Eastern European countries and the former Soviet union combine traditional industrial air pollutants with poorly controlled pollutants from car exhausts.

China and India contain almost half of the world’s population and represent, at the same time, the two most dramatic examples of environmental pollution. In China the extent of urban air pollution with particulates and sulphur dioxide is extremely high. In many big cities of China, the daily levels of air pollution are as high as the occasional maxima of air pollution observed in London 50 years ago.

Environmental degradation is becoming a growing health threat in many developing countries. The danger appears to be especially alarming because typically these countries do not have enough resources and capacities to solve these emerging problems.

The important recent concerns include also the cumulative consequences of many man-made toxic agents that accumulate in the world’s environment and the global changes in the atmosphere and the climate.

Large burden of injuries and violence among young adults. A special focus on urban zones.

Injuries and violence have been historically neglected as a PUBLIC health problem. They have not been perceived to be amenable to PUBLIC health interventions.

Since the 1970s, very little progress has been achieved in the reduction of mortality from injuries and violence among young and middle-aged adults. In the majority of modern populations a gradual decline in mortality from diseases and motor vehicle accidents is balanced (or even overbalanced) by an increase in mortality from violent causes of death. According to the last WHO forecasts, no progress in the reduction of violent deaths is expected during the next two decades for the whole population of the world. No single ministry, institution or department can control the growing problem effectively. Only a combined and continuous effort by various sectors in society can be effective.

The problem is especially acute in poor urban areas in America and in Sub-Saharan Africa. The influential example of Harlem showed that life expectancy of a black man in the late 1980s was about 45 years, primarily due to the high probability of violent death. Mortality from homicide and other intentional violence experienced a two-three-fold increase over the 1990s in countries of the former Soviet union.

In recent years, the frequency of successions of collective violence due to local ethnic conflicts has increased in the Middle East, south-eastern Europe, Caucasus, Sub-Saharan Africa, and Southern Asia. It appears that some types of societies and their governments are not well enough protected against this danger. Most likely, these are multi-ethnic societies without strong democratic traditions where individual rights and values are not considered as a priority.