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 rst use of the term transition by Adolphe Landry (3). But it is Frank Notestein who is given credit for the rst 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 populations development. It ts 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. 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 ndings 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 inuences 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 identied. 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 fth 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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The Demographic Equation P = Births Migration - Deaths

Family Values Fecundity Gender roles Contraception Economics Politics Persecution Opportunities Disease Famine War Senescence Suicide Risky behavior

FIGURE 1. The demographic equation.

economic and healthcare support, and, medically, greater dependence on advanced technological devices and procedures to diagnose and treat diseases. This newly proposed stage we may call that of aging and shrinking populations. Many developed nations are already well into this phase. What can we look forward to in the twenty-rst 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. 3, lower panel). In those societies that are at the pre-modern stage, where disease levels are high and famine is still a constant threat, epidemiologists can contribute to improving health by advocating for basic improvements in sanitation and wider immunization of children. They can also urge the development of basic epidemiologic toolsdvital registration and health statistics systems. Lacking accurate and complete data, it is difcult to assess the magnitude of health problems, identify vulnerable subgroups, or measure the impact of public health programs. Although great progress has been made in controlling infectious diseases in virtually all developed nations, emerging infections, exemplied by HIV/AIDS, are a major problem in urbanizing/industrializing areas. Combating these

diseases will engage epidemiologists for decades to come. 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. Better city planning, avoidance of overcrowding, provision of adequate transportation systems, safe work environments, and modern educational systems would go far to preventing future health problems as well as many other social ills. In mature industrial societies epidemiologists will devote most of their efforts to preventing chronic diseases, educating the public about healthy lifestyles, assessing early detection and treatment programs, and improving the availability, accessibility, and utilization of health services. These activities will merge with evolving progress in the elds of genomics, immunology, and diagnostics to better dene and detect illnesses. Epidemiologists will broaden their involvement in social diseases, including substance abuse and violence. They will also be major players in understanding and ameliorating subgroup disparities in health and longevity. As we enter the fth stage of the epidemiologic transition model, epidemiologists will become increasingly involved with the health conditions that prevail at both extremes of the age distribution. Providing for the health needs of older patients will encumber greater proportions of communities resources. Broader aspects of the well-being of older persons, especially the oldest old, will necessitate expanded information about their physical, social, economic, and psychologic environments, not only their biologic, physiologic, and cognitive functioning. As the birth rates decrease, children will become increasingly precious. There will be ever-increasing devotion to the salubrious development of children in all aspects, including physical, mental, emotional, and societal.

50 45 40 35 30 25 20 15 10 5 0

Epidemiologic Transition Model

1 2 3 4 5 1 - Pestilence and famine 2 - Receding pandemics 3 - Declining births 4 - Degenerative & man-made disease 5 - Aging and shrinking population

Time
CDR CBR Population

FIGURE 2. The epidemiologic transition model.

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Impact of Epidemiology
Stage 1 Premodern 2 Urbanizing/ Industrializing Reduced infectious diseases & infant mortality HIV/AIDS, emerging infections, city planning 3 Mature industrial 4 Post Industrial 5

Past

Nil

Birth control, occupational health, nutrition Prevention of chronic diseases, Health services

Injuries, Smoking & other technological riskfactors, fixes environmental risks Genomics, Education to modify life styles, substance abuse, violence Elder care physical, social, economic, psychologic, Child development

Sanitation, Future immunization, Vital registration & Health Statistics

FIGURE 3. Impact of epidemiology.

This has been a wide view of the accomplishments of epidemiology and some of the challenges we will encounter in coming decades. The American College of Epidemiology has played an important role in encouraging and recognizing epidemiologists in their endeavors and will continue to provide leadership, guidance, and stimulation in the future. It has been a pleasure and an honor for me personally to have been a participant in these activities.

REFERENCES
1. Kirk D. Demographic transition theory. Population Studies. 1996;50:361 387. 2. Thompson WS. Population. Am J Sociol. 1929;34:959975. 3. Landry A. La revolution demographique. Paris; 1934. 4. Notestein F. Population: the long view. In: Schultz T, ed. Food for the world. Chicago: University of Chicago Press.; 1945. p. 3657. 5. Omran AR. The epidemiologic transition: a theory of the epidemiology of population change. Milbank Mem Fund Q. 1971;49:509538.