Michael J. Klag, MD, MPH Dean
Health in the 21st Century: Trends and Predictions
TOP TEN PUBLIC HEALTH ISSUES 1. Noncommunicable diseases 2. Lack of access to safe water 3. Increasing urbanization 4. Emerging diseases 5. Global warming 6. Emerging contaminants 7. Disempowerment of women 8. Deaths from natural disasters 9. Neglected tropical diseases, poor access to health care,
global maldistribution of providers, inequities 10. Population growth
INTERNATIONAL CONFERENCE ON POPULATION AND DEVELOPMENT SEPTEMBER 1994
• Held in Cairo, Egypt • Coordinated by the UN; 20,000 attendees • Produced the steering document for the United
Nations Population Fund (UNFPA) • Consensus on 4 goals: universal education,
reduction of infant and child mortality, reduction of maternal mortality, access to reproductive health services
3
CHANGE IN DONOR ASSISTANCE FOR FAMILY PLANNING PROGRAMS, WOMEN, AGED 15-49, 1996 TO 2006
United Na+ons Popula+on Division, 2011
Per capita assistance increased Per capita donor assistance declined
(by less than 50 per cent)
Per capita donor assistance declined (by 50 per cent or more)
No data available or not applicable
GLOBAL POPULATION 1 CE TO PRESENT IN BILLIONS
0
1
2
3
4
5
6
7
WORLD POPULATION MILESTONES
• 1 billion in 1804 • 2 billion in 1927 (123 years later) • 3 billion in 1960 (33 years later) • 4 billion in 1974 (14 years later) • 5 billion in 1987 (13 years later) • 6 billion in 1999 (12 years later) • 7 billion in 2011 (12 years later)
46 years
39 years
RATE OF CHANGE, WORLD POPULATION, 1750-2011
0.0
0.5
1.0
1.5
2.0
2.51750
1800
1850
1900
1950
1975
2000
United Na+ons Popula+on Division, 2011 courtesy of H. Zlotnik
ESTIMATED AND PROJECTED WORLD POPULATION, BILLIONS, 1950-2100
Source: United Na+ons, Department of Economic and Social Affairs, Popula+on Division (2011): World Popula+on Prospects: The 2010 Revision. New York
(Updated: 15 April 2011)
TOTAL FERTILITY BY COUNTRY 2005-10
0
1
2
3
4
5
6
7
8
China, Hon
g Ko
ng SAR
Singapore
Japan
Romania
Portugal
Belarus
Czech Re
public
Spain
Russian Fede
ra+o
n Sw
itzerland
Moldo
va
Georgia
Serbia
Estonia
Mauri+
us
Arub
a Be
lgium
Finland
United Arab Emira
tes
Chile
Bahamas
Norway
Nethe
rland
s An+
lles
Saint Lucia
Myanm
ar
Brun
ei Darussalam
Guadelou
pe
Azerbaijan
New
Caled
onia
Kuwait
Sri Lanka
Morocco
Réun
ion
Colombia
Turkmen
istan
Kazakhstan
Panama
Peru
Dominican Rep
ublic
Libya
Fiji
Egypt
Belize
Saud
i Arabia
Fren
ch Guiana
Hond
uras
Nam
ibia
Bolivia
Microne
sia
Djibou
+ To
nga
Mayo`
e Solomon
Island
s Co
ngo
Burund
i Mauritania
Central A
frican Rep
ublic
Comoros
Sierra Leo
ne
Libe
ria
Benin
Nigeria
Malaw
i Zambia
Mali
Niger
Germany 1.36 U.S. 2.07
Niger 7.19
Source: UN Department of Economic and Social Affairs – Popula+on Division
Source: United Na+ons, Department of Economic and Social Affairs, Popula+on Division (2011): World Popula+on Prospects: The 2010 Revision. New York
ESTIMATE OF TOTAL FERTILITY 2005-2010
RISK OF POST-NEONATAL MORTALITY BY PRECEDING INTER-OUTCOME INTERVAL, MATLAB
Davano, 2004
ODDS OF PREGNANCY OUTCOMES BY PRECEDING INTER-PREGNANCY INTERVAL, MATLAB
Davano, 2004
13 Chowdhury, J Health Popul Nutr 2009
Analysis based on 769 maternal deaths and 215,779 pregnancy records
50% 40%
79% 48%
UNMET NEED FOR FAMILY PLANNING
0
5
10
15
20
25
30
35
40
45
50
Belize 1999
Benin 20
06
Bolivia 2008
Botswana 1988
Bulgaria 1998
Burkina Faso 2003
Burund
i 200
2 Cambo
dia 2005
Cameroo
n 2004
Comoros 199
6 Cô
te d'Ivoire 1999
DRC 2007
Eritrea 2002
Ethiop
ia 2005
Gabo
n 2000
Ghana 2008
Guatem
ala 2002
Guinea 2005
Hai+ 2006
Kenya 2009
Laos 2005
Lesotho 2010
Libe
ria 2007
Malaw
i 2004
Maldives 2
009
Mali 2006
Mauritania 2001
Nam
ibia 2007
Nep
al 2006
Nigeria 2008
Pakistan 2007
Philipp
ines 2008
Rwanda 2005
Samoa 2009
Sao To
me and
Sene
gal 2005
Sierra Leo
ne 2008
Sudan 1993
Swaziland
2007
Timor-‐Leste 2010
Togo 1998
Tuvalu 2007
Ugand
a 2006
Tanzania 2005
Yemen
1997
Zambia 2007
Limi+ng Spacing
Source: UN Department of Economic and Social Affairs – Population Division
KAMPALA CONFERENCE, NOVEMBER 2009
15
CHILDHOOD MORTALITY, 1950-2050
WHO World Popula+on Prospects: The 2004 Revision
Gains in U.S. Life Expectancy: 1900-2050
76.5
72.6
46.4
82.979.7
49.0
82.580.4
76.4
84.4 86.5
76.7
30
40
50
60
70
80
90
1900 1920 1940 1960 1980 2000 2020 2040
Age
Male e0Female e0Male e65Female e65
GAINS IN LIFE EXPECTANCY, U.S.,1900-2050
Courtesy of Agree, 2011
h`p://www.iiasa.ac.at/Research/LUC/ChinaFood/data/anim/pop_ani.htm
ACTIVE LIFE EXPECTANCY AND DISABLED LIFE EXPECTANCY AT AGE 85 BY GENDER: 1992, 1997, 2002
Cai & Lubitz 2007. “Was There Compression of Disability for Older Americans From 1992 to 2003?” Demography, Volume 44, Number 3, August 2007, pp. 479-‐495
ADL activities of daily living limitations IADL instrumental activities of daily living limitations
Andersen, NEJM, 2007
FOOD SECURITY • “The scale, severity and duration of the world food problem
are so great that a massive, long-range, innovative effort unprecedented in human history will be required to master it.”
– U.S. President’s Science Advisory Committee,1967 • Rockefeller and Ford foundations took the lead in
establishing an international agricultural research system • Modern plant breeding, improved agronomy, and the
development of inorganic fertilizers and modern pesticides fueled these advances
• High yield varieties of rice and wheat – Wheat yields increased from 0.5 to 2 metric tons per
hectare over 1,000 years – Only 40 years to increase from 2 to 6 metric tons per
hectare Hazell, The Oxford Encyclopedia of Economic History 2003
NORMAN BORLAUG
• Developed semi-dwarf, high-yield, disease-resistant wheat varieties
• “Father of the Green Revolution“ • Credited with saving a billion
lives • Won the Nobel Peace Prize, the
Presidential Medal of Freedom and the Congressional Gold Medal
• Technology saved our lunch! • Increases in productivity have not
occurred in Africa • Given dependence on pesticides,
fertilizers and irrigation, is the Green Revolution sustainable?
CULTURAL EXPORTS
h`p://krieger.jhu.edu/magazine/fw07/r3.html
GALLONS OF WATER REQUIRED TO PRODUCE ONE POUND OF:
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Beef Pork Chicken Soybeans Wheat Corn
24 Source: Water Footprint Network
*8 Pounds of Grain
URBAN AND RURAL POPULATIONS BY DEVELOPMENT AREA, 1950-2050
25 UN, World Urbaniza+on Prospects : The 2011 Revision
MEGACITIES POPULATION, MILLIONS, 1970 1. Tokyo, Japan 23.3 2. New York-Newark, USA 16.2
26
MEGACITIES POPULATION, MILLIONS, 1990 1. Tokyo, Japan 32.5 2. New York-Newark, USA 16.1 3. Ciudad de México (Mexico City), Mexico 15.3 4. São Paulo, Brazil 14.8 5. Mumbai (Bombay), India 12.4 6. Osaka-Kobe, Japan 11.0 7. Kolkata (Calcutta), India 10.9 8. Los Angeles-Long Beach-Santa Ana, USA 10.9 9. Seoul, Republic of Korea 10.5 10. Buenos Aires, Argentina 10.5
MEGACITIES POPULATION, MILLIONS, 2011 1. Tokyo, Japan 37.2 2. Delhi, India 22.7 3. Ciudad de México (Mexico City), Mexico 20.4 4. New York-Newark, USA 20.4 5. Shanghai, China 20.2 6. São Paulo, Brazil 19.9 7. Mumbai (Bombay), India 19.7 8. Beijing, China 15.6 9. Dhaka, Bangladesh 15.4 10. Kolkata (Calcutta), India 14.4 11. Karachi, Pakistan 13.9 12. Buenos Aires, Argentina 13.5 13. Los Angeles-Long Beach-Santa Ana, USA 13.4 14. Rio de Janeiro, Brazil 12.0 15. Manila, Philippines 11.9 16. Moskva (Moscow), Russian Federation 11.6 17. Osaka-Kobe, Japan 11.5 18. Istanbul, Turkey 11.3 19. Lagos, Nigeria 11.2 20. Al-Qahirah (Cairo), Egypt 11.2 21. Guangzhou, Guangdong, China 10.8 22. Shenzhen, China 10.6 23. Paris, France 10.6
MEGACITIES POPULATION, MILLIONS, 2025 1. Tokyo, Japan 38.7 2. Delhi, India 32.9 3. Shanghai, China 28.4 4. Mumbai (Bombay), India 26.6 5. Ciudad de México (Mexico City), Mexico 24.6 6. New York-Newark, USA 23.6 7. São Paulo, Brazil 23.2 8. Dhaka, Bangladesh 22.9 9. Beijing, China 22.6 10. Karachi, Pakistan 20.2 11. Lagos, Nigeria 18.9 12. Kolkata (Calcutta), India 18.7 13. Manila, Philippines 16.3 14. Los Angeles-Long Beach-Santa Ana, USA 15.7 15. Shenzhen, China 15.5 16. Buenos Aires, Argentina 15.5 17. Guangzhou, Guangdong, China 15.5 18. Istanbul, Turkey 14.9 19. Al-Qahirah (Cairo), Egypt 14.7 20. Kinshasa, Democratic Rep. of the Congo 14.5 21. Rio de Janeiro, Brazil 13.6 22. Bangalore, India 13.2 23. Jakarta, Indonesia 12.8 24. Chennai (Madras), India 12.8 25. Wuhan, China 12.7 26. Moskva (Moscow), Russian Federation 12.6 27. Paris, France 12.2 28. Osaka-Kobe, Japan 12.0 29. Tianjin, China 11.9 30. Hyderabad, India 11.6 31. Lima, Peru 11.5 32. Chicago, USA 11.4 33. Bogotá, Colombia 11.4 34. Krung Thep (Bangkok), Thailand 11.2 35. Lahore, Pakistan 11.2 36. London, United Kingdom 10.3
TOTAL POPULATION BY CITY SIZE, 1970-2025
30 UN, World Urbaniza+on Prospects : The 2011 Revision
URBANIZATION AND HEALTH • One in three urban dwellers lives in slums, 1 billion people
worldwide • Increases use of motor vehicles, leading cause of death • Urban air pollution kills around 1.2 million people each year
around the world, mainly due to cardiovascular and respiratory diseases
• Tuberculosis (TB) incidence is much higher in big cities – 4x in New York City – In the DRC, 83% of people with TB live in cities.
• Urban environments tend to discourage physical activity and promote unhealthy food consumption, higher prevalence of obesity, diabetes and related diseases
• But provision of services is more efficient in cities
31 Source: World Health Organization
INCOME INEQUALITY IN INDIA
32
CHANGE IN GINI COEFFICIENTS SINCE THE 1990’s, %
-‐8 -‐6 -‐4 -‐2 0 2 4 6 8 10
Brazil
Colombia
Ecuador
Malaysia
Philippines
Argen+na
Mexico
India (rural)
India (urban)
Hong Kong
China (rural)
China (urban)
33 Source: World Bank
INCOME INEQUALITY IN THE U.S.
34 Source: Congressional Budget Office
35
RIGGS GLACIER, ALASKA
36
NORTHERN HEMISPHERE TEMPERATURES OVER 1,000 YEARS
37
Mean, 1961-90
Black line, mean Gray line, uncertainty
Mann, 1999
GLOBAL TEMPERATURE, 1880-2004
38 NASA, Goddard Institute for Space Studies
TOTAL CO2 EMISSIONS, 2000
39 St. Louis, 2008
ESTIMATED DEATHS ATTRIBUTED TO CLIMATE CHANGE IN 2000
40 Source: Annual Review of Public Health, Vol. 29
IMPLICATIONS OF CLIMATE CHANGE FOR GLOBAL HEALTH
Health Effect • Increase in malnutrition and consequent disorders,
including child growth and development • Increase in death, disease, and injury from heat
waves, floods, storms, fire, and drought • Mixed effects on malaria, with some contractions
balanced by expanded geographic range and change in seasonality
• Change in the range of some vectors of infectious diseases
• Increase in diarrheal diseases • Increase in number of people exposed to dengue
fever • Decrease in cereal crop productivity in low
latitudes for even small local temperature increases
Confidence Level • High
• High
• Very high • High
• Moderate
• Low
• Moderate
41 IPCC Fourth Assessment Report Climate, 2007
© 2010, Johns Hopkins University. All rights reserved.
TECHNOLOGY • mHealth
• Big data
• Informatics
• Microbiome
• Gene therapy
• Disruptive technology (Game changers)
42
BIOPRINTING TECHNIQUES
43 Ozbolat and Yu, IEEE, 2013
(A) laser-‐based wri+ng of cells (B) ink-‐jet based systems (C) extrusion-‐based deposi+on.
© 2010, Johns Hopkins University. All rights reserved.
45
Ozbolat and Yu, IEEE, 2013
SUMMARY (1) • In the future, the world will be:
– More populous – Older – More obese – More urbanized – More unequal, in both health and economic status
• All trends will impact poor countries more than wealthy countries
• Population growth underlies many of the most important challenges facing the world
– Many reasons to provide family planning services – Need to de-politicize issue
46
SUMMARY (2)
• Climate change • Technology
– Game changers we can’t envision • More demand and need for health care
– Maldistribution by geographic area and medical specialty
47
FACTORS INFLUENCING HEALTH
• Population dynamics – Growth – Urbanization – Inequities
• Demand for access to health care – Manpower shortages and
maldistribution by specialty and geographic area
WHAT TO DO?
Paina and Peters, 2012
THANK YOU!
50
RATIONALE FOR PROVISION OF FAMILY PLANNING SERVICES
• Continued growth is not sustainable • Health benefits for infants and mothers • Unmet need • Human rights
– Empowerment of women – Economic and educational opportunity
51
TOP TRENDS INFLUENCING HEALTH • Population dynamics
– Epidemiologic transition – Aging – Growth
MEXICO CITY POLICY • Also called “global gag rule” • US policy--tax dollars not to be used for abortions
• Ronald Reagan, in1984, directed USAID to withhold funds from NGOs that use non-USAID funds to provide advice, counseling, or information regarding abortion, or lobbying a foreign government to legalize or make abortion available
• Withdrawn by Democratic administrations
GALLONS OF WATER REQURIED TO PRODUCE ONE POUND OF: • Beef = 441 to 12,008 (8 pounds of grain) • Pork = 576 • Chicken = 468 • Soybeans = 206 • Wheat = 138 • Corn = 108
55
57 Chowdhury, J Health Popul Nutr 2009
Analysis based on 769 maternal deaths and 215,779 pregnancy records
FACTORS INFLUENCING HEALTH • Population dynamics
– Growth – Urbanization – Inequities
• Climate change • Demand for access to health care
– Manpower shortages and maldistribution by specialty and geographic area
• Technology – Game changers we can’t envision
RATE OF NATURAL INCREASE* BY MAJOR AREA, 1950 – 2010
0
5
10
15
20
25
30
1950-‐55 1955-‐60 1960-‐65 1965-‐70 1970-‐75 1975-‐80 1980-‐85 1985-‐90 1990-‐95 1995-‐2000 2000-‐05 2005-‐10
Per tho
usan
d
World
More developed regions
Less developed regions
Least developed regions
*(Crude birth rate − Crude death rate) / midyear population
Source: UN Department of Economic and Social Affairs -‐ Popula+on Division, June 2011
INCOME INEQUALITY IN THE U.S.
60 Source: Congressional Budget Office
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 Age
Propo
r+on
Surviving Life Expectancy
at Birth
Mortality (C)
Morbidity (A)
Disability (B)
Source: Bell, Wade, and Goss, 1992, and authors' tabula+ons.
Life Expectancy at 65
SURVIVAL CURVE FOR U.S. WOMEN, 1990 AND HYPOTHETICAL DISABILITY AND MORBIDITY CURVES
Agree, 2011
YEARS OF HEALTHY AND DISABILITY-FREE LIFE, US, 1998-2006
Crimmins EM, Beltrán-‐Sánchez H 2011. “Mortality and morbidity trends: is there compression of morbidity? J Gerontol B Psychol Sci Soc Sci. 2011;66B(1):75–86
© 2010, Johns Hopkins University. All rights reserved.
ORGAN PRINTING
64
h`p://www.makepartsfast.com/2009/12/836/3d-‐bio-‐printer-‐manufactures-‐human-‐+ssue-‐and-‐organs/