Routledge Advances in Asia-Pacific Studies, 14. London; New York: Routledge, 2013. xiii, 317 pp. (Figures, tables.) US$155.00, cloth. ISBN 978-0-415-57543-0.
This informative edited volume addresses the complexities of “the epidemiological transition” in countries in Asia and the Pacific. The epidemiological transition—a theory first proposed by demographer Abdel Omran in 1971—states that as populations “modernize” (i.e., adopt medical technologies, such as childhood immunizations and essential medicines, and improve sanitation and housing), their members go from having relatively brief lives, typically cut short by communicable diseases (CDs), such as measles, tuberculosis, malaria and cholera, to living relatively long lives, burdened by chronic non-communicable diseases (NCDs), such as cardiovascular disease, cancer and diabetes. A recent addendum to the epidemiological transition is the “nutritional transition,” the shift towards the increasing consumption of meat, salt, sugar, saturated fat, and refined or highly processed foods, with an accompanying decrease in the consumption of vegetables and whole foods.
In wealthy Western countries the epidemiological transition is thought to have largely taken place. Most other countries around the world, however, are experiencing what has come to be called the “double-disease burden.” They are mid-transition, as it were, and thus some segments of their populations continue to suffer from deadly infectious diseases; other segments suffer from the hazards associated with sedentary lifestyles and over-nutrition; and yet other segments find themselves plagued by the ailments of both pre- and post-transition. To use the term “mid-transition” implies that it is inevitable: that the transition will eventually occur for all and that it will look roughly the same everywhere. However, epidemiological transition theory is based on the broad contours of the histories of Western nations. These histories may not be replicable and, moreover, the broad contours tend to hide the internal variability and inequalities that were and continue to be experienced in high-income nations. For example, the very compelling chapter in this volume about Australia clearly shows that the health transition for the Aboriginal population has been markedly different and worse than for the non-Aboriginal population, with Aboriginal populations experiencing a double-disease burden and suffering disproportionately from both CDs and NCDs.
For the most part, each chapter in this volume is devoted to one nation, and each follows approximately the same template of describing the history of the nation’s shift thus far from CDs to NCDs, the nature of its double-disease burden, the health policies and services intended to address the burden, and the challenges encountered. Considering that a whole book could be written about these topics for each of the nations in question, most of the chapters do a very good job of laying out the crucial information in a necessarily succinct yet interesting way. Thus, the volume as a whole is a very valuable compendium of useful and important information about the epidemiological history of each country.
My initial impression of the volume was that each chapter told pretty much the same story: as India (or South Korea or Thailand, etc.) came to provide its citizens with childhood immunizations, better access to clean water, and improved living conditions, the burden of communicable diseases decreased. And, as the citizens of Sri Lanka (or the Philippines or Indonesia, etc.) came to eat more fat, sugar, and salt, and as they became more urbanized and sedentary, they came to suffer more from cardiovascular disease, diabetes, chronic respiratory diseases, and cancer. This overarching narrative is perhaps inevitable when the disease history of each country must be collapsed into 20 pages, thus smoothing out most of the unique vagaries of each case.
However, each case does, in fact, convey some of its singular trajectory. For example, while 21 percent of Papua New Guinea’s mortality is now caused by cardiovascular disease (CVD), in fact coronary heart disease (which ranks as the first or second cause of CVD deaths in other Pacific Island countries) is not the leading cause of its CVD deaths. Rather, CVD deaths in Papua New Guinea are from rheumatic heart disease (caused by staphlyccocal infection) and from cor pulmonale (likely caused by lifelong exposure to domestic wood-smoke, not surprising given that much traditional housing is not ventilated). In other words, fat, sugar, salt and increasing sedentism may have similar effects everywhere, but the details of how a citizenry live (e.g., how they cook, how they build their houses) also matter a great deal.
The edited volume is a lesson in how national economic policies can have profound health outcomes, again contributing to the unique nature of each case. For example, the authors of the chapter about Thailand discuss that nation’s rapid economic growth due to industrialization, the state’s reluctance to discourage foreign investment in factories that produce hazardous wastes, and the consequent increase in ailments associated with industrial pollution in communities living near industrial estates—not only cancers and chromosomal abnormalities in children, but also a very high rate of suicide. The volume is also interesting for the information each chapter provides about how these nations are trying to address their rapid increases in costly NCDs. For example, the authors of the chapter about Singapore note that it became the world’s first country to require adult children to care for their aging parents.
The best chapters for me were the ones that focused a bit more on the social and political histories of health and a bit less on the health statistics. For example, the chapter about Japan nicely explains how Chinese medicine, two centuries of isolation policy under the Edo Shogunate, and Buddhist philosophies all influenced health regimens there. That said, the volume is quite even in the sense that most of the chapters provide a good balance of socio-political history and epidemiological data. In sum, I think this volume will be an extremely useful resource for medical historians, public health practitioners in the Asia/Pacific region, and scholars and practitioners anywhere who are interested in the double-disease burden.
Holly Wardlow
University of Toronto, Toronto, Canada
pp. 559-561