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RTD info logoMagazine on European Research Special issue - July 2005   
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EPIDEMIOLOGY
Title  The price of change

Economic change affects everything: lifestyles, demography, relationships between town and country, culture and education. It also has an impact on health, bringing changing patterns of sickness and mortality. Over recent years, the developing countries – like the industrial regions before them – have experienced what is known as 'epidemiological transition'. The Tahina project is endeavouring to analyse these changes in Tunisia and Algeria, where they affect principally urban populations.

Lifestyle, and diet in particular, plays an important role in the risk factors for ‘new’ pathologies. In North Africa, vegetables and fish are excellent sources of health. But their consumption is decreasing, together with that of cereals, to be replaced mainly by meat and poultry.
Lifestyle, and diet in particular, plays an important role in the risk factors for ‘new’ pathologies. In North Africa, vegetables and fish are excellent sources of health. But their consumption is decreasing, together with that of cereals, to be replaced mainly by meat and poultry.
Chronic diseases (cancer, cardiovascular disease, diabetes, obesity), which account for 88% of deaths in industrialised countries, are now also responsible for 40% of deaths in the emerging countries. The World Health Organisation (WHO) reports that 63% of diabetics live in the developing countries (where they were rare just 20 years ago), a figure that is expected to rise to 75% in 2025. Cancer and cardiovascular disease are now the primary cause of death in China and, since the 1980s, they have killed twice as many people as infectious diseases in Mexico. Many other examples could be given, all illustrating the same pattern.

"All over the world, the epidemiological transition has been sparked by two major phenomena: socio-economic development and progress in medicine, leading to a decline in the traditional causes of death," explains Habiba Ben Romdhane of the National Public Health Institute in Tunis, scientific coordinator of the Tahina project (Epidemiological Transition and Health Impact in North Africa). French, Tunisian, Algerian and Belgian researchers are all contributing to Tahina's multidisciplinary approach by epidemiologists, nutritional experts, economists, sociologists and anthropologists to the study of both the medical situation and the socio-economic and cultural context. The am is to strengthen the capacity of North African health sectors to manage the epidemiological transition and implement a health policy that takes changing lifestyles into account.

Fewer and different deaths
In Tunisia, chronic diseases today account for more than 60% of deaths. This trend should not, however, be stigmatised as a 'negative' price paid for modernity. It is rather a reflection of the fact that, since 1970, an effective health and population policy has brought a sharp fall in mortality – infant mortality in particular – and that life expectancy rose from 52 years in the late sixties to 72 in the year 2000. At the same time, the birth rate fell from 7.2 children per woman in the early 1960s to 2.09 in 1999. Tunisian women are marrying later in life and 63% of them use contraceptives, a pattern found throughout the country. 

"But it is true that new problems are appearing. The epidemiological situation for cancers is at an intermediary stage between that found in the developed and in the developing countries. We know that lifestyle, and especially diet, play an important role as a risk factor for these pathologies, and that the latter in particular has changed. Although cereals remain a basic foodstuff in Tunisia, the level of consumption is falling progressively, while consumption of meat and poultry is increasing," points out Habiba Ben Romdhane.

The same trend is apparent in Algeria. "Communicable diseases, previously the principal cause of morbidity and death, are now giving way to non-communicable diseases, chronic and/or caused by lifestyles, of a kind that are typical of the industrialised countries," believes Dr Abdelkrim Ouchfoun, a specialist in epidemiology and preventive medicine and the Algerian partner in the Tahina project.

Refining the statistics
During the first two years of the project, which was launched in 2002, researchers sought to better describe the mortality and its causes, as well as hospital morbidity. In both Algeria and Tunisia this involved revising procedures for recording the medical causes of deaths by making the issuing of a death certificate standard practice – as recommended by the WHO – and by training personnel responsible for the collecting, medical coding and analysis of certificates. "This aroused a certain interest and very positive co-operation between the participants and the health authorities in question, thereby helping to achieve the objectives," believes Bernard Maire, administrative coordinator with the Tahina project. 

The first results relate to 44 033 deaths recorded in Tunisia in 2002-2003 and 13 817 recorded in Algeria in 2002. To assess the level of epidemiological transition, the analysts consider the relative importance of the major categories of cause of death: trauma and accidents; infectious diseases and prenatal affections; transmissible and perinatal diseases; and the group of non-communicable diseases. The latter group includes all the chronic diseases that affect mainly adults, some of which are linked to lifestyles (diet, sedentariness, smoking or consumption of alcohol, etc.).

Cardiovascular disease comes top
The first global results give 83% for the group of non-communicable diseases in Tunisia and between 58% and 67% in Algeria.(1) Cardiovascular disease easily tops the list, accounting for about a quarter of deaths. 

A survey has also been started to investigate the importance of these non-communicable diseases in Tunisia's principal pubic hospitals. The results concern all cases of hospitalisation, grouped according to medical speciality and considering the average length of stay, treatment administered, discharge figures and hospitalisation costs. An analysis was also carried out per hospital, per governorship and per region. Data on more than 150 000 hospital admissions were gathered but only those relating to cardiovascular disease have been the subject of an in-depth study to date, including a comparison between the 1992 and 2000 figures (see box).

In Algeria, the study lasted two weeks,(2) and was carried out on a representative sample of hospitals in each Wilaya (administrative region). During this very short period, 21 560 hospitalisations (including 3 887 births) were studied. The results are a useful supplement to national statistics on global morbidity. "Excluding births, traumatisms ad accidents accounted for about 10% of hospitalisations during this period. Non-communicable diseases accounted for over 50% – including 28% for disorders of the digestive system, 13% for respiratory diseases and 12% for cardiovascular disease," explains Dr Atek of the Algiers Institute of Public Health. 

Rapid transition
Invitation to a modern diet in North Africa
Invitation to a modern diet in North Africa
"In Tunisia, our surveys have provided solid confirmation of the level and rate of epidemiological transition. In Algeria, where we knew less about the situation, the results also show that this transition is well under way and developing fast. The initial picture provided by these indications will be further completed by individual data on morbidity (nutritional state, state of health, risk factors) and lifestyle (physical activity, diet, occupation, level of education, etc.). This information will soon be collected on representative samples at national level," explains the project coordinator.

A study is also in progress on the health systems in these two countries, as well as on way they are or should be changing. It will be based on an analysis of steps taken to prevent and treat chronic non-communicable diseases elsewhere in the world. The research must serve as a basis for discussions with health system specialists and decision-makers with a view to setting new health policy strategies. 

Prevention requires knowledge. One of the project's tasks, therefore, is to identify, measure and understand the various factors that lie behind these changes, such as tobacco smoking (especially among young people), obesity, dietary changes, conditions of urban and rural life, etc. To develop a realistic health policy it is necessary to define the cost of these 'new' diseases (for which treatment is expensive), assess all the benefits of prevention, study the possible lessons that can be learned from the experiences of industrialised countries, and involve the actors and the population. "Combat strategies that are adapted to what is possible economically for the country in question and to the socio-cultural needs of the population must be developed and made available to doctors," believes Dr Ouchfoun. "The medical profession and health managers must also play a leadership role in regard to other sectors and associations involved in the protection or promotion of public health." 

(1) If the uncertainties linked to ill-defined causes and the sampling are taken into account. These results also show major regional variations in the two countries (for example, between 66.8% and 87.9% for con-communicable diseases in Tunisia).
(2) The difference in the situation, and above all size of country, and thus in the survey costs, did not permit a study of the same kind as in Tunisia.  


Printable version

Features 1 2 3
  One sea, three continents
  A shared heritage
  The price of change

  READ MORE  
  Trends in cardiopathies

Cardiopathies take various forms. Comparisons were made between those recorded in Tunisian hospitals in 1992 and in 2002. In 1992, rheumatic cardiopathies (type of cardiac disease associated with poverty, poor nutritional condition, late take-up by care systems and linked to infection with staphylococcus) ...
 
  Partners

  • National Public Health Institute (INSP), Tunis
  • IRD (Research Institute for Development), Paris
  • National Public Health Institute (INSP), Algiers
  • Prince Leopold Institute of Tropical Medicine, Antwerp (BE)
  • Mediterranean Agronomic Institute of Montpellier (FR)
  • National ...
  •  

      TO FIND OUT MORE  
     
  • Tahina 
    (Epidemiological Transition And Health Impact in North Africa)
  •  

      CONTACTS  
     
  • Habiba Benromdhane
  • Bernard Maire
  •  


       
      Top
    Features 1 2 3
      Trends in cardiopathies

    Cardiopathies take various forms. Comparisons were made between those recorded in Tunisian hospitals in 1992 and in 2002. In 1992, rheumatic cardiopathies (type of cardiac disease associated with poverty, poor nutritional condition, late take-up by care systems and linked to infection with staphylococcus) accounted for 12% of cardiopathies in men and 25% in women; ischaemic cardiopathies (cardiac infections linked to a modern, sedentary lifestyle, with a calorie-rich unbalanced diet) accounted for 39% of hospitalisations among men and 16% among women; finally, illnesses linked to high blood pressure represented 6% and 10% of male and female patients respectively.  

    In 2002, rheumatic cardiopathies represented just 7% of hospitalisations (5% among men, 12% among women), ischaemic cardiopathies increasing to 46% (54 % among men, 31% among women) and high blood pressure accounted for 9% of hospitalisations. "In the space of just ten years, we have seen marked change in the causes of hospitalisation. This fully confirms the rapid progress of epidemiological transition,” concludes Habiba Ben Romdhane.

    Trends in cardiopathies (% in specialised service)
    Trends in cardiopathies (% in specialised service)
      Partners

    • National Public Health Institute (INSP), Tunis
    • IRD (Research Institute for Development), Paris
    • National Public Health Institute (INSP), Algiers
    • Prince Leopold Institute of Tropical Medicine, Antwerp (BE)
    • Mediterranean Agronomic Institute of Montpellier (FR)
    • National Institute of Nutrition and Dietary Technology (INNTA), Tunis
    • University of Oran, Faculty of Medicine, Algeria

    TO FIND OUT MORE

    • Tahina 
      (Epidemiological Transition And Health Impact in North Africa)

    CONTACTS