Background Global and regional projections of mortality and burden of disease by cause for the years 2000, 2010, and 2030 were published by Murray and Lopez in 1996 as part of the Global Burden of Disease project. These projections, which are based on 1990 data, continue to be widely quoted, although they are substantially outdated; in particular, they substantially underestimated the spread of HIV/AIDS. To address the widespread demand for information on likely future trends in global health, and thereby to support international health policy and priority setting, we have prepared new projections of mortality and burden of disease to 2030 starting from World Health Organization estimates of mortality and burden of disease for 2002. This paper describes the methods, assumptions, input data, and results. Methods and Findings Relatively simple models were used to project future health trends under three scenarios—baseline, optimistic, and pessimistic—based largely on projections of economic and social development, and using the historically observed relationships of these with cause-specific mortality rates. Data inputs have been updated to take account of the greater availability of death registration data and the latest available projections for HIV/AIDS, income, human capital, tobacco smoking, body mass index, and other inputs. In all three scenarios there is a dramatic shift in the distribution of deaths from younger to older ages and from communicable, maternal, perinatal, and nutritional causes to noncommunicable disease causes. The risk of death for children younger than 5 y is projected to fall by nearly 50% in the baseline scenario between 2002 and 2030. The proportion of deaths due to noncommunicable disease is projected to rise from 59% in 2002 to 69% in 2030. Global HIV/AIDS deaths are projected to rise from 2.8 million in 2002 to 6.5 million in 2030 under the baseline scenario, which assumes coverage with antiretroviral drugs reaches 80% by 2012. Under the optimistic scenario, which also assumes increased prevention activity, HIV/AIDS deaths are projected to drop to 3.7 million in 2030. Total tobacco-attributable deaths are projected to rise from 5.4 million in 2005 to 6.4 million in 2015 and 8.3 million in 2030 under our baseline scenario. Tobacco is projected to kill 50% more people in 2015 than HIV/AIDS, and to be responsible for 10% of all deaths globally. The three leading causes of burden of disease in 2030 are projected to include HIV/AIDS, unipolar depressive disorders, and ischaemic heart disease in the baseline and pessimistic scenarios. Road traffic accidents are the fourth leading cause in the baseline scenario, and the third leading cause ahead of ischaemic heart disease in the optimistic scenario. Under the baseline scenario, HIV/AIDS becomes the leading cause of burden of disease in middle- and low-income countries by 2015. Conclusions These projections represent a set of three visions of the future for population health, based on certain explicit assumptions. Despite the wide uncertainty ranges around future projections, they enable us to appreciate better the implications for health and health policy of currently observed trends, and the likely impact of fairly certain future trends, such as the ageing of the population, the continued spread of HIV/AIDS in many regions, and the continuation of the epidemiological transition in developing countries. The results depend strongly on the assumption that future mortality trends in poor countries will have a relationship to economic and social development similar to those that have occurred in the higher-income countries.

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Projections of Global Mortality and Burden of Disease from 2002 to 2030

Background Observational studies suggest that male circumcision may provide protection against HIV-1 infection. A randomized, controlled intervention trial was conducted in a general population of South Africa to test this hypothesis. Methods and Findings A total of 3,274 uncircumcised men, aged 18–24 y, were randomized to a control or an intervention group with follow-up visits at months 3, 12, and 21. Male circumcision was offered to the intervention group immediately after randomization and to the control group at the end of the follow-up. The grouped censored data were analyzed in intention-to-treat, univariate and multivariate, analyses, using piecewise exponential, proportional hazards models. Rate ratios (RR) of HIV incidence were determined with 95% CI. Protection against HIV infection was calculated as 1 � RR. The trial was stopped at the interim analysis, and the mean (interquartile range) follow-up was 18.1 mo (13.0–21.0) when the data were analyzed. There were 20 HIV infections (incidence rate ¼0.85 per 100 person-years) in the intervention group and 49 (2.1 per 100 person-years) in the control group, corresponding to an RR of 0.40 (95% CI: 0.24%–0.68%; p , 0.001). This RR corresponds to a protection of 60% (95% CI: 32%–76%). When controlling for behavioural factors, including sexual behaviour that increased slightly in the intervention group, condom use, and health-seeking behaviour, the protection was of 61% (95% CI: 34%– 77%).

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Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial.

Demographic and health surveys

PIP: This paper presents the effects of climate, topography, and natural ecology on public health, nutrition, demographics, technological diffusion, international trade and other determinants of economic development in Africa. The goal of this paper is to emphasize the need for intensified research on the issues at the intersection of ecology and human society. Geography was given emphasis because of three reasons: the minimal gain from another recitation of the damage caused by statism, protectionism and corruption to African economic performance; negligence of the role of natural forces in shaping economic performance; and tailoring of policies to geographical realities. The paper also discusses the general problems of tropical development and the focus of Africa's problems in worldwide tropical perspectives; demographic trends in Africa; use of standard cross-country growth equations with demographic and geographic variables, to account for the relative roles of geography; and the future growth strategies and the need for urban-based export growth in manufacturing and services. Lastly, the authors provide a summary of conclusions and discuss the agenda for future research.

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Geography, demography, and economic growth in Africa.

In this paper we formulate and estimate a finite-horizon, structural dynamic model of agricultural investment behavior that incorporates the major features of low-income agricultural environments: income uncertainty, constraints on borrowing and rental markets, and the use of investment assets to generate income and smooth consumption. The model is fit to longitudinal Indian household data on farm profits, bullock stocks, and pump sets. The estimated structural parameters are used to assess the effects on the life cycle accumulation of bullocks, agricultural profits, and welfare associated with complete markets and bullock liquidity and with second-best policies that provide assured sources of income to farmers and weather insurance.

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Credit Market Constraints, Consumption Smoothing and the Accumulation of Durable Production Assets in Low-Income Countries: Investments in Bullocks in India

Sub-Saharan Africa may offer greater resistance to fertility decline than any other world region as a result of a lineage-based traditional belief system. Traditional African religious values have sustained high fertility in 2 ways: 1stthey have acted directly to equate fertility with virtue and reproductive failure with sin and 2nd they have provided support for a system of upward flows of wealth. The African family structure generally places reproductive decision making in the hands of the husband and the economic burden for the support of children on the shoulders of the wife. Because of the weakness of the conjugal bond men tend not to realize the full burden of reproductive decisions. Thus reproductive decisions and behavior are only loosely related to the subsequent dependency burden. On the other hand there are signs of a destabilization of this high fertility system. At the individual level growing numbers of women in sub-Sahara Africa are facing economic difficulties and would like to take defensive action to limit births. At the national level there are recurrent problems with faltering economic growth and uncertain food supplies. Secular influences such as models of the family taught by the media and the schools may help make the conjugal family more dominant than homage to living ancestors. The demand for female contraceptive methods in sub-Sahara Africa is likely to grow. The pill and the IUD will probably be most employed but a demand for injectables and implants can be expected as well. However the authors predict that radical fertility declines should not be expected in sub-Saharan Africa during this century. In the absence of radical change in government attitudes toward family planning the crude birth rate is not likely to fall from its present level of 47/1000 to much less than 45/1000 by the year 2000.

The Cultural Context of High Fertility in Sub-Saharan Africa

The world region most likely to record the greatest numbers of deaths from Acquired Immunodeficiency Syndrome (AIDS) is sub-Saharan Africa where most transmission of the HIV virus is heterosexual. Drawing extensively on the primarily anthropological often scattered literature and on their own research the authors argue that sexual activity in sub-Saharan Africa has not been subject to the same moral and religious constraints as in the West. Sexuality has been treated in a more matter-of-fact way and sexual relations quite distinct from prostitution often involve material transactions. The pervasiveness of this transactional element means that sudden changes in sexual networking will lead to the deterioration of the situation of many socially marginal women and their children. The lesser constraints on acceptable sexual activity have resulted in a high level of heterosexual networking which provides both a considerable risk of HIV transmission and a strong resistance to the control of AIDS through the enforcement of monogamy. The parameters of likely change areunknown because of the inadequacy of social scientific research into the nature and extent of African sexual networks. (authors)

The social context of AIDS in sub-Saharan Africa.

Botswana Zimbabwe and Kenya appeared in 1990 to be experiencing fertility declines of 15-25% and there is some 1991 evidence that parts of Nigeria experienced fertility declines of over 10%. These trends are in contrast to the widely held belief that sub-Saharan Africa is the only region in the world not experiencing fertility transition. The nature of the African fertility transition is characterized and the reasons for resistance to fertility decline are summarized. The type of fertility transition specific to Africa is discussed and followed by a detailed account of the 1990 Ado-Ekiti Fertility Study in Ondo State in northeastern Nigeria. The study is presented in terms of the contraceptive providers the population surveyed social changes occurring in the region the use of contraception among unmarried women and the demand for fertility control. The Ado-Ekiti experience suggests that contraceptive use has increased due to a National Population Policy which has provided a plentiful supply of a variety of methods through family planning clinics and private distributors and has legitimized family planning for women as a moral right. Availability of family planning methods was not the only influence on fertility reduction. There had been unmet demand for 20 years and massive economic and social change. There arose a demand by young unmarried women for fertility control as age at marriage increased. Female education affected young unmarrieds and married women who substituted contraception for abstinence for birth spacing. Urbanization was another influence fed by economic growth. The Ado-Ekiti experience suggests that contraceptives should be readily available to all particularly young single teenage girls and women for child spacing; women must be recognized as leaders in urging and practing contraception even without their partners knowledge. Privacy in obtaining supplies must be provided. The rising demand is being fed by education and an increasingly modern economy. The unique feature of Africas transition is the uniformity among all ages; the patterns will not follow the Asian or European pattern.

https://www.jstor.org/stable/pdfplus/1973678.pdf

Fertility Decline in Africa: A New Type of Transition?

The average age at marriage of women has been rising in most developing countries including India. In this paper we report on the use of case studies, surveys and anthropological methods in a rural area of South India to investigate the mechanisms involved in this change. In an area where all marriages are still arranged it was found that there had been a recent shift from bridewealth to dowry and a diminution in the proportion of all marriages occurring between relatives. The rise in the age at marriage of women was explained by a marriage squeeze resulting from changes in the age structure of the population with mortality decline, an increasing concern of parents of daughters to secure sons-in-law with education and urban occupations, and a growing concept of child dependency. There was no evidence of the rise being a conscious effort to control family size. In the immediate future some women will probably remain unmarried, but the squeeze is already being reduced by a reduction in the age gap ...

The causes of marriage change in South India

The persistence of high fertility in sub-Saharan Africa while all other world regions have been able to control population growth represents a grave threat. Tradtional explanations for this phenomenon--e.g. lower levels of income education health and urbanization--are not adequate given the fact that many Asian countries have been able to reduce fertility in the face of the same obstacles. It is suggested instead that the primary cause of sub-Saharan Africas high fertility can be found in its social and family patterns. Central cultural precepts include the notions that many descendents must be produced to ensure the survival of lineage the equation of female virtue with the production of a large number of children the stronger influence of the lineage than the nuclear family and a belief in the power of ancestral spirits. Given the overriding importance of lineage and the relative weakness of emotional and economic conjugal links the factors believed to be producing lowered birth rates in other developed countries (e.g. the high costs of child raising and the negative impact of large family size on the standard of living in that family) are not operable in sub-Saharan Africa. Most African fathers receive far more from their children in terms of loyalty and support than they expend on them giving them little motivation to restrict fertility. Womens growing determination to extend their current economic independence into the domain of reproduction represents the most likely source of change in sub-Saharan Africas fertility patterns. Also essential is reduced infant and child mortality through integrated health services-family planning programs. Progress can be expected to be slow however given the persistence of the African traditional social structure and belief system.

Pat Caldwell

Papers

The Cultural Context of High Fertility in Sub-Saharan Africa

The social context of AIDS in sub-Saharan Africa.

Fertility Decline in Africa: A New Type of Transition?

The causes of marriage change in South India

High fertility in sub-Saharan Africa.