The Triple Burden: Disease in Developing Nations

By Frenk, Julio; Gomez-Dantes, Octavio | Harvard International Review, Fall 2011 | Go to article overview

The Triple Burden: Disease in Developing Nations

Frenk, Julio, Gomez-Dantes, Octavio, Harvard International Review

The world is currently going through one of the most radical health transformations in history. During the past few years, health has ceased being the exclusive concern of domain experts and specialized agencies. Interconnected with national security, economic development, democratic governance, and human rights, it now rightly occupies a central place in the global agenda. We are at the threshold of a new global health era, which poses additional challenges but also offers fresh opportunities.


The growing recognition of the importance of health has driven an unprecedented expansion in development assistance for health. According to Christopher Murray and colleagues from the Institute for Health Metrics and Evaluation, development assistance increased from US$10.5 billion in 2000 to US$26.8 billion in 2010. It has also led to the creation of new forms of organization; for example, there are now close to 120 multilateral agencies and partnerships active in health.

If we are to meet the challenges and reap the opportunities offered by global health, we need to renew global cooperation, which requires a re-discussion of the complex context of the held, especially in low- and middle-income countries. Most of these countries suffer from a triple burden of disease: the backlog of common infections, undernutrition, and maternal mortality, the emerging challenges of non-communicable diseases (NCDs), such as cancer, diabetes, heart disease, and mental illness, and the problems directly related to globalization, like pandemics and the health consequences of climate change. This triple burden is the central topic of the first part of this article. The second part is devoted to a discussion of the strategies needed to address these challenges. Such strategies include strengthening the local, regional, and global initiatives designed to meet the Millennium Development Goals (MDGs), integrating NCDs into the global health agenda, and transforming the global health architecture to guarantee a rational division of labor among all global health actors. Working in cooperation, we can perform three basic functions: the production of global public goods, the management of externalities across countries, and the mobilization of global solidarity.

Lost in Transition

In the past half-century we witnessed a fundamental transformation in the nature of both death and disease. First, during the 20th century, the world experienced a larger gain in average life expectancy than in all the previously accumulated history of humankind. Life expectancy was only 30 years in 1900. By 1985 it had more than doubled to 62 years. In 2010, according to the United Nations, the average estimate for the world reached 68 years, but with huge regional differences, ranging from 82 years in Japan to scarcely 36 years in Swaziland.

The dramatic increase in life expectancy at birth is only one of a series of demographic changes related to health that are taking place. Because they are not cataclysmic, we tend to lose sight of them. As Joel Cohen points out in a paper on the growth of the human population, during the opening decade of the 21st century there were three firsts in the history of humankind.

In the year 2000, for the first time in history, people aged 60 years and older outnumbered children aged four and younger. In 2007, the urban population outnumbered the rural population, again for the first time ever. In 2003, the average woman in the world started having just enough children during her lifetime to replace herself and the father in the following generation.

From a health perspective, the most fundamental change has been in the dominant patterns of disease. The relative weight of different causes of death has been moving along two dimensions: toward higher age groups and toward chronic conditions.

Thanks to improvements in nutrition, access to water and sanitation, and access to public health interventions such as immunizations and oral rehydration therapy, the burden of disease attributed to undernutrition and common infections has decreased. …

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