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/