Book review: Health Transitions and the Double Disease Burden in Asia and the Pacific

Health Transitions and the Double Disease Burden in Asia and the Pacific: Histories of Responses to Non-Communicable and Communicable Diseases

Edited by Milton J. Lewis and Kerrie L. MacPherson

Routledge Publishing, 2012

322 pp., US $155.00 (hardback)


The phrase “double disease burden” is one that has been increasingly used in modern public health discussions.  The concept applies to “developing countries that shoulder a growing load of ‘new’ chronic NCD’s (non-communicable diseases) in addition to the burden of ‘old’ infectious diseases.”[i]  Throughout the developing world health care has been harrowed with issues of both communicable, infectious diseases such as tuberculosis, and NCD’s like cancer and diabetes. In the 1990’s researchers described the transitions taking place throughout the world as “the complex changes in patterns of health, disease and mortality resulting from demographic and associated economic and societal changes in a world population that is getting older.”[ii] These transitions, along with a double disease burden, have exhausted health care resources, local and international governments, and have caused a crisis among health care professionals regarding the best way to address the issues at hand. In Asia and the Pacific, these burdens have increased tenfold and are the geographical subject of Lewis and MacPherson’s volume on the histories and transitions of NCD’s and communicable diseases (CD’s).

Abdel Omran, in 1971 developed his epidemiological transition theory which states, “populations move from traditional demographic and health regimes characterized by high fertility, high infant mortality, low life expectancy, and death from epidemics and famine, to modern regimes of low fertility, low infant mortality, long life expectancy, and sickness and chronic degenerative diseases.”[iii] This is certainly the case in modern international health care, as the rates of NCD’s have increased in countries across the globe. While many developed nations, especially in the West, throughout the last century have been able to control CD rates (in some cases almost enough to exterminate CD’s entirely) while NCD’s increase, developing nations cannot boast the same results. Although economic development can be associated with many health transitions around the world (p. 3), in high-income countries economic development has been sufficient to lower rates of CD’s (through vaccination programs and investments in social infrastructures to improve living conditions, for example) so that effort can be focused on the rise of NCD’s in populations. In lower income countries, such as those in the Asia-Pacific region significant economic development has been thwarted by social and political factors that have created and continued inequalities among populations. These concerns have led to the transitions and double disease burden that is the central concentration of the book.

Lewis and MacPherson’s fundamental goal is to analyze the historical experiences of the countries in the Asia-Pacific region “in order to provide insights helpful to understanding the double disease burden and to the formulation of more effective policy” (p. 2). Their hypothesis is that by using a historical approach, the various “health transitions [will] present [a] idiosyncratic picture with country-specific, historical factors influencing the particular path taken in the transition” (p. 5). In fifteen articles, written by several established researchers and public health professionals, Health Transitions examines the historical forces driving modern health transitions and categorizes them into two growth areas: economic and social (p. 15).  By examining these areas in this fashion, Health Transitions takes on the delicate and expansive task of the demographic, epidemiological and socio-economic evolutions in health throughout the region.

Each article inspects the historical background of health and medicine and how these approaches have influenced modern trends, all the while sticking to the two specific transitional growths already mentioned (economic and social). In China and Hong Kong, in order to reduce radical policies that were prevalent in traditional society, populations were trained in productions like industry and agriculture; these influences helped move China from a low-income to a high-income society. However, rapid increases in industrialization have also increased chemical and industrial pollution, leading to high rates of liver cancer and the Hepatitis B virus (p. 62). India has seen rapid urbanization due to population growth as well as increased pace of economic development, yet rural areas remain exceptionally deprived. Additionally, India’s situation is significant not only because of its unique under-and over-nutrition deficiencies (India is currently the diabetes capital of the world), but also because of its breakouts in lifestyle norms (trends in tobacco use, for example, have increased economic cost of major tobacco-related deaths to “more than the revenue received by the government from tobacco sales”) (p. 81-82). Japan is unique because although the country has seen great success in preventing, treating and/or eradicating both acute and chronic infections, renowned longevity in life is Japan’s greatest enemy, with geriatric diseases being its “double disease burden” rather than the visual CD/NCD pairing (p. 92-108).

Not all the countries in the region are in major crisis, however. In Thailand a public investment in health during stagnant economic growth led to major advancements (p. 144). In Papua New Guinea, exceptionally interesting trends: the burden of NCD’s is the smallest in the region, and although 8% of Papua New Guinea’s mortality is due to cancers, its oral (from betelnut chewing) and cervical (HPV) cancer rather than “modern” (lung, liver, etc.) cancer that affects populations (despite these trends, CD’s vastly predominates NCD’s and rates are extremely high) (p. 252-259). And in Singapore, great advancements in the health care system were seen. As Lim explains:

Pragmatism… would guide social policies… As the government and people focused single-mindedly on expanding the size of the economic pie, citizens were encouraged to assume personal responsibility for their own welfare. Realizing that health-care costs would ineluctably rise as the population aged and technology advanced, the government assiduously avoided policies that would transfer the financial burden to future generations, instead preferring to shift the cost of health care to private pockets. (p. 180)

All the countries discussed in this volume have succeeded and failed in many different ways, and the authors themselves have succeeded in creating an interesting and dynamic timeline of health and progress. By examining the historical forces behind health transactions one is able to pinpoint almost precisely where countries begin to merge from “traditional” societies into their modern, globalized selves, and the health trends that come with these transformations. An extremely interesting feature when examining all the countries as a whole is that despite different speeds of globalization and industrialization, the majority of the countries all reached their health transitions and double disease burden in extremely similar ways.

It is this point where Lewis and MacPherson, as the main contributors of this volume, show their error. In each chapter, with each country discussed, the dialogue is exactly, precisely, the same: an introduction to the country and its current health crisis, a historical look into the policies and approaches that defined the country’s’ past century, a transition into how urbanization, globalization and industrialization framed the country’s emergence into the twentieth century, rates of CD’s, rates of NCD’s, the biggest ailments, and finally what can be done about it. Literally, every chapter is structured identically. This unfortunately leads to an extremely repetitive and at times, frustrating read. Each chapter (with the exception of the articles focusing on Papua New Guinea and Singapore) concentrates on the double disease burden in exactly the same way: CD’s flourished in the past, specific programs were implemented and succeeded in getting rates under control, then globalization, economic growth and increased life expectancy led to increased rates of NCD’s, causing CD’s to be placed on the backburner, and thus, double disease burden. For this reason, it is the opinion of this reviewer that this volume would have been better served as one extended investigation into health transitions and the double disease burden in the Asia-Pacific region as a whole, using specific case in point illustrations from countries to establish the authors’ arguments rather than break up each country individually. By examining the trends in this way one would be able to grasp the full severity of the issue and the authors would have more liberty to make their arguments, as well as review and assess the movements accordingly (in addition to this analysis there is a questions regarding the diacritical markings in the chapter discussing Vietnam but perhaps that discussion would best be left for the editor). If the authors had produced a more complete investigation rather than separate each country individually there may have been more availability to discuss the full burden of CD’s in this region of the world. By focusing the majority of thee articles on the current trends of NCD’s some chapters overlook the concept of double disease burden by not discussing in enough detail current trends. In their conclusions the authors argue that ‘more historical information- more attention to the particular historical experience of individual nations- was needed to understand better the modern health transition’ (p. 302). Yet with Health Transitions they have actually accomplished this. There are very few questions as to how the situation came to be in this region of the world. Perhaps instead, in the future, the authors could use historical information to hypothesize how to stop these transitions from happening in other places, or at least what we as professionals can do to better the situation.

Health Transitions and the Double Disease Burden in Asia and the Pacific is an extremely intelligent, well-versed book. This book would be practical to people seeking to understand the what, how, and why in modern health trends. What the authors have provided is a wonderful and detailed insight into the modern perils of health care in a region of the world so complex and diverse it warrants all debates and discussions. Despite my criticism I would highly recommend this volume to anyone looking to increase their knowledge and understanding of Asia and Pacific health matters, as well as those analyzing modern health trends and their influences.


Kristin Childers-Buschle graduated from the University of Edinburgh in 2010 with a Masters degree in Medical Anthropology.  Her thesis focused on the role of major health organizations in infectious disease control and management.  Since 2010 she has developed research projects examining the psychosocial role of HIV in India and the role of stigma towards infectious disease patients from their doctors in developing counties.  Her current research examines environmental stresses on pregnant and expectant women in the US and UK.  Kristin lives in Edinburgh, Scotland.

[i] Marshall, S.J. (2004) ‘Developing Countries Face Double Disease Burden of Disease’, Bulletin on the World Health Organization, 82(7): 556; WHO (World Health Organization) (2010a) Noncommunicable Disease Risk Factors and Socioeconomic Inequalities: What Are The Links? Geneva: WHO Western Pacific Region. In Lewis and MacPherson 2013: pp. 252

[ii] Volster, H.H., Bourne, L.T., Venter, C.S., and Oosthuizen, W. (1999) “Contribution of Nutrition to the Health Transition in Developing Countries: A Framework for Research and Intervention’, Nutrition Reviews, 57(11): 341- 349. In Lewis and MacPherson, 2013: pp. 2.

[iii] Omran, A.R. (1971) ‘The Epidemiological Transition: A Theory of the Epidemiology of Population Change’, Milbank Memorial Fund Quarterly, 49(4): 509-538. In Lewis and MacPherson, 2013: pp. 252.