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MORTALITY IN LESS DEVELOPED COUNTRIES 225

determinant of death prevailing at that time. Essentially, the concept of convergence
The first stage, which occurred in Europe lies at the heart of these theories (Goesling
through the eighteenth century, is the ‘age of and Firebaugh, 2004; Omran, 1971; Vallin
pestilence (infections) and famine’. This and Meslé, 2005; Wilson, 2001), and they
stage was patterned by extremely high and implicitly assume that less-developed coun-
fluctuating mortality, where life expectancy tries would follow the experiences of the
varied between 20 and 40 years. Most devel- West and consequently there will be a demo-
oping countries remained in this stage until graphic convergence between various
the mid-twentieth century and some of them regions. This notion has led most demogra-
(several countries in sub-Saharan Africa, for phers and statistical agencies to assume a
example) are still struggling to move to the convergence of mortality patterns in their
next stage. The main factors responsible for population projections, including those
high and fluctuating mortality during this prepared by the UN (2007) periodically for
period were infectious and parasitic diseases, various countries.
plagues, wars, natural disasters, and famines. Studies have pointed out a number of lim-
This stage emerged slowly into the second itations of the transition theory (Salomon and
stage of transition, the ‘age of receding pan- Murray, 2002), the detailed discussion of
demics’, when major infections first began to which is beyond the scope of this chapter. A
decline. This stage occurred in Europe during major limitation of the theory is its claim to
the nineteenth century and the early part of be a universal theory of a ‘linear’ and ‘unidi-
the twentieth century and was characterized rectional change’ (Frenk et al., 1989: 30;
by a decline in major infectious diseases and Salomon and Murray, 2002: 205). Most ana-
the frequency of epidemics, which have nearly lysts assume that once mortality starts to con-
disappeared. Life expectancy increased to verge across countries, the trend does not
between 30 and 50 years. In the early stages reverse (Goesling and Firebaugh, 2004). As
of the transition, the decline in mortality was discussed later, a number of countries have
mostly due to improved food supply and substantially deviated from the path of con-
overall better living conditions and to a lesser vergence (McMichael et al., 2004; Moser
degree due to medical progress, sanitation et al., 2004; Ruzicka and Hansluwka, 1982;
measures, or organized public health activi- Vallin and Meslé, 2005), while others have
ties (McKeown, 1976; Rockett, 1994). In the shown the sign of ‘counter transitions’
latter half of the nineteenth century, substan- (Frenk et al., 1989: 31). Another limitation of
tial mortality declines were due to improve- the theory is its lack of emphasis on the
ments in public health and sanitation inherent conflict and competition that dis-
measures, such as purification of water, courage convergence between various popu-
better sewage disposal, and better food lation subgroups. When Omran revisited his
hygiene. Thus, diseases such as whooping theory of epidemiological transition 30 years
cough, respiratory tuberculosis, measles, after his original publication, he hypothe-
scarlet fever, and diphtheria were brought sized that ‘while the transition produces
under control long before any medical inter- change in all social classes, it usually starts
ventions. The third stage, ‘the age of degen- earlier and proceeds more quickly among the
erative and man-made diseases’, was more affluent and privileged than among the
distinguished by a continued decline in mor- poor and disadvantaged sectors of the same
tality, which eventually reached stability at a society’ (Omran, 1998: 110). The privileged
relatively low level, with life expectancy are better informed, have better access to the
reaching around 70 years. Typhoid, tubercu- health care system and make better use of the
losis, and cholera were replaced by man- available resources, whereas the less privi-
made degenerative diseases such as cancer, leged lag behind and in certain
heart disease, stroke, and diabetes, as the instances – particularly in highly segmented
major causes of death. societies – have a hard time catching up.