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tuberculosis, and to some extent wars and Swaziland (20 years), Zambia (19 years), and
armed conflicts are known to be responsible Kenya (18 years). Although there are some
for these mortality conditions (Bloom and success stories including those of Zambia,
Sachs, 1998; Sachs et al., 2001; UN, 2000: Kenya, Uganda, Thailand, and Cambodia
18–19). Even today, a large segment of the where the prevalence rate has declined, there
population in many African and Asian coun- do not seem to be any signs of significant
tries is at the early stages of epidemiological change in many other developing countries.
transition, marred by largely avoidable dis- Signs of divergence and stagnation are
eases. Around 2000, 15% of the total popu- apparent when the average annual percent
lation in Ghana, 34% in Zambia, and 49% in decline in the infant mortality rate between
Botswana were affected by malaria; the 1950–1955 and 2000–2005 is plotted against
prevalence of tuberculosis exceeded 500 per the initial (i.e., 1950–1955) level of infant mor-
100,000 persons in countries such as tality (UN, 2007). Countries with a low initial
Zambia, Zimbabwe, Ethiopia, Nigeria, mortality level (for example, with an infant
Kenya, and Indonesia; and the maternal mor- mortality rate below 100 during 1950–1955)
tality rate exceeded 500 per 100,000 live are a homogeneous group, which experienced
births in Kenya, Nigeria, Zambia, and India large declines in their mortality rates over the
(UN, 2005; WHO, 2005). 45-year period, mostly at a rate above 2.0%
In recent years, AIDS has emerged as a annually and only a few between 1.0 and 2.0%.
major killer in Africa. The AIDS epidemic on However, countries with high initial mortality
this continent has been called the ‘most dev- (for example, with a rate over 150 during
astating health disaster in human history’ 1950–1955) are a very heterogeneous group.
since the Black Death, and sub-Saharan Africa, This has led some analysts to conclude that
the hardest hit region, has been called a while richer countries are converging around
‘dying continent’ (Ezzell, 2000: 96; Lamptey much lower mortality levels, poorer countries
et al., 2006: 3). According to one estimate, in are converging around very high mortality
2003 there were about 38 million (1.1%) levels (Goesling and Firebaugh, 2004).
adults (15–49 years) infected with HIV
globally, of whom 25 million (7.5% of all
adults) were in sub-Saharan Africa alone.
The adult HIV prevalence rate exceeded 25% FOUR MAJOR DETERMINANTS OF
in Swaziland, Lesotho, Zimbabwe, and CHANGES IN HEALTH AND
Botswana (World Bank, 2005b). In recent MORTALITY PATTERNS
years, there has been an increase in the preva-
lence of HIV in a number of countries on There is a vast literature on the correlates and
other continents, with India, Russia, Brazil, determinants of health and mortality change.
China, Thailand, Cambodia, Vietnam, and Broadly speaking, they can be classified into
Myanmar in the forefront (Cohen, 2003; two categories. The first category includes
Steinbrook, 2004). The numbers for India are factors such as population size, population
staggering: about 4.5 million people (0.8% of density, geography, climate, and ethnic het-
all adults) were infected with HIV in 2002, erogeneity, which facilitate or impede health
up from less than half a million ten years ear- improvement programme, but cannot be
lier (Cohen, 2004). AIDS alone is estimated manipulated by policy makers. The second
to have reduced life expectancy by 4 to 26 category includes factors which directly or
years in a number of African countries (US indirectly influence health and mortality
Bureau of the Census, 1999). Potential years levels and can be manipulated by policy
of life lost due to the AIDS epidemics are makers. In this chapter, we examine the roles
particularly large in Zimbabwe (26 years), of four factors in the latter category, which
Namibia (24 years), Botswana (21 years), governments, non-governmental organizations,