Social Science & Medicine 57 (2003) 539550

Epidemiological transition: Model or illusion? A look at the

problem of health in Mexico
Mart!nez S Carolina*, Leal F Gustavo
Department of Health Care, Autonomous Metropolitan University (Xochimilco), Calzada del Hueso 1100, Col. Villa Quietud,
Mexico City 04960, Mexico
The present is merely the culmination of the past and the future does not exist. Vladimir Nabokov

Abstract
This paper discusses the validity of the epidemiological transition model to interpret changes in the structure of
mortality and morbidity. Epistemological and political questions are posed. The case of Mexico is used to illustrate the
limitations its use imposes on understanding the constellation of components explaining the epidemiological prole,
and the problems involved in designing a public health policy on the basis of this sort of misinterpretation. It is
suggested that the illusory certainty of a pre-determined destiny distorts the prospective that would enable to construct
scenarios; what is actually happening remains hidden by the model and health policies are designed without adequate
parameters for evaluating their effective impact. We conclude with some remarks on the usefulness of constructing
alternative forms of interpretation for understanding changes in the epidemiological prole, one of the most important
inputs for designing better policies to face the challenges posed by health care and dealing with illness in modern-day
societies.
r 2003 Elsevier Science Ltd. All rights reserved.
Keywords: Epidemiological transition; Health policy; Epidemiological epistemology; Mexico

Introduction
How does one account for the current widespread use
of a term as conceptually weak as epidemiological
transition? Specialist articles in which it continues to be
used give the impression that, with very few exceptions
(Gaylin & Kates, 1997; Cabello & Springer, 1997), the
only thing that remains of the original postulates of the
early 1970s (Omran, 1971, 1977) is the shred of common
sense contained in the idea that populations health
!
proles change over time (Frenk, Bobadilla, Sepulveda,
!
& Lopez,
1989; Frenk et al., 1991; Phillips, 1991;
Marshall, 1991; Wolpert, Robles, & Reyes, 1993;
Vigneron, 1993; Boedhi-Darmojo, 1993; Hungerbuhler,
Bovet, & Shamlaye, 1993; Reddy, 1993; Albala & Vio,
*Corresponding author. Tel.: +52-5-54-83-72-44; fax: +525-54-83-72-18.
E-mail address: msoc1298@cueyatl.uam.mx
(M.S. Carolina).

1995; Gulliford, 1996; Murray & Lopez, 1997; Tapia,

1997; Albala, Vio & Yanez, 1997; Ghannem & Fredj,
1997; Elman & Myers, 1997; Serow, Cowart, &
Camezon, 1998; Smallman-Raynor & Phillips, 1999;
Seale, 2000).
One thing is certain, however; the set of
illnesses suffered by the population at a particular
time (some of which lead to death) is never the same
as the next. Abrupt changes may be more easily
perceived than those that take place more slowly over
a longer period of time (Braudel, 1989). Nevertheless,
these processes are essentially in a continuous state of
ux.
In our view, the main theoretical problem posed by
the insistence on using the epidemiological transition
model to interpret changes in the structure of mortality
and morbidity is that it provides a phenomenological
description that is merely approximate (as well as
partial), rather than a theoretical explanation of the
causal constellations responsible for these events and

0277-9536/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved.
doi:10.1016/S0277-9536(02)00379-9

540

M.S. Carolina, L.F. Gustavo / Social Science & Medicine 57 (2003) 539550

their links with the changes experienced in the societies

where this all takes place.
The other even more worrying problem it raises is
political. Using a model instead of a detailed analysis of
what is in fact taking place creates the false impression
that one already has all the answers: we can put it all
down to the fact that the country is undergoing an
epidemiological transition. It prevents one from understanding what is actually happening, since this is hidden
by the model. The illusory certainty of a predetermined
destiny distorts the prospective that would enable one to
construct scenarios. Consequently, health policies are
designed virtually in the dark, without parameters for
evaluating their effective impact.
The validity of this model (the epidemiological
transition) will be discussed below. The case of Mexico
will be used to illustrate the limitations its use imposes
on understanding the constellation of components
explaining the epidemiological prole, and the problems
involved in designing a public health policy on the basis
of this sort of misinterpretation. We shall end with some
remarks on the usefulness of constructing alternative
forms of interpretation, in the search for a more solid
basis for understanding changes in the epidemiological
prole, one of the most important inputs for designing
better responses to the challenges posed by health care
and dealing with illness in modern-day societies.

From the original model to its current interpretations

Omrans proposal: the limits of a vision
The stimulating, thought-provoking conception of the
historical determinants of changes in the epidemiological prole that Omran (1971) organized in the epidemiological transition model was based on the scientic,
social perspectives that prevailed at the time, governed
by gradualistic conceptions of the economy and linear
visions of social time.
The economic theories of over 30 years ago, with their
references to development, underdevelopment and
modernization (Rostow, 1960; Prebisch, 1963; Huntington, 1983) were compatible with the idea of progress
put forward by social sciences of the time (Wallerstein,
2000) and with the medical views that subscribe to the
idea of societies going through pre-determined stages,
rather like biological organisms.
However, Omrans conception was distorted by the
new conservatives, who, in their attempts to systematically freeze social time, vulgarized it at the same time
as they generalized the use of apparently sophisticated
models that were actually oversimple for the situation
they were intended to explain (WHO, 1999, 2000).
Articially freezing social time enabled them to take
the first step towards establishing a before and an

afterwards, so that it could then be re-constructed into

two sub-times. The rst included a challenge that had
already been supposedly met by the health agenda,
namely the control of communicable diseases, while the
second contained one that was regarded as still pending,
i.e. the front opened up by non-communicable diseases.
From there, it was not difcult to take the second step:
making this epidemiological alibi the major objective of
health policy and establishing the fact that although
some issues remained pending, other goals had already
been achieved. Having established this two-fold challenge, as it was called in the 1999 World Health Report
(WHO, 1999), it was then easier to achieve the necessary
gradualness for turning health policies into genuine
constructs oriented and dened by frozen time, and to
create a prole of policies with deadlines that had
already been met and deadlines that had yet to be met, in
an attempt to justify the progress of government work
and that of its experts (Frenk et al., 1989).1
As a result, the new conservatives felt that they had
achieved their goal of modernization, the dream of
aligning their model as part of the discourse of
modernity, by projecting an action required by the
present onto the distant fulllment of an unattainable
progressive future (Habermas, 2000).
Meanwhile, most of the analyses drawn up under the
doctrine of epidemiological transition, including the most
recent ones, continued to show the same two constants:
(a) the assumption that the economic development of
countries takes place in stages and
(b) the assumption of epidemiological transition as a
natural destiny of societies, a sort of path that
sooner or later, all countries would have to follow.
Over time, it has become common to use the term
epidemiological transition to designate ...the shift in
the main causes of death-from infectious diseases to
degenerative cardiovascular diseases and cancers, as a
point of inection in which most members of a society
have obtained access to the satisfaction of the basic
material needs for their lives (Wilkinson, 1994, p. 65)
despite the fact, as has been so rightly pointed out
(Wilkinson, 1994, p. 65) that:
The impact of medical science is not reected in the
epidemiological transition. In fact the transition
would have happened (and largely did happen)
without it. The great infectious diseases of the
1

It is hardly surprising, then, to nd Omrans foundational

work in the section on public health classics in the most recent
issue of Bulletin (WHO, 2001), but it is worthy to notice that it
is preceded by excerpts from a respectful yet extremely sharp
comment by Caldwell (2001) who since then, and on the basis of
his thought-provoking demographic approach, has expressed
his reservations about Omrans proposal.

M.S. Carolina, L.F. Gustavo / Social Science & Medicine 57 (2003) 539550

nineteenth and early twentieth centuries dwindled to

a fraction of what they had been long before
immunization or effective medical treatment became
available. Strongly associated with poverty, in the
past as in the Third World today, the decline of the
great infections reected improved living standards
and conditions.
The past three decades have yielded ample evidence
showing the various possible congurations of the
epidemiological prole in each country, region or subregion, which, far from taking a single route, follow a
wide range of paths, attributable to the specic risks
derived from the circumstances in which their inhabitants live, in each context (Vigneron, 1989, 1993;
Marshall, 1991; Castillo-Salgado, Mujica, & Loyola,
1999; Seale, 2000). As Phillips (1991, p. viii) notes: The
rich and the poor, urban and rural dwellers and other
sub-groups of populations of many countries effectively
live in different epidemiological worlds; a focus on
national averages does a disservice to virtually all
people.
Despite this, Omrans postulates have continued to be
used, rst, as though they actually constituted a theory
of general validity, and more recently, as a technical tool
for health care planning.
The rst of these uses (as a theory of general validity)
has drawn the most criticism. It has been pointed that
the linear progression suggested by the theory is in
question; that a number of variants has been described
at different spatial scales and population sub-groups to
show the complexity of epidemiological change; that it
focus on mortality and it fails to understand the
correlation between the causes of death and the actual
morbidity that people experience during their lives
(Phillips, 1994).2 It also has been sustained (Caldwell,
2001) that it is not clear what Omran meant by
degenerative and man-made disease; that he treated
the population as an undifferentiated unit; that the
conclusions drawn from the mortality statistics of
Sweden and England and Wales are contestable; that
the theory fails to grasp the global nature and the
historical sequence of the mortality transition as it
spread, and that it is insufciently epidemiological in
that its focus was the changing causes of death rather
than the changing causes of patterns of illness
(Caldwell, 2001 p. 160).
An attempt to overcome the conceptual drawbacks of
the model led a multidisciplinary group of authors to
introduce the alternative term health transition which
incorporated new elements into Omrans theoretical
assumptions (Caldwell et al., 1990). Some of them
suggested extremely thought-provoking interpretations
2
Nevertheless, this author recommends its use for health care
planning.

541

(Caldwell, 1990; Das, 1990; Palloni, 1990; Riley, 1990;

Ruzicka & Kane, 1990; Zimmet, Serjeantson, Dowse, &
Finch, 1990), unlike those who used it as though it
merely involved a change of name, without noticing the
very real difference in meaning (Robles, Garc!a, &
Bernabeu, 1996; Frenk et al., 1989).
Conversely, use of the concept epidemiological transition as a technical tool for health care planning continues
to be widely recommended and even defended even by
those who are well aware of its shortcomings in dealing
with the complexity of changes in the patterns of
mortality and morbidity (Phillips, 1991, 1994).
The lack of concern over the epistemological problems and political implications of this position makes
one wonder whether the insistence on continuing to
interpret the epidemiological prole on the basis of a
theoretically inadequate model is merely a problem of
terminological inertia, or whether it may not in fact
imply some sort of political subterfuge, not to say
government alibi (Deutsch, 1993).
Evidence in search of another interpretation
The circumstances that have led to a decline in
mortality from communicable diseases and an increase in
morbidity and mortality from non-communicable diseases (Omrans man-made diseases) in countries now
classied as low- and middle-income (WHO, 2000) are
radically different from those that gave rise to the socalled epidemiological transition in early industrialized
countries (Zimmet et al., 1990; Iannuzzi, Acanfora,
Furgi, & y Rengo, 1999; Palloni, 1990a; CastilloSalgado et al., 1999; Seale, 2000).
Moreover, we now know that not even high-income
countries are entirely safe from communicable diseases
(MHWS, 1999; Smallman-Raynor & Phillips, 1999;
Cabello & Springer, 1997). We still do not know how
solid the supposed triumph of medical technology over
this type of pathology has been.
To make matters worse, attempts to explain changes
in the health levels of various countries using a
classication based on their overall income levels
(low-, middle- or high-income countries) could hardly
have been less apt. Analyses based on information from
the past three decades suggest that mortality rates in
early industrialized countries are no longer related to per
capita income but rather to the levels of inequality
within a single country, meaning that above certain
levels of average income in a society, what begins to
correlate with health levels is not economic growth but
income distribution. Thus, countries with the highest life
expectancy are not the richest but those with the least
polarization in the income levels of their inhabitants and
the lowest proportion of poor people (Wilkinson, 1994).
Yet beyond economic variables, the causal constellations to which inhabitants of the so-called low- and

542

M.S. Carolina, L.F. Gustavo / Social Science & Medicine 57 (2003) 539550

middle-income countries have been exposed leave no

doubt as to what has happened in many of them.
Traditional agricultural societies abruptly transformed
into poor urban societies left their members exposed to
the lowest level of the modern industrial lifestyle from
whose risks they are entirely unprotected (Van Rooyen
et al., 2000; Wassenaar, Van der Veen, & Pillay, 1998;
Hodge, Dowse, Toelupe, Collins, & Zimmet, 1997;
Gulliford, 1995; Musaiger, 1992). Moreover, health
policies of the past decade focussed on low-cost, highyield, preventive interventions, aimed at reducing
mortality from the most frequent communicable diseases (World Bank, 1993; Musgrove, 1995), yet did not
necessarily affect morbidity rates in many of these, since
they were not designed to prevent the risks that caused
them.
The overall balance expressed in the epidemiological
prole combined the worst of both worlds (pre- and
post-transitional). The result is hardly surprising;
indeed, it can be described as a sort of provoked
epidemiological transition, caused by the effects of health
risks inherent in the path that economies and prevailing
forms of social organization have taken, linked to the
direction in which they were oriented through health
policies.
New interests in the health arena
There is a third and nal constant in the recent
bibliography within the doctrine of epidemiological
transition: the assumption that the basic problem in
the current handling of the health problem continues to
be the need for more prevention.
Scientic and technological advances and the preventive aspirations of the last quarter century seem to
have created an illusion of a disease-free world. The
economic interests fought over in the health sector have
denitely fostered this boundless illusion, as though it
were genuinely possible to guarantee total immunity
through promotion and prevention. A closer examination of this point of view, however, leads to recognition
of the fact that:
(a) Truly preventive interventions would imply radical
transformations of the entire universe of production and consumption that surround the populations life, in order to effectively modify the health
risks caused by the environmental and social
environment. This would require a joint social
process led by a government capable of ensuring its
implementation, that would be almost as costly as
the most advanced curative procedures. Outside
this scenario, interventions aimed at modifying
individual behavior through information campaigns
might prove useful for disseminating certain
important measures for health care. However, they

have a limited impact, since people are rarely able

to adopt forms of behavior that exceed the limits
imposed by the world of which they form part.
Being aware of risk factors and wanting to eliminate
them do not always go hand in hand with the actual
possibility of achieving this.
(b) Medium-term prevention reduces the frequency of a
disease (or may even eliminate it, at least temporarily.) As historical experience has shown, however,
other new or even previously known ones tend to
emerge. Disease is one of the conditions of
existence of our species, which, despite its achievements, is unable to escape from its biological basis.
Thus, despite even the most effective preventive
measures, the human body will always be susceptible to disease, which makes it impossible to
dispense with the curative aspect.
(c) Strong demographic pressures, together with the
complex patterns of mortality and morbidity
derived from contemporary lifestyles pose enormous challenges to the curative front. Despite its
high degree of technology, modern medicine is
forced to cope with the limits imposed by its
growing costs, which restrict patients access to the
resources it has managed to develop. Given the
difculty of assuming a commitment to achieving
timely, effective medical care coverage (from which
the high-risk group is usually excluded) governments tend to exaggerate the pressures that bear on
health systems and to hide behind preventive
discourse.
Responsible health policy management should not get
carried away by the illusion of absolute prevention.
The epidemiological proles will continue to change in
accordance with the lifestyles that societies create for
themselves. Consequently, health ministries in the socalled low- and middle-income countries would do well to
abandon the illusion of epidemiological transition in
order to deal with the difcult yet unavoidable task of
caring for their populations. Many of these populations
are fairly large nowadays and undergoing a process of
demographic ageing, yet as members of societies whose
governments have admitted risk portfolios (Douglas
& Wildavsky, 1982) extremely burdensome to health,
they are unlikely to relieve governments of the
responsibility of providing the medical services that
their specic structures of mortality and morbidity
require, that will be more complex and undoubtedly
more costly than their present ones.

Evidence from the Mexican case

In the late 1980s, a group of Mexican experts, led by
the incumbent health secretary of the recently elected

M.S. Carolina, L.F. Gustavo / Social Science & Medicine 57 (2003) 539550

government, used the term epidemiological transition to

refer to the path taken by the global epidemiological
prole in Mexico, classied as a middle-income country
(Frenk et al., 1989).
The term was adopted surprisingly quickly and almost
universally as a feature of sectoral policy (IMSS, 1995;
Arredondo, 1997a, b), with no audible objections from
either the most critical medico-social or demographic3
approaches. But let us see how far this model reects what
actually happened in Mexico during the past century.
A century of transformations
Between 1900 and 2000, Mexico evolved from a rural,
agricultural country with just over 13 million inhabitants and a high proportion of children to a predominantly urban one with over 90 million inhabitants
mainly ages 15 to 44, and primarily employed in the least
productive, worst-paid activities in the tertiary sector
!
(Unikel, Ruiz, & Garza, 1978; Alba, 1977; Cordova,
Leal, & Mart!nez, 1989; Conapo, 1993; INEGI, 1990,
1993, 1996, 1998).
The 1910 revolution near the beginning of the century
was a traumatic watershed that left its legacy. As Cos!o
Villegas (1997, pp. 3435) so accurately points out:
(...) the achievements of the Mexican revolution as
regards its three main goals: political freedom,
agrarian reform and the organization of workers
are far from insignicant (...) It was not, however,
humanly possible to retain ones faith in a mediocre,
dishonest government.
By the end of the century, the government had failed
to consolidate a modern urban, industrial sector or a
powerful primary sector. The type of urbanization that
took place led, on the one hand, to a multitude of small
rural localities as a result of the atomization of old
hamlets and villages and on the other, to enormous
urban concentrations in which a highly polarized,
bifrontal universe was created, with a small group of
3
Despite the fact that Latin American demographers had
already sharply criticized the explanatory capacity of a model
with similar conceptual bases: that of demographic transition.
They pointed out the differences between the processes that led
to demographic transition in Latin America and countries in
Western Europe and well as their timing and the circumstances
that had given rise to them (Palloni, 1990a; Tapinos, 1994).
They also argued that the demographic transition model was
only approximately descriptive but in no way explanatory
(Lopes & Ferreira, 1986). It is interesting to note this, since the
later epidemiological transition model circulated in the early
1970s by Omran (1971, 1977) can be regarded as a sort of
health extension of the demographic proposal drawn up
during the rst half of the 20th century (Thompson, 1929;
Notestein, 1945) meaning that, as a theoretical proposal, it
shares at least these two drawbacks.

543

the population with medium or high incomes and an

increasingly large impoverished mass.
If one had to select a single constant at the beginning
and end of the century, one of the most signicant would
be a feature that is not even remotely reected in the new
classication of the middle-income country: the sharp
polarization of income levels with an extremely high
proportion in the bottom of the pyramid (INEGI, 1998,
1990, pp. 165173).
Balance in the epidemiological profile
As regards health, the testimony of the health ofcers
who lived between the 1920s and 1970s recreates some
aspects of the gradual transformation that took place in
the country during this period (Pruneda, 1997/1922;
Hern!andez, 1994/1941; Mart!nez, 1995/1966).
One of the most striking facts is undoubtedly the
sharp decline in mortality, particularly child mortality
(Table 1). During the rst stage, this drastic change in
mortality levels combined with the high-fertility rates
following the 1910 revolution to produce a sharp
increase in the population.4 A process of demographic
aging followed the beginning of the decline in fertility in
the 1970s. These are some of the expressions of what
experts call the demographic transition (Conapo, 1995,
1996, 1997, 1998).
The prole of the causes of death also experienced
signicant changes. The rst available records after the
1910 revolution, dating from 1922, show at that time,
people dying mainly from pneumonia and inuenza,
diarrhoea and enteritis, fever, and paludal cachexia,
whooping cough and small pox (the last two of which
were subsequently eliminated through vaccinations). At
the end of the century, nearly half of all deaths were due
to cardiovascular diseases (cardiac ischemia and cerebrovascular disease), malign tumors (in the trachea,
bronchus, lung, stomach and cervix of the uterus),
diabetes mellitus and car accidents (Table 2).
Transition...towards what?
Calling this process epidemiological transition is
undoubtedly one way of describing it. It refers to the
4

Although population growth has tended to be negatively

evaluated by government ofcials over the past three decades, a
historian has pointed out that: 1) this is the rst time that
Mexico (which has an area of approximately 2 million sq. km)
has had an optimal ratio between its space and number of
inhabitants; 2) it was not easy to build a nation with 25 islands
(population nuclei) separated by large deserts and 3) beginning
the century with the proportion of young people that there are
in Mexico constitutes a fabulous capital that is undoubtedly
scarce in other parts of the world (Meyer, 1999; see also Cos!o
Villegas, 1997, p. 23).

M.S. Carolina, L.F. Gustavo / Social Science & Medicine 57 (2003) 539550

544

Table 1
Population, general and child deaths Mexico 18951995
Year

Population

General deaths

Deaths in infants
under 12 months

General mortality
rates per 1000 inhabitants

Child mortality rate

per 1000 live births

1895
1900
1910
1921
1930
1940
1950
1960
1970
1980
1990
1995

12,632,427
13,565,942
15,160,369
14,333,082
16,552,722
19,653,552
25,779,254
34,923,129
48,225,238
66,846,833
81,249,645
91,158,290

391,177
456,581
N/A
364,832
441,712
458,906
418,430
402,545
485,686
434,465
422,803
430,278

N/A
N/A
N/A
99,783
107,921
110,039
113,032
119,316
146,028
94,116
65,428
48,023

31.0
33.7
N/A
25.5
26.7
23.3
16.2
11.5
10.1
6.5
5.2
4.7

N/A
N/A
N/A
220.0
131.6
125.7
96.2
74.2
68.5
38.9
23.9
17.5

!
N/A: Not available. Sources: SSA (1993). Compendio historico.
Estad!sticas Vitales 18931993. Estados Unidos Mexicanos. M!exico:
! General de Estad!stica, Inform!atica y Evaluacion,
! Secretar!a de Salud (p. 7). INEGI (1995). Conteo de Poblacion
! y Vivienda,
Direccion
!
95. Resultados Definitivos. Tabulados Basicos.
Estados Unidos Mexicanos. M!exico: Instituto Nacional de Estad!stica, Geograf!a e
! General de Estad!stica e Inform!atica, Secretar!a de Salud.
Inform!atica. SSA (1996). Mortalidad 1995. M!exico: Direccion

fact that the Mexican health scenario experienced a shift

from the prevalence of infectiouscontagious to
chronicdegenerative diseases. However, it says nothing
of the complex balance between morbidity and mortality, or of their relationship to the specic constellations
from which they have arisen, or of the role they played
in medical and health interventions (or the lack of the
latter).
From the point of view of mortality, what is now
known as the burden of disease (WHO, 1999) began to
shift towards the side of non-communicable diseases,
accidents and violent injuries in the late 1970s and early
!
1980s (Cordova
et al., 1989; Mart!nez, 1990). Yet, a look
at morbidity shows that communicable diseases are still
very much in evidence. Low-cost, high-yield preventive
measures managed to stop many of these from proving
fatal,5 yet the conditions of lack of sanitation and
poverty in which large groups of population live, in both
the increasingly atomized rural and the ever more
crowded urban space means that this aspect of the
burden of disease is unlikely to be eliminated from the
health scenario in the near future.
Despite its shortcomings, the rst National Health
Survey, conducted in Mexico during the second half of
the 1980s, documented what is part of clinical physicians everyday experience: the extremely high incidence
of acute respiratory infections and diarrhoeas (with
prevalences of 13.2 and 1.5 for every hundred inhabitants respectively, for the 2 weeks prior to the survey)
!
(SSA, 1988; Mart!nez, Cordova,
& Leal, 1991).
Although the second National Health Survey, taken in
5
For example, the impact of vaccination and oral rehydration programs on the under-5 mortality rate.

the early 1990s, was designed to detect patterns of health

service use rather than morbidity levels, it revealed a
similar panorama: the principal causes of morbidity
reported were respiratory, musculo-skeletal and gastrointestinal infections (with rates of 25.4, 12.9 and 10.8 per
thousand inhabitants, respectively) (SSA, 1994). The
1993 National Survey on Chronic Illnesses also showed a
high prevalence of arterial hypertension and diabetes
mellitus (24.6 and 6.7 per hundred inhabitants ages 20
69, respectively), as well as a high proportion of illnesses
that had not been previously diagnosed (59% of the
total number of those suffering from hypertension and
31.3% of all diabetics) (SSA, 1993).
A more detailed analysis reveals another aspect:
differences in the levels and proles of mortality and
morbidity in the various regions of the country6 and the
concentration of all types of damage (communicable and
non-communicable illnesses, accidents and violence)
among the most disadvantaged socio-economic groups
!
(Cordova
et al., 1989; Mart!nez, 1990, 1994).
6
For further details on the changes in mortality that took
place during the century, see Ben!tez and Cabrera, 1967;
Corona, Jim!enez, and Minujin, 1982; Rabell and Mier y Ter!an,
1986; Mier y Ter!an, 1987; Rodr!guez, 1989; Camposortega,
1992; Conapo, 1998, pp. 1014. Another interesting source is
the historical compendium of vital statistics drawn up by the
Department of Health in 33 volumes, one for each state and one
for the country as a whole (SSA, 1993a). These documents show
the course of these changes among the various sectors of the
population, as well as the way some have lagged behind others.
As regards the differential distribution of morbidity, evidence
found in the databases of these surveys (and others conducted
in Mexico during the past two decades) shows the virtually
unfathomable world of the populations illnesses.

M.S. Carolina, L.F. Gustavo / Social Science & Medicine 57 (2003) 539550

545

Table 2
Percentage of total deaths caused by the ve leading causes of overall mortality for each year Mexico, 19221995
Causea

Year
1922

1930

1940

1950

1960

1970

1980

11.2

11.0

16.3

16.7

12.5

17.2

8.8

Diarrhea and enteritis/

gastroenteritis and colitis/
enteritis and other diarrheal diseases/
infectious intestinal diseasesc

7.1

18.1

21.0

17.2

14.1

14.8

9.5

Fever and paludal cachexia/

malariad

6.9

6.2

5.2

5.5

Violent or accidental deaths/

accidents, poisoning and violence/
accidentse

5.1

5.9

3.2

Measles

3.9
6.0

10.4

5.2

2.8

3.8

6.1

9.7

11.2

6.9

8.5

12.5

14.8

6.1

7.7

Pneumonia and inuenza/

inuenza and pneumoniab

Whooping cough

3.9

4.2

Smallpox

3.3

3.9

Certain early childhood diseases/

early childhood diseases/
certain causes of perinatal morbidity and
mortalityf
Malignant tumorsg
Heart diseases

11.1

1990

1995

9.3

8.3

5.5

Diabetes mellitus
Cerebro-vascular disease
% Of total deaths per year due
to ve leading causes

5.4
32.4

43.4

51.6

51.3

43.0

48.0

44.0

43.1

47.4

a
As one would expect, the International Disease Classication (IDC) used for grouping these ailments changed during the century
(WHO, 1993); but beyond these changes, it is quite easy to see the progressive modication of the prole itself. Below are some of the
modications in the causes included in this table.
b
For 1922 and 1930: 11,99,100: Pneumonia and inuenza, code nos. 11, 99, 100 of the 3rd and 4th IDC revisions: From 1940 to
1960: Flu and pneumonia, code nos. 33, 107109 of the 5th revision and 480483, 490493 of the 6th and 7th revisions, respectively.
From 1970 onwards, pneumonia and inuenza, code nos. 470474, 480486 of the 8th revision, and 321, 322 of the 9th revision
(although by 1990 this was no longer one of the ve leading causes).
c
From 1922to 1940: Diarrhea and enteritis, code nos. 112, 113 of the 3rd and 4th revisions, and 119, 120 of the 5th revision. In 1950
and 1960: Gastroenteritis and colitis except neonatal diarrhea, code nos. 571, 572 of the 6th and 7th revisions. In 1970: Enteritis and
other diarrheal diseases (including typhoid fever, paratyphoid and other types of salmonella), code nos. 001003, 008, 009, 390428 of
the 8th revision. In 1980: infectious intestinal diseases, code no. 01 of the 9th revision.
d
For 1922 and 1930: Fever and paludal cachexia, code no. 5 of the 3rd and 4th revisions. For 1940 and 1950, Malaria, code no. 28 of
the 5th revision and code nos. 110117 of the 6th revision, respectively.
e
For 1940, Violent or accidental deaths, code nos. 163198 of the 5th revision. For 1950: Accidents, poisoning and violence, code
nos. E800E999 of the 6th revision. For 1960: Accidents, code nos. 800962 of the 7th revision (homicides appear in a separate
category with code nos. 964, 965, 980999). From 1980 onwards: Accidents, code nos. E47E53 of the 9th revision.
f
In 1950: Certain childhood diseases, code nos. 760776 of the 6th revision. In 1960: Early childhood diseases, code nos. 760776 of
the 7th revision. In 1970: Certain causes of perinatal morbidity and mortality, code nos. 760779 of the 8th revision. From 1980
onwards: Certain infections originating during the perinatal period, code no. 45 of the 9th revision.
g
In 1960: Malignant tumors including tumors of the lymphatic and haematopoietic tissue, code nos. 140205 of the 7th revision.
From 1970 onwards: Malignant tumors, code nos. 140209 of the 8th revision, and 0814 of the 9th revision.
! General
!
Sources: SSA. (1993). Compendio historico.
Estad!sticas Vitales 18931993. Estados Unidos Mexicanos. M!exico: Direccion
! Secretar!a de Salud (pp. 3541).
de Estad!stica, Inform!atica y Evaluacion,
! General de Estad!stica e Inform!atica, Secretar!a de Salud (p. 69).
SSA. (1996). Mortalidad 1995. M!exico: Direccion

546

M.S. Carolina, L.F. Gustavo / Social Science & Medicine 57 (2003) 539550

An alternative interpretation
If one manages to resist the illusion of epidemiological
transition, the Mexican case yields a prole of mortality
and morbidity that appears to be shifting towards new
and increasingly difcult moments characterized by:
(a) An increase in the incidence and prevalence of noncommunicable diseases that appear before the onset
of old age, with a natural history that takes place in
conditions of poverty, and often beyond the realm
of medical care (post-transitional illnesses in
pre-transitional circumstances?)
(b) A high incidence of communicable illnesses, including those that have existed for centuries
(infectious respiratory diseases, parasitic and infectious intestinal diseases, tuberculosis) and those
that have only recently emerged (HIV/AIDS)
together with the return of those that were thought
to have been eradicated (cholera, malaria, dengue)
but are now present in an era of bacterial resistance
and new, yet unaffordable medication (pre-transitional illnesses in post-transitional circumstances?)
(c) New and complex causal constellations adding to
old ones to explain accidents, homicides, suicides
and violent injuries.7
(d) The fact that all this takes place among a
population of 100 million with growing proportions of adults and elderly adults, whose lives
evolve against a background of extremely heterogeneous conditions of risk.
(e) With a concentration of damage in the most
disadvantaged sector, at a time when access to
medical care is about to depend on the patients
ability to pay, despite the fact that large sectors of
the population tend to view this service as a public
asset, and that even today, Mexico possesses an
enormous network of public health institutions
(unfortunately, in a state of severe disrepair owing
their neglect over the past two decades).
Subscribers to the doctrine to epidemiological transition usually respond to atypical scenarios by extending the list of adjectives used to describe any
developments that diverge from the classic model.
Nowadays, there are not only accelerated or delayed
7

Some of the injuries and violent deaths that have occurred

during the past two decades cannot be explained without
analyzing the links between the impoverishment of the urban
population, criminal activities (drug smuggling, robbery,
assaults) and even the course that addictions are beginning to
take (some of which are long established, such as alcoholism,
and others which have only recently begun to emerge on the
national scene, such as addiction to marijuana, cocaine and
heroin).

versions of Omrans model (1971, p. 553) but overlapped,

reversed, protracted and polarized ones (Frenk et al.,
1989). Although this procedure fails to contribute
convincing epidemiological explanations, it serves to
illustrate the difculty of adjusting the course of
observed epidemiological proles to that proposed in
the early 1970s.
This brings us back, once again, to our original
question: why continue to use this model, instead of
undertaking a detailed analysis of the relation between
what is happening to the epidemiological prole and the
specic causal constellations responsible for each of the
illnesses that comprise them in each country? Would this
not shed more light on their likely development and
enable responsible health policies to be designed? What
is the use of insisting on the unlikely premise that the
course of a prole will blindly obey the dictates of a
model that pre-supposes its destiny?

Beyond the epidemiological transition model

A model is nothing more than an approximate,
hypothetical and invariably reduced version of the
complexity of reality and its continuous evolution. Its
explanatory and prospective capacity depends on its
proximity to the complexity of the phenomenon it
refers to.
But not only in the generation of knowledge but
alsoand above allin public policy design, one should
start from the complexity of reality even though it may
not always be possible to measure it.8 As Morin (1997,
p. 33) so rightly points out, we cannot elude, dissolve or
conceal socio-anthropological complexity, despite the
difculties posed by its intelligibility. Political strategy
works for and against uncertainty and randomness, for
and against ...tissue of events, actions, interactions,
retroactions, determinations, and chance, that constitute
our phenomenological world, as a result of which we
cannot dispense with complex knowledge (Morin, 1997,
p. 32).
8
The use of indicators that fragment, reduce and freeze
processes to make them measurable should not tempt us to
overlook the true complexity contained in the balance of the
numerous possible combinations of the various types of illness
and their outcomes, a balance always difcult to achieve,
particularly since the component features are in a continuous
state of ux. However, nor does the solution lie in the
construction of risky indicators such as the so-called disabil!
ity-adjusted life years (WHO, 1999; Murray & Lopez,
1997;
Nedel, Rocha, & Pereira, 1999) whose deceptive complexity
takes us even further away from an understanding of the health
problem we are attempting to explore (for a criticism of this
indicator, see Mart!nez & Leal, 1999; Mosley, 1999; Gwatkin,
Guillot, & Heuveline, 1999).

M.S. Carolina, L.F. Gustavo / Social Science & Medicine 57 (2003) 539550

547

New challenges for epidemiological research

References

The postulates of epidemiology hold that, on the basis

of peoples genetic predisposition, illnesses originate in
the complex causal constellations to which they are
exposed, while their outcomes vary according to the
types of exposure; intensity, duration, interactions
between the different components.
This is why the prole of mortality and morbidity is
closely linked to the prevailing circumstances in the
world in which populations lives take place, together
with the characteristics of the environmental surroundings (Corvalan, Kjellstrom, & Smith, 1999), lifestyles
(Levins & Lopez, 1999) or, as Douglas and Wildavsky
(1982) would say, the risk portfolio each society has
selected for its members.
If this discipline is to continue studying causal
constellations in sufcient depth to be able to
construct scenarios capable of predicting the probability of occurrence of disease in the future, it will
have to incorporate not only the advances in natural
scientic knowledge, but also the most recent epistemological, historical, economic and social conceptions.
Because in the light of current knowledge, it is difcult
to continue sustaining the theoretical postulates on
which the old epidemiological transition model was
based.
Contemporary historical trends (Braudel, 1989) show
that societies always follows a more complex course
than a single theory is able to predict (Morin, 1997).
Thus, understanding the transformations of the
damage prole will require using less simplistic and
reductive interpretations than the mere passage of time
and the supposedly linear progress from one stage to
another of economic development and carefully studying the causal constellations that give rise to it in each
context.
Moreover, the task of constructing scenarios for
prevention and cure cannot continue to dispense with
the criteria of clinical opinion, currently excluded from
the health sphere as a result of a deformation of the
legitimate preventive aims of the mid-20th century.
Incorporating this opinion into the prospective exercises
carried out by epidemiologists on the possible course of
the damage prole is crucial to nding a proper balance
between the preventive proposals that seek to reduce the
occurrence of the expected pathology and reinforcing
the curative front to deal with the cases that cannot be
prevented.
Given the inevitability of illness and death, a coherent
expression of governments responsible commitment not
only to prevent but also to deal with illness, would
enable citizens to rest secure in the knowledge that they
were supported by National Health Systems that would
strive continuously, within their possibilities, to provide
a timely, effective response.

! de M!exico: Evolucion
! y dilemas
Alba, F. (1977). La poblacion
[>The Population of Mexico: Evolution and dilemmas].
M!exico: El Colegio de M!exico.
Albala, C., & Vio, F. (1995). Epidemiological transition in
Latin America: The case of Chile. Public Health, 109(6),
431442.
Albala, C., Vio, F., & Yanez, M. (1997). Epidemiological
transition in Latin America: A comparison of four
countries. Revista M!edica de Chile, 125(6), 719727.
Arredondo, A. (1997a). Economic assessment of the epidemiological prole change: Information for health care reforms.
Revista M!edica de Chile, 125(2), 244252.
Arredondo, A. (1997b). Costs and nancial consequences of the
changing epidemiological prole in Mexico. Health Policy,
42(1), 3948.
Ben!tez, R., & Cabrera, G. (1967). Tablas abreviadas de
! de M!exico 1930, 1940, 1950 y
mortalidad de la poblacion
1960 [Abridged mortality rate tables for the population of
Mexico 1930, 1940, 1950 and 1960]. M!exico: El Colegio de
M!exico.
Boedhi-Darmojo, R. (1993). The pattern of cardiovascular
disease in Indonesia. World Health Statistics Quarterly,
46(2), 119124.
Braudel, F. (1989). La historia y las ciencias sociales [History
and the social sciences]. M!exico: Alianza Editorial.
Cabello, F., & Springer, A. D. (1997). Emergent diseases: Old
and new diseases. Etiological and climatic aspects. Socioeconomic and cultural inuences. Revista M!edica de Chile,
125(1), 7484.
Caldwell, J. (1990). Introductory thoughts on health transition.
In J. Caldwell, et al. (Eds.), What we know about health
transition: The proceedings of an international workshop
(pp. xixiii). Canberra, May 1989. Canberra: The Australian National University.
Caldwell, J. C. (2001). Population health in transition. Bulletin
of the World Health Organization. The International Journal
of Public Health, 79(2), 159160.
Caldwell, J., Findley, S., Caldwell, P., Santow, G., Cosford, W.,
Braid, J., & Broers-Freeman, D. (Eds.), (1990). What we
know about health transition: The proceedings of an international workshop, 2 vols. Canberra, May 1989. Canberra: The
Australian National University.
!
!
Camposortega, S. (1992). Analisis
demografico
de la mortalidad
en M!exico 19401980 [Demographic analysis of mortality in
Mexico 19401980]. M!exico: El Colegio de M!exico.
Castillo-Salgado, C., Mujica, O., & Loyola, E. (1999). A subregional assessment of demographic and health trends in the
Americas: 19801998. Statistical Bulletin (Metropolitan Life
Insurance Company), 80(2), 212.
!
Conapo. (1993). Indicadores socioeconomicos
e !ndice de
! municipal 1990 [Socioeconomic indicators and
marginacion
index of municipal marginalization 1990]. M!exico: Consejo
!
Nacional de Poblacion.
! 19952000
Conapo. (1995). Programa nacional de poblacion
[19952000 National population program]. M!exico: Consejo
!
Nacional de Poblacion.
! demografica
!
Conapo. (1996). La situacion
de M!exico [The
demographic status of Mexico]. M!exico: Consejo Nacional
!
de Poblacion.

548

M.S. Carolina, L.F. Gustavo / Social Science & Medicine 57 (2003) 539550

! demografica
!
Conapo. (1997). La situacion
de M!exico [The
demographic status of Mexico]. M!exico: Consejo Nacional
!
de Poblacion.
! demografica
!
Conapo. (1998). La situacion
de M!exico [The
demographic status of Mexico]. M!exico: Consejo Nacional
!
de Poblacion.
!
Cordova,
A., Leal, G., & Mart!nez, C. (1989). El ingreso y el
dano. Pol!ticas de salud en los ochenta [Income and damage.
Health policies in the 1980s]. M!exico: Universidad Au!
tonoma
Metropolitana, Xochimilco.
Corona, R., Jim!enez R., & Minujin, A. (1982). La mortalidad en
M!exico. Tasas abreviadas de mortalidad para las
!
entidades federativas y el total de la Republica,
1940, 1950,
1960 y 1970 [Mortality in Mexico. Abridged mortality
rates for the states and the country as a whole, 1940, 1950,
1960 and 1970]. M!exico: Instituto de Investigaciones
!
Sociales de la Universidad Nacional Autonoma
de
M!exico.
Corvalan, D. F., Kjellstrom, T., & Smith, K. R. (1999). Health,
environment and sustainable development: Identifying links
and indicators to promote action. Epidemiology, 10(5),
656660.
Cos!o Villegas, D. (1997). La crisis de M!exico [The crisis in
Mexico]. In Obras completas [Complete works]. M!exico: El
Colegio Nacional.
Das, V. (1990). What do we mean by health? In J. Caldwell,
et al. (Eds.), What we know about health transition: The
proceedings of an international workshop (pp. 2746).
Canberra, May 1989 Canberra: The Australian National
University.
Deutsch, K. W. (1993). Los nervios del gobierno [The govern! Studio Basica.
ments nerves]. M!exico: Paidos
Douglas, M., & Wildavsky, A. (1982). Risk and culture. An
essay on the selection of technical and environmental
dangers. Berkeley and Los Angeles: University of California
Press.
Elman, C., & Myers, G. (1997). Age- and sex-differentials in
morbidity at the start of an epidemiological transition:
Returns from the 1880 US Census. Social Science and
Medicine, 45(6), 943956.
!
!
Frenk, J., Bobadilla, J., Sepulveda,
J., & Lopez,
M. (1989).
Health transition in middle-income countries: New challenges for health care. Health Policy and Planning, 4(1),
2939.
Frenk, J., Frejka, T., Bobadilla, J. L., Stern, C., Lozano, R.,
!
Sepulveda,
J., & Jose, M. (1991). The epidemiological
transition in Latin America. Bolet!n de la Oficina Sanitaria
Panamericana, 111(6), 485496.
Gaylin, D. S., & Kates, J. (1997). Refocusing the lens:
Epidemiological transition theory, mortality differentials,
and the AIDS pandemic. Social Science and Medicine, 44(5),
609621.
Ghannem, H., & Fredj, A. J. (1997). Epidemiological transition
and cardiovascular risk factors in Tunisia. Revue Epidemiologique de Sant!e Publique, 45(4), 286292.
Gulliford, M. C. (1995). Controlling non-insulin-dependent
diabetes mellitus in developing countries. International
Journal of Epidemiology, 24(S1), 5359.
Gulliford, M. C. (1996). Epidemiological transition in Trinidad
and Tobago, West Indies 19531992. International Journal
of Epidemiology, 25(2), 357365.

Gwatkin, D., Guillot, M., & Heuveline, P. (1999). The burden

of disease among the global poor. The Lancet, 354(9178),
586589.
Habermas, J. (2000). Concepciones de la modernidad. Una
mirada retrospectiva a dos tradiciones [Conceptions of
modernity. A retrospective look at two traditions] in La
! posnacional [The post-national constellation].
constelacion
!
Madrid: Paidos.
Hern!andez, M. A. (1994/1941). Dieciocho anos de trabajos
sanitarios en M!exico. Mis opiniones personales [Eighteen
years of health work in Mexico. My personal views]. Salud
!
Publica
de M!exico, 36(4), 449457.
Hodge, A. M., Dowse, G. K., Toelupe, P., Collins, V. R., &
Zimmet, P. Z. (1997). The association of modernization
with dyslipidaemis and changes in lipid levels in the
Polynesian population of Western Samoa. International
Journal of Epidemiology, 26(2), 297306.
Hungerbuhler, P., Bovet, P., & Shamlaye, C. (1993). The
cardiovascular disease situation in Seychelles. World Health
Statistics Quarterly, 46(2), 108112.
Huntington, S. (1983). El orden pol!tico en las sociedades en
cambio [The political order in societies in transition]. Buenos
!
Aires: Paidos.
Iannuzzi, G., Acanfora, D., Furgi, G., & y Rengo, F. (1999).
Ageing and cardiovascular disease in developing countries.
The Lancet, 353(9149), 323.
!
IMSS. (1995). Diagnostico
[Diagnosis]. March 1995, M!exico:
Instituto Mexicano del Seguro Social.
!
INEGI. (1990). Estad!sticas historicas
de M!exico, Tomo I
[Historical statistics of Mexico, vol. 1]. M!exico: Instituto
Nacional de Estad!stica, Geograf!a e Inform!atica.
INEGI. (1993). ENIGH-92. Encuesta nacional de ingresos y
gastos de los hogares [ENIGH-92. National household income
and expenditure survey]. M!exico: Instituto Nacional de
Estad!stica, Geograf!a e Inform!atica.
INEGI. (1996). ENIGH-94. Encuesta nacional de ingresos y
gastos de los hogares [ENIGH-94. National household income
and expenditure survey]. M!exico: Instituto Nacional de
Estad!stica, Geograf!a e Inform!atica.
INEGI. (1998). ENIGH-96. Encuesta nacional de ingresos y
gastos de los hogares [ENIGH-96. National household income
and expenditure survey]. M!exico: Instituto Nacional de
Estad!stica, Geograf!a e Inform!atica.
Levins, R., & Lopez, C. (1999). Toward an ecosocial view
of health. International Journal of Health Services, 29(2),
261293.
Lopes, N., & Ferreira, C. (1986). Repensando a transi@ao
!
demografica: Formulasoes
criticas e perspectivas de analise
[Rethinking demographic transition: Critical propositions and
analysis perspectives]. Brasil: UNICAMP.
Marshall, M. (1991). The second fatal impact: Cigarette
smoking, chronic disease and the epidemiological transition
in Oceania. Social Science and Medicine, 33(12), 13271342.
!
Mart!nez, S. C. (1990). Causas de muerte como manifestacion
de las desigualdades sociales [Causes of death as a
manifestation of social inequalities]. Demos. Carta demogr!aca sobre M!exico, 3, 1012.
! reciente de la mortalidad por
Mart!nez, S. C. (1994). Evolucion
causas en M!exico [Recent evolution of mortality by causes
! cient!ca,
in Mexico]. In Cuarta semana de investigacion
! Universitaria, tomo I [University
Cuadernos de Extension

M.S. Carolina, L.F. Gustavo / Social Science & Medicine 57 (2003) 539550
Extension Handbooks, vol. 1] (pp. 127130). M!exico:
!
Universidad Autonoma
Metropolitana, Xochimilco.
Mart!nez, P. (1995/1966). El m!edico que el pa!s necesita [The
!
type of physician the country needs]. Salud Publica
de
M!exico, 37(5), 472476.
!
Mart!nez, C., Cordova,
A., & Leal, G. (1991). Un acercamiento
a la problem!atica de salud en M!exico a nes de los ochenta
[An approach to the problem of health in Mexico in the late
!
1980s]. Estudios Sociologicos,
9(26), 253278.
!
Mart!nez, C., & Leal, G. (1999). Comentarios a la sesion:
Consecuencias para el sector salud. In K. En Hill, B.
Morelos, & R. Wong (Coords.), Las consecuencias de las
!
!
transiciones demografica
y epidemiologica
en Am!erica Latina
(pp. 185194). M!exico: El Colegio de M!exico and Johns
Hopkins University.
Meyer, J. (1999). La explosi!on demogr!aca, clave en el
desarrollo urbano de M!exico [The demographic explosion,
the key to Mexicos urban development]. Interview by
Mar!a Rivera for La Jornada, Thursday, January 14, 1999
(pp. 1 and 14).
MHWS. (1999). The health care budget in a nutshell. VWS
Bulletin, Ministry of Health Welfare and Sport, The
Netherlands, 1999. (22 pp. quoted September 21, 1999).
Available at: URL: http://www.minvws.nl/internationaal/
inter index.htm.
Mier y Ter!an, M. (1987). Aspects de la relation entre les
schemas de fecondite et la sant!e: lexemple du Mexique.
Rapport Trimestriel de Statistiques Sanitaires Mondiales,
40(1), 4153.
! al pensamiento complejo
Morin, E. (1997). Introduccion
[Introduction to complex thought]. Barcelona: Gedisa.
! Consecuencias
Mosley, H. (1999). Comentarios a la sesion:
para el sector salud. In K. En Hill, B. Morelos, & R. Wong
!
(Coords.), Las consecuencias de las transiciones demografica
!
y epidemiologica
en Am!erica Latina (pp. 195200). M!exico:
El Colegio de M!exico and Johns Hopkins University.
Murray, C. J., & Lopez, A. D. (1997). Global mortality,
disability and the contribution of risk factors: Global
burden of disease study. The Lancet, 349(9063), 14361442.
Musaiger, A. O. (1992). Diabetes mellitus in Bahrain: An
overview. Diabetic Medicine: A Journal of the British
Diabetic Association, 9(6), 574578.
! de los costos y la
Musgrove, P. (1995). La ecacia en funcion
reforma del sector salud [Effectiveness as a function of costs
!
and health sector reform]. Salud Publica
de M!exico, 37(4),
363374.
Nedel, F. B., Rocha, M., & Pereira, J. (1999). Years of life lost
by mortality: A component of the burden of disease. Revista
de Saude Publica, 33(5), 461469.
Notestein, F. (1945). Population: The long view. In Th. Schultz
(Ed.), Food for the world. Chicago: University of Chicago
Press.
Omran, A. (1971). The epidemiologic transition. A theory of
the epidemiology of population change. Milbank Memorial
Fund Quarterly, XLIX(4), 509538.
Omran, A. (1977). Epidemiologic transition in the United
States: the health factor in population change. Population
Bulletin, 32(2), 142.
Palloni, A. (1990). The meaning of the health transition. In J.
Caldwell, et al. (Eds.), What we know about health transition:
The proceedings of an international workshop (pp. xvixvii).

549

Canberra, May 1989. Canberra: The Australian National

University.
Palloni, A. (1990a). Health levels and care in Latin America:
The case of infant mortality 19001985. In J. Caldwell, et al.
(Eds.), What we know about health transition: The proceedings of an international workshop (pp. 189212). Canberra,
May 1989. Canberra: The Australian National University.
Phillips, D. R. (1991). Problems and potential of researching
epidemiological transition: Examples for Southeast Asia.
Social Science and Medicine, 33(4), 395404.
Phillips, D. R. (1994). Does epidemiological transition have
utility for health planners? Social Science and Medicine,
38(10), viix.
Prebisch, R. (1963). Toward a dynamic development policy for
Latin America. New York: United Nations.
! de la
Pruneda, A. (1997/1922). Discurso de inauguracion
Escuela de Salubridad [Keynote address at the School of
!
Health]. Salud Publica
de M!exico, 39(2), 153155.
Rabell, C., & Mier y Ter!an, M. (1986). El descenso de la
mortalidad en M!exico de 1940 a 1980 [The decline in
mortality in Mexico from 1940 to 1980]. Estudios Demo!
graficos
y Urbanos, 1(1), 3972.
Reddy, K. S. (1993). Cardiovascular diseases in India. World
Health Statistics Quarterly, 46(2), 101107.
Riley, J. C. (1990). Long-term morbidity and mortality trends:
inverse health transition. In J. Caldwell, et al. (Eds.), What
we know about health transition: The proceedings of an
International Workshop (pp. 165188). Canberra, May 1989.
Canberra: The Australian National University.
Robles, G. E., Garc!a, B. F., & Bernabeu, M. J. (1996). Health
transition in Spain from 1900 to 1990. Revista Espanola de
!
Salud Publica,
70(2), 221233.
! de las causas de
Rodr!guez, L. (1989). M!exico: Contribucion
muerte al cambio en la esperanza de vida, 19701982
[Mexico: Contribution of causes of death to changes in life
expectancy, 19701982]. In CELADE Serie B, No. 56.
Santiago, Chile: Centro Latinoamericano de Demograf!a.
Rostow, W. (1960). The stage of economic growth: A noncommunist manifesto. London: Cambridge University Press.
Ruzicka, L., & Kane, P. (1990). Health transition: The course
of morbidity and mortality. In J. Caldwell, et al. (Eds.),
What we know about health transition: The proceedings of an
international workshop (pp. 126). Canberra, May 1989.
Canberra: The Australian National University.
Seale, C. (2000). Changing patterns of death and dying. Social
Science and Medicine, 51(6), 917930.
Serow, W. J., Cowart, M. E., & Camezon, J. (1998).
Epidemiologic transition theory and aging: Hispanic
populations of North America and the Caribbean.
Journal of Health Human Services Administration, 20(3),
333347.
Smallman-Raynor, M., & Phillips, D. (1999). Late stages of
epidemiological transition: Health status in the developed
world. Health Place, 5(3), 209222.
SSA (1988). Encuesta nacional de salud. 1987 [1987 National
Health Survey]. M!exico: Sistema Nacional de Encuestas de
Salud, Secretar!a de Salud.
!
SSA (1993). Encuesta nacional de enfermedades cronicas
1993
[1993 National Survey on Chronic Diseases]. M!exico:
! General de Epidemiolog!a, Subsecretar!a de
Direccion
Coordinaci!on y Desarrollo, Secretar!a de Salud.

550

M.S. Carolina, L.F. Gustavo / Social Science & Medicine 57 (2003) 539550

!
SSA (1993a). Compendio historico.
Estad!sticas Vitales 1893
1993 [Historical Compendium, Vital Statistics 18931993],
! General de Estad!stica, Inform33 vols. M!exico: Direccion
a! tica y Evaluaci!on, Secretar!a de Salud.
SSA (1994). Encuesta nacional de salud II [II National Health
Survey]. M!exico: Secretar!a de Salud.
Tapia-Conyer, R. (1997). Molecular epidemiology in the
epidemiological transition. Gaceta M!edica de M!exico,
133(S1), 161166.
Tapinos, G. (1994). Crecimiento demogr!aco y crecimiento
econ!omico [Demographic and economic growth]. In R.
!
Ben!tez, & G. Ram!rez G. (Coords.), Pol!ticas de poblacion
en Centroam!erica, El Caribe y M!exico [Population policies in
Central America, The Caribbean and Mexico] (pp. 6572).
M!exico: Instituto de Investigaciones Sociales de la Uni!
versidad Nacional Autonoma
de M!exico, Programa Lati! e Instituto
noamericano de Actividades en Poblacion
! Publica
!
Nacional de Administracion
de Guatemala.
Thompson, W. (1929). Population. The American Journal of
Sociology, 34(6), 959975.
Unikel, L., Ruiz, C., & Garza, G. (1978). El desarrollo urbano
de M!exico [Urban development in Mexico]. M!exico: El
Colegio de M!exico.
Van Rooyen, J. M., Kruger, H. S., Huisman, H. W., Wissing,
M. P., Margetts, B. M., Venter, C. S., & Vorster, H. H.
(2000). An epidemiological study of hypertension and
its determinants in a population in transition: The
THSA study. Journal of Human Hypertension, 14(12),
779787.
Vigneron, E. (1989). The epidemiological transition in an
overseas territory: Disease mapping in French Polynesia.
Social Science and Medicine, 29(8), 913922.
Vigneron, E. (1993). Epidemiological transition and geographical discontinuities: The case of cardiovascular mortality
in French Polynesia. Social Science and Medicine, 37(6),
779790.
Wallerstein, I. (2000). El eurocentrismo y sus avatares: Los
dilemas de las ciencias sociales [Eurocentrism and its ups

and downs: The dilemmas of the social sciences]. New Left

Review, 0, 97113.
Wassenaar, D., Van der Veen, M., & Pillay, A. (1998). Women
in cultural transition: Suicidal behavior in South African
Indian world. Suicide and Life-Threatening Behavior, 28(1),
8293.
World Bank (1993). Informe sobre el desarrollo mundial 1993.
Invertir en salud [World Development Report 1993:
Investing in Health]. Washington, DC: World Bank.
WHO (1993). The International Classication of Diseases and
Related Health Problems, Tenth Revision. Geneva, Switzerland : World Health Organization.
WHO (1999). The World Health Report 1999. Making a
Difference. May 10 1999, Geneva (121 pp, quoted January
27, 2000). Available at: URL: http://www.sho.int/whr/1999/
en/report-htm.
WHO (2000). The World Health Report 2000. Health Systems:
Improving Performance. 21 June 2000, Geneva (206 pp,
quoted July 18, 2000). Available at: URL: http://
www.sho.int/whr/2000/en/report-htm.
WHO (2001). Omran, A.R. Bulletin of the World Health
Organization. The International Journal of Public Health,
79(2), 161170.
Wilkinson, R. G. (1994). The epidemiological transition: From
material scarcity to social disadvantage? Daedalus. Journal
of the American Academy of Arts and Sciences, 123(4),
6177.
Wolpert, E., Robles, D. G., & Reyes, L. P. (1993). The
epidemiological transition of chronic and degenerative
diseases in Mexico. Gaceta M!edica de M!exico, 129(3),
185189.
Zimmet, P., Serjeantson, S., Dowse, G., & Finch, C. (1990).
Killed by the good life: The chronic disease epidemicadverse effects of lifestyle change in developing Pacic
nations. In J. Caldwell, et al. (Eds.), What we know about
health transition: The proceedings of an international workshop (pp. 275283). Canberra, May 1989. Canberra: The
Australian National University.