The Epidemiologic Transition Model: Accomplishments and Challenges
MANNING FEINLEIB, MD, DRPH, FACE
Changes in population size and structure are determined by
basic processes that can be summarized by the demographic
equation (Fig. 1). While demographers and those concerned
with population growth tend to emphasize fertility trends,
and immigration policy is very much on the current political
agenda, epidemiologists tend to concentrate their efforts
studying the factors associated with the third part of the
equation.
Late in the nineteenth century, demographers, following
Malthusian principles, developed several theories to de-
scribe how populations change over long periods of time.
Dudley Kirk (1) points out that, in 1929, Warren Thompson
categorized populations on the basis of fertility and mortality
(2), followed in 1934 by the first use of the term ‘‘transition’’
by Adolphe Landry (3). But it is Frank Notestein who is
given credit for the first full statement of the demographic
transition model in 1945 (4). This model was expanded by
Abdel Omran in a seminal article in 1971 in which he re-
named the model the epidemiologic transition model (5).
Whereas earlier demographers were concerned primarily
with changes in fertility, Omran emphasized the mortality
aspects. Omran renamed the four stages of the demogra-
phers’ transition model for population evolution to empha-
size some epidemiologic aspects (Fig. 2): Stage 1, which
demographers called pre-modern, he labeled the stage of
pestilence and famine characterized by high death rates
and high birth rates with low population size. Stage 2dur-
banizing and industrializingdhe described as the stage of re-
ceding pandemics resulting from a gradual conquest of
disease primarily through better sanitation and nutrition
and resulting in a reduction of mortality, especially child
mortality, and a concomitant gradual increase in population
size. Stage 3dmature industrialdhe called the stage of de-
clining births with a peaking of the size of the population.
Stage 4dpostindustrialdwas characterized as the stage of
degenerative and man-made disease with a balance between
birth and death rates, both at low levels, and a leveling off of
the population size.
It should be pointed out that the model is an idealized
summary of the stages in a population’s development. It
fits fairly well the demographic changes which occurred in
Western Europe and the English-speaking countries during
Address correspondence to: Dr. Manning Feinleib, Johns Hopkins
Bloomberg School of Public Health, Epidemiology, Bloomberg E6153,
Baltimore, MD. Tel: (410) 614-0146. Fax: (410) 955-0863. E-mail:
mfeinlei@jhsph.edu.
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the late eighteenth century through the mid-twentieth cen-
tury, and there is evidence that the pattern is being followed
by many developing countries, although the pace of the
transitions varies greatly.
My aim in this short essay is not to discuss the details of
the various stages of the epidemiologic transition model but
to use it as a platform to mention some of the major accom-
plishments of epidemiology in the past and to highlight the
challenges and opportunities that lay ahead (Fig. 3).
I view epidemiology as the provider of the evidential
basis for public health action and for many clinical practices.
Thus the accomplishments of epidemiology in preventing
and controlling disease and enhancing longevity are intri-
cately dependent on the implementation of its findings at
the individual patient level and through community public
health programs.
During the pre-modern stage, epidemiology contributed
little other than to emphasize the periodic increases in mor-
tality resulting from epidemics, famine, and other hardships.
But during stage 2, as epidemiologic and medical knowledge
and public health applications increased, there was a gradual
diminution of infectious diseases generally and some curtail-
ment of epidemics. Infant mortality especially improved
while the birth rate remained high so that populations grad-
ually increased in size.
The third stage is characterized in this model by a reduc-
tion in the birth rate. The reasons for this decline are com-
plex, involving many societal, cultural, and economic
factors (1), but some of the epidemiologic and public health
influences were the improved survival of children and, more
recently, the availability of effective birth control methods.
This period also saw improvements in nutrition and greater
concern with the health and safety of the labor force. With
both mortality and birth rates at low levels the growth of the
population leveled off and the concerns of epidemiologists
and public health workers shifted to chronic diseases and
their prevention. Many personal risk factors related to life-
style and individual behaviors were identified. A greater
awareness of environmental hazards grew and many regula-
tory and educational policies were instituted to reduce envi-
ronmental risks. Omran dubbed this stage the age of
degenerative and man-made disease (5).
I would like to propose that we should now recognize
a fifth stage in the epidemiologic model. This stage is char-
acterized by birth rates below the population replacement
level, an aging population with many more elderly depen-
dent on a diminishing working population for their
1047-2797/08/$–see front matter
doi:10.1016/j.annepidem.2008.08.004
866 Feinleib AEP Vol. 18, No. 11
EPIDEMIOLOGIC TRANSITION November 2008: 865–867

The Demographic Equation
ΔP = Births ± Migration - Deaths
Family Values Economics Disease
Fecundity Politics Famine
Gender roles Persecution War
Contraception Opportunities Senescence
Suicide
Risky behavior
FIGURE 1. The demographic equation.
economic and healthcare support, and, medically, greater
dependence on advanced technological devices and proce-
dures to diagnose and treat diseases. This newly proposed
stage we may call that of aging and shrinking populations.
Many developed nations are already well into this phase.
What can we look forward to in the twenty-first century?
I think that there is still much that epidemiologists and pub-
lic health workers in general can contribute at every stage of
the epidemiologic transition model (see Fig. 3, lower panel).
In those societies that are at the pre-modern stage, where
disease levels are high and famine is still a constant threat,
epidemiologists can contribute to improving health by
advocating for basic improvements in sanitation and wider
immunization of children. They can also urge the develop-
ment of basic epidemiologic toolsdvital registration and
health statistics systems. Lacking accurate and complete
data, it is difficult to assess the magnitude of health prob-
lems, identify vulnerable subgroups, or measure the impact
of public health programs.
Although great progress has been made in controlling in-
fectious diseases in virtually all developed nations, emerging
infections, exemplified by HIV/AIDS, are a major problem
in urbanizing/industrializing areas. Combating these
diseases will engage epidemiologists for decades to come.
There is also the opportunity for epidemiologists to guide
planners and policy makers in developing countries in
avoiding some of the hazards that urbanized communities
have experienced. Better city planning, avoidance of over-
crowding, provision of adequate transportation systems,
safe work environments, and modern educational systems
would go far to preventing future health problems as well
as many other social ills.
In mature industrial societies epidemiologists will devote
most of their efforts to preventing chronic diseases, educat-
ing the public about healthy lifestyles, assessing early detec-
tion and treatment programs, and improving the
availability, accessibility, and utilization of health services.
These activities will merge with evolving progress in the
fields of genomics, immunology, and diagnostics to better
define and detect illnesses. Epidemiologists will broaden
their involvement in ‘‘social diseases,’’ including substance
abuse and violence. They will also be major players in under-
standing and ameliorating subgroup disparities in health and
longevity.
As we enter the fifth stage of the epidemiologic transition
model, epidemiologists will become increasingly involved
with the health conditions that prevail at both extremes
of the age distribution. Providing for the health needs of old-
er patients will encumber greater proportions of communi-
ties’ resources. Broader aspects of the well-being of older
persons, especially the ‘‘oldest old’’, will necessitate
expanded information about their physical, social, economic,
and psychologic environments, not only their biologic,
physiologic, and cognitive functioning. As the birth rates
decrease, children will become increasingly precious. There
will be ever-increasing devotion to the salubrious develop-
ment of children in all aspects, including physical, mental,
emotional, and societal.

Epidemiologic Transition Model

50
1 2 3 4 5 1 - Pestilence and
45
famine
40 2 - Receding
pandemics
35
3 - Declining
30 births
4 - Degenerative
25 & man-made
20 disease
5 - Aging and
15 shrinking
10 population

5
0
Time
CDR CBR Population

FIGURE 2. The epidemiologic transition model.

AEP Vol. 18, No. 11 Feinleib 867
November 2008: 865–867 EPIDEMIOLOGIC TRANSITION

Impact of Epidemiology
1 2 3 4 5
Stage Pre- Urbanizing/ Mature Post
modern Industriali- industrial Industrial
zing

Reduced Birth Smoking & Injuries,

Past Nil infectious control, other technological
diseases & occupa- riskfactors, fixes
infant tional environmen-
mortality health, tal risks
nutrition
Sanitation, HIV/AIDS, Prevention Genomics, Elder care –
Future immunization, emerging of chronic Education to physical,
Vital infections, diseases, modify life social,
registration & city Health styles, economic,
Health planning services substance psychologic,
Statistics abuse, Child
violence development

FIGURE 3. Impact of epidemiology.

This has been a wide view of the accomplishments of

epidemiology and some of the challenges we will
encounter in coming decades. The American College
of Epidemiology has played an important role in encour-
aging and recognizing epidemiologists in their endeavors
and will continue to provide leadership, guidance, and
stimulation in the future. It has been a pleasure and
an honor for me personally to have been a participant
in these activities.
REFERENCES
1. Kirk D. Demographic transition theory. Population Studies. 1996;50:361–
387.
2. Thompson WS. Population. Am J Sociol. 1929;34:959–975.
3. Landry A. La revolution demographique. Paris; 1934.
4. Notestein F. Population: the long view. In: Schultz T, ed. Food for the
world. Chicago: University of Chicago Press.; 1945. p. 36–57.
5. Omran AR. The epidemiologic transition: a theory of the epidemiology of
population change. Milbank Mem Fund Q. 1971;49:509–538.