This discussion focuses on the concept of disease burden, which you will learn about in-depth in Chapter 3 of the eText attached.
For this discussion, in addition to Chapter 3, please refer to the “Global burden of 87 risk factors in 204 countries and territories” article provided in the Module 2 Learning Resources folder. Read the article summary and peruse the article.
This is a one-page perusal of both articles to answer the three questions below.
1) What information presented in this article was most surprising to you about disease burden?
2) Why was that information surprising?
3) In your own words, explain how disease burden is measured and how it is used to define global health.
Global Health Metrics
www.thelancet.com Vol 396 October 17, 2020 1223
Global burden of 87 risk factors in 204 countries and
territories, 1990–2019: a systematic analysis for the Global
Burden of Disease Study 2019
GBD 2019 Risk Factors Collaborators*
Summary
Background Rigorous analysis of levels and trends in exposure to leading risk factors and quantification of their effect on
human health are important to identify where public health is making progress and in which cases current efforts are
inadequate. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a standardised and
comprehensive assessment of the magnitude of risk factor exposure, relative risk, and attributable burden of disease.
Methods GBD 2019 estimated attributable mortality, years of life lost (YLLs), years of life lived with disability (YLDs),
and disability-adjusted life-years (DALYs) for 87 risk factors and combinations of risk factors, at the global level,
regionally, and for 204 countries and territories. GBD uses a hierarchical list of risk factors so that specific risk factors
(eg, sodium intake), and related aggregates (eg, diet quality), are both evaluated. This method has six analytical steps.
(1) We included 560 risk–outcome pairs that met criteria for convincing or probable evidence on the basis of research
studies. 12 risk–outcome pairs included in GBD 2017 no longer met inclusion criteria and 47 risk–outcome pairs for
risks already included in GBD 2017 were added based on new evidence. (2) Relative risks were estimated as a function
of exposure based on published systematic reviews, 81 systematic reviews done for GBD 2019, an
Courtesy of Mark Tuschman
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CHAPTER
3
The Global Burden of Disease
LEARNING OBJECTIVES
By the end of this chapter, the reader will be able to do the
following:
■ Discuss the concepts of health-adjusted life expectancy
(HALE), disability-adjusted life years (DALYs), and the
burden of disease
■ Describe the leading causes of disability, deaths, and
DALYs by region, country income group, age, and sex
■ Describe the leading risk factors for disability, deaths, and
DALYs by region, country income group, age, and sex
■ Discuss the demographic and epidemiologic transitions
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▶ Vignettes
rincess is a 3-year-old girl who lives near the town of
Kenema in Sierra Leone. Although Sierra Leone has made
some progress in reducing young child death, the country remains
very poor, still suffers from the ravages of its earlier civil war, and
continues to have a very weak health system. Access to safe
water and sanitation and good knowledge of hygiene are also
limited. The burden of malaria has gone down, but the disease is
still very prevalent. What are the leading causes of death for
young children like Princess? What are the most important risk
factors for those causes? Is there good evidence about what can
be done in cost-effective and fair ways to reduce the burden of
deaths among young children in Sierra Leone and similar
countries?
Aisha is a 50-year-old woman who lives in the northern part of
Nigeria. She is from a lower middle-class family, in an area that is
still quite poor. Aisha has been feeling unwell and recently visited
the outpatient clinic at the regional hospital. The check-up and
tests the doctors carried out indicated that she has high blood
pressure, high cholesterol, and diabetes. The doctors prescribed
medicines for her to reduce her blood pressure and cholesterol
and another drug to lower her blood sugar. As Aisha returned
home, she thought about how people’s health had changed in the
last decade in her town. Earlier, she rarely heard about the
conditions with which she had been diagnosed. Now, however, it
seemed like many of her friends had been diagnosed with the
same problems.
Jose is a 30-year-old man in Bolivia. He is from an indigenous,
relatively poor community in the highlands. Two decades ago,
Jose’s community still faced many child deaths, especially from
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pneumonia and diarrhea. The community also had a substantial
burden of undernutrition and tuberculosis (TB). To what extent
have such causes of death declined in Jose’s community? If so,
what are the leading causes of death now? Is there a
“convergence” between the leading causes of death in Jose’s
community and the lowland communities populated mostly by
people of European descent?
Shireen is a 22-year-old woman in Bangladesh. She is just starting
a family. Her mother and grandmother have given her advice
about when to have her first child and where to get and how to use
family planning methods. They have also suggested that she
should have only two children and that she should space them 3
or more years apart. A community health worker has been in touch
with Shireen regularly and has made the same suggestions as her
mother and grandmother. In Bangladesh in 1960, women had on
average more than six children and the median age of the
population was around 19 years of age. In 2016, women had on
average just over two children and the median age of the
population was around 26 years of age. What causes these
shifts? Do they occur consistently as countries develop socially
and economically? What will the age distribution of the population
look like in Bangladesh in 25 years and why?
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▶ Measuring the Burden of Disease
The World Health Organization (WHO) defines health as “a state
of complete physical, mental and social well-being and not merely
the absence of disease or infirmity.” Those who work on global
health have attempted for a number of years to construct a single
indicator that could be used to compare how far different countries
are from the state of good health. Ideally, such an index would
take account of morbidity, mortality, and disability; allow one to
calculate the index by age, by gender, and by region; and allow
one to make comparisons of health status across regions within a
country and across countries. This kind of index would measure
what is generally referred to as the burden of disease.
One such indicator is health-adjusted life expectancy, or HALE.
This is a health expectancy measure. HALE is the number of
years a person of a given age can expect to live in good health,
taking account of mortality and disability. This can also be
seen as “the equivalent number of years in full health that a
newborn can expect to live, based on current rates of ill health and
mortality.” To calculate HALE, “the years of ill health are weighted
according to severity and subtracted from the overall life
expectancy.”
TABLE 3-1 shows life expectancy at birth in 2016 for a number of
low-, middle-, and high-income countries and how it compares with
HALEs for those countries in the same year, for males and
females. In principle, each country should strive to help its people
live as long and as healthy as possible. In that case, health-
adjusted life expectancy and life expectancy at birth would
converge at a relatively high number.
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TABLE 3-1 Life Expectancy at Birth and Health-Adjusted Life
Expectancy by Sex, Selected Countries, 20
16
The composite indicator of health status that is most commonly
used in global health work is called the disability-adjusted life
year, or DALY. This indicator was first used in conjunction with the
1993 World Development Report of the World Bank and is a
health gap measure. It is now used consistently in burden of
disease studies. In the simplest terms, a DALY is “the sum of
years lost due to premature death (YLLs) and years lived with
disability (YLDs). DALYs are also defined as years of healthy life
lost.”
The calculation of years lost to premature death is based on the
difference between the age at which one dies and one’s life
expectancy at that age. To make this calculation, those involved in
the key studies on the global burden of disease have constructed
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a reference standard life table that takes account of the highest
life expectancy at birth globally. For the 2016 study, this was set at
86.6 years. This life table is used to calculate premature death for
all countries in the study.
One might ask why the study is not based on life tables for each
individual country. In very simple terms, one could respond by
noting that, in principle, any death before the life expectancy of the
people who live the longest globally is “premature.” One might also
add that in order to make the world a healthier place, a goal must
be to have people live “as long as possible,” rather than live only
as long as they live now.
FIGURE 3-1 illustrates the calculation of years of life lost due to
premature death for three different scenarios.
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FIGURE 3-1 Calculating Years of Life Lost (YLLs) Due to
Premature Death
Adapted with permission from Session 6, Module 2 of Essentials of Global Health,
Coursera/Yale University, 2016. Data from Institute of Health Metrics and Evaluation
(IHME). (n.d.). Global Burden of Disease Study 2016 (GBD 2016) data resources:
GBD 2016 reference life table. Retrieved from http://ghdx.healthdata.org/gbd-2016
As noted in Figure 3-1, if a newborn were to die in Liberia, for
example, that newborn would have suffered 87 years of life lost
due to premature death. Life expectancy at 40 according to the
reference life tables is 87, or 47 more years. Thus, if a 40-year-old
woman in Malawi were to die in a car accident, she would have
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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http://ghdx.healthdata.org/gbd-2016
suffered 47 years of life lost due to premature death. Life
expectancy at 60 years of age according to the standard reference
life table is 88, or 28 more years. Thus, if a French male were to
die of a heart attack at age 60, he would have suffered 28 years of
life lost.
The value for years lived with disability is calculated by weighting
these years by a disability index. For the Global Burden of Disease
Study 2010, 14,000 people were surveyed directly and 16,000
people were involved via the internet in establishing disability
weights. The disability weights used in the 2016 study were
based on the 2010 weights, supplemented by data gathered from
additional surveys done for the 2013 GBD study. The study
authors also made some additional refinements to these weights,
especially as they related to the severity of different health
conditions.
FIGURE 3-2 illustrates the disability weights for five different
conditions. It also shows model calculations of years of life lived
with disability (YLDs) for three scenarios of people living with
disability.
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FIGURE 3-2 Calculating Years Lived with Disability (YLDs)
Adapted with permission from Session 6, Module 2 of Essentials of Global Health,
Coursera/Yale University, 2016. Data from Salomon, J. A, Haagsma, J. A., Davis, A.,
de Noordhout, C. M., Polinder, S., Havelaar, A. H., . . . Vos, T. (2015). Disability
weights for the Global Burden of Disease 2013 study. Lancet Global Health, 3(11),
e712–e723.
As noted in Figure 3-2, let’s say that a person in Tanzania lives
30
years with a disability that has been given a weight of 0.10. In this
case the person suffers 3 years of life lived with disability, equal to
the number of years lived with disability, multiplied by the weight of
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that disability. If a person in France lived 20 years with a disability
that has a weight of 0.25, then that person would have suffered
the equivalent of 5 years lived with disability. If a person in Sri
Lanka lived 10 years with a disability that has a weight of 0.5, then
that person would have suffered 5 years of life lived with disability.
As noted earlier, a DALY is the sum of years of life lost due to
premature death (YLL) and years of life lost due to disability
(YLD). FIGURE 3-3 illustrates the calculation of a DALY for two
different scenarios.
FIGURE 3-3 Calculating Disability-Adjusted Life Years (DALYs)
Adapted with permission from Session 6, Module 2 of Essentials of Global Health,
Coursera/Yale University, 2016.
As you can see in Figure 3-3, Person A dies at 50 years of age of
drug-resistant tuberculosis, after living 3 years with this condition.
In this case, the person’s life expectancy at 50 was 87. Thus the
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person suffered a loss of 37 years of life due to premature death.
The disability weight for multidrug-resistant TB is 0.333. Thus, the
person would have suffered 1 year of life lived with disability. The
total DALYs for this person would be 37 plus 1, or 38.
Person B dies at 65 after living 10 years with moderate disability
brought on by a stroke. This person died 23 years prematurely.
This person also suffered about 3 years of life lived with disability.
The total DALYs associated with this person would be 23 YLLs,
plus 3 YLDs, or about 26 years.
A society that has more premature death, illness, and disability
has more DALYs per person in the population than a society that
is healthier and has less premature death, illness, and disability.
One of the goals of health policy is to avert these DALYs in the
most cost-efficient and fair manner possible. If, for example, a
society has many hundreds of thousands of DALYs due to malaria
that are not diagnosed and treated in a timely and proper manner,
what steps can be taken to avert those DALYs at the lowest cost
and in the fairest ways?
An important point to remember when considering DALYs,
compared to measuring deaths, is that DALYs take account of
periods in which people are living with disability. By doing this,
DALYs and other composite indicators try to give a better estimate
of the true health of a population instead of measuring deaths
alone. This is easy to understand. Contrary to most popular belief,
mental health problems, for example, are associated with an
important number of deaths. However, they may also cause an
enormous amount of disability. Several parasitic infections, such
as schistosomiasis, cause very few deaths but large amounts of
illness and disability. If we measured the health of a population
with an important burden of schistosomiasis and mental illness
only by measuring deaths, we would miss a major component of
morbidity and disability and would seriously overestimate the
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health of that population. The next section elaborates on the
concept of DALYs and how DALYs compare to deaths for a
number of health conditions.
A number of critiques of DALYs have been written. Nonetheless,
this text repeatedly refers to DALYs because this measure is so
extensively used in global health work. In addition, a considerable
amount of important analysis has been carried out that is based on
the use of DALYs for measuring overall health status and
assessing the most cost-effective approaches to dealing with
various health problems.
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▶ Burden of Disease Data
As you start a review of global health, it is important to get a clear
picture of the leading causes of illness, disability, and death in the
world. It is also very important to understand how they vary by
age, sex, ethnicity, and socioeconomic status, both within and
across countries. Additionally, it is essential to understand how
these causes have varied over time and how they might change in
the future. These topics are examined next.
Much of the data that follows on the burden of disease and risk
factors is based on the findings of the Global Burden of Disease
Study 2016, published in The Lancet in September 2017. The
Institute of Health Metrics and Evaluation (IHME) coordinated that
study. Those interested in the study methods may wish to consult
the study directly. This chapter also heavily uses data from
interactive data visualizations that the IHME has posted on its
website. The reader should note that, while some data refer to
“deaths” and some data refer to “DALYs,” references to the
“burden of disease” refer to DALYs.
Wherever possible, data are shown by World Bank region or
World Bank country income group. However, readers should be
aware that the IHME data can be categorized into a range of
regional groupings and by groups that are listed according to their
ranking on a composite “social and economic development index”
developed by the IHME.
Earlier burden of disease studies placed causes of deaths and
DALYs into three categories:
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Group I—Communicable, maternal, and perinatal
conditions (meaning in the first week after birth) and
nutritional disorders
Group II—Noncommunicable diseases
Group III—Injuries, including, among other things,
road traffic accidents, falls, self-inflicted injuries, and
violence
The Global Burden of Disease Study 2016 does not use the
groupings as they had been used earlier. Nonetheless, such
groupings can be valuable to those who are new to the study of
the burden of disease. Thus, they are used occasionally here.
Overview of Patterns and Trends in the
Burden of Disease
Understanding the patterns and trends in the burden of disease is
central to understanding and dealing with key issues in global
health. Some of the main findings of the burden of disease studies
are summarized here :
■ People in much of the world are living longer than before.
■ Globally, women live longer than men by about 5 years on
average.
■ In the last 4 decades, there have been significant declines in
communicable, maternal, neonatal, and nutritional causes of
death.
■ Globally, mortality rates have decreased for all age groups, with
very substantial decreases for children under 5 years of age.
■ Nonetheless, there are substantial differences in the rate of
mortality decrease across countries.
■ The years of life lost due to premature death are increasing for
diabetes, some cancers, and, in some places, for drug use
14-17
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disorders, conflict, and terrorism.
■ The burden of disease is predominantly noncommunicable in
all World Bank regions and for all World Bank country income
groups, except sub-Saharan Africa and low-income countries.
■ Over the last few decades, the burden of disease has shifted
increasingly toward noncommunicable diseases in all World
Bank regions and for all country income groups.
■ This shift has been fueled by, among other things, a reduction
in communicable diseases and the aging of populations.
■ The 10 leading causes of total YLLs in 2016 were ischemic
heart disease, cerebrovascular disease, lower respiratory
infections, diarrheal diseases, road injuries, malaria, neonatal
preterm birth complications, HIV/AIDS, chronic obstructive
pulmonary disease, and neonatal encephalopathy due to birth
asphyxia and trauma.
■ As life expectancies increase, death rates decline, and
populations age, there is an increase in the number of years
people live with disability, and this has increased as a share of
the total burden of disease.
■ Globally, low back pain, migraine, age-related and other
hearing loss, iron-deficiency anemia, and major depressive
disorder were the five leading causes of years lived with
disability in 2016.
■ Globally, the top 10 risk factors for the burden of disease are
high blood pressure, smoking, low birthweight and short
gestation, high fasting plasma glucose, high body mass index,
ambient particulate matter, alcohol use, high total cholesterol,
child growth failure, and household air pollution.
■ There are a number of countries in which life expectancy is
greater than one might predict on the basis of social and
economic development. These countries could provide some
useful lessons for other countries that have not made such
progress in health.
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The Leading Causes of Deaths and DALYs
TABLE 3-2 shows the 10 leading causes of death and the 10
leading causes of DALYs by country income group for 2016. Both
deaths and DALYs are ranked in order of importance.
TABLE 3-2 Leading Causes of Deaths and DALYs, by World
Bank Country Income Group, 2016
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TABLE 3-3 shows the 10 leading causes of deaths and DALYs by
region.
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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TABLE 3-3 Leading Causes of Deaths and DALYs, by World
Bank Region, 2016
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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These tables and figures raise a number of key points concerning
deaths and DALYs for all age groups and males and females
globally:
■ The low-income countries have a unique pattern of deaths and
DALYs, compared to other country income groups, that is still
dominated by Group I causes. While about 61 percent of the
total DALYs were associated with Group I causes in low-
income countries, about 86 percent of total DALYs were
associated with noncommunicable diseases (NCDs) in high-
income countries.
■ The pattern of deaths and DALYs in lower middle-income
countries has some resemblance to that in the low-income
countries but also has similarities with the upper middle-income
and high-income countries. In lower middle-income countries
about 36 percent of total DALYs were associated with Group I
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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causes, compared to 61 percent in low-income countries and
11 percent in upper middle-income countries.
■ There is a great deal of convergence in the causes of deaths
and DALYs in the upper middle-income and high-income
countries, both dominated by noncommunicable causes. About
77 percent of total DALYs were associated with
noncommunicable diseases in upper middle-income countries,
compared with 86 percent in high-income countries.
■ Injuries are important causes of deaths and DALYs. They make
up between 8 percent and 11 percent of total DALYs,
depending on the region.
■ The only Group I cause in the top 10 causes of death in upper
middle-income and high-income countries is lower respiratory
infections. While these are associated mostly with young child
deaths in lower-income countries, they are associated mostly
with deaths in older people in higher-income countries.
■ It is important to note the significance in most of the country
income groups of DALYs attributable to low back and neck
pain, sense organ diseases, skin diseases, and depressive
disorders.
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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PHOTO 3-1 A healthcare worker is pictured here, taking the
blood pressure of a man in a health center in Mexico. Why is
this so important? What risks does high blood pressure pose?
What are some of the most important risk factors for having
hypertension?
Courtesy of Mark Tuschman.
In general, the higher the level of income of the countries in a
region, the more likely it is that the leading causes of deaths and
DALYs will be noncommunicable. The lower the level of income,
the more likely it is that communicable diseases will be important.
What is most essential to note is the extent to which the burden of
disease in the sub-Saharan Africa region remains dominated by
Group I causes and the continuing importance of these causes in
the South Asia region, as well. Of course, these are in the face of
a growing burden, even in these regions, of noncommunicable
diseases.
Trends in the Causes of Deaths and DALYs,
1990–2016
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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TABLE 3-4 indicates changes that have occurred between 1990
and 2016 in the leading causes of deaths and DALYs globally.
TABLE 3-4 Changes in the Leading Causes of Deaths and
DALYs Globally, 1990 and 2016
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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The table indicates the important extent to which the burden of
deaths globally, when considering all age groups and both sexes,
has shifted toward noncommunicable diseases. The trend has
been similar for DALYs, with some significant shifts from
communicable diseases and other Group I causes to
noncommunicable diseases and injuries. In light of longer lives
and aging populations, low back and neck pain and sensory organ
disorders also appear in the list of 10 leading causes of DALYs in
2016, which was not the case in 1990. HIV/AIDS appears in 2016
and not in 1990 because the burden of HIV/AIDS was still
relatively small in 1990.
Causes of Death by Age
TABLE 3-5 shows the leading causes of death for children aged 0
to 5 years by country income group.
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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TABLE 3-5 Leading Causes of Death in Children Under 5 by
World Bank Country Income Group, 2016
The leading causes of deaths of under-5 children in low-income
countries are dominated by communicable diseases—malaria,
diarrhea, and lower respiratory infections. Conditions of the
newborn and protein-energy malnutrition are also among the 10
leading causes of death of this age group in low-income countries.
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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The leading causes of death among children under 5 years of age
in lower middle-income countries does not differ significantly from
the causes in low-income countries. As we move to upper middle-
income countries, we see causes outside of Group I, including
road injuries and drowning. The leading causes of death in high-
income countries include congenital defects and neonatal
conditions, as in the other country income groups. They also
include lower respiratory conditions, which is an important cause
of death for young children in all country income groups. However,
in the high-income countries, 4 of the 10 leading causes of death
in this age group are different from the leading causes in the other
country income groups: sudden infant death syndrome, road
injuries, endocrine and blood disorders, and mechanical forces.
TABLE 3-6 shows the leading causes of death for children ages 5
to 14 by country income group.
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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TABLE 3-6 Leading Causes of Death in Children Ages 5–14 by
World Bank Country Income Group, 2016
It is striking how the leading causes of death of children ages 5 to
14 in low- and lower middle-income countries are dominated by
preventable or treatable communicable diseases, such as malaria,
HIV/AIDS, lower respiratory diseases, and tuberculosis. Nutritional
issues are also prominent in the lowest-income countries, and
road traffic injuries and drowning are important causes of death in
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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the low- and lower middle-income countries. In this age group, the
significant shift in the causes of death occurs as one moves to
upper middle-income countries and continues across the high-
income countries. In these two country income groups, we see the
importance of road injuries, drowning, violence, and cancers
among the leading causes of death. In the high-income countries
alone, self-harm is also among the 10 leading causes of death in
this age group.
PHOTO 3-2 This picture depicts a group of older Ethiopian
children. What health conditions are likely to be the most
important causes of death for children 8 to 10 years old in
Ethiopia? How would that vary between better-off places and
lower-resource places within Ethiopia?
Courtesy of Mark Tuschman.
TABLE 3-7 examines the leading causes of deaths and DALYs for
the age group 15 to 49, by World Bank country income group.
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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TABLE 3-7 Leading Causes of Deaths and DALYs, Ages 15–49,
by World Bank Country Income Group, 2016
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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A number of key points emerge from Table 3-7. The leading
causes of death in low-income countries are strikingly different
from those in the higher country income groups and still include a
number of communicable diseases beyond lower respiratory
infections, such as HIV/AIDS, tuberculosis, diarrheal disease,
malaria, and meningitis. The leading causes of DALYs in this
country income group, however, also include a number of
conditions that are mostly linked with disability, including low back
and neck pain, skin disease, depressive disorders, and migraines.
The leading cause of death in lower middle-income countries is
ischemic heart disease. However, the leading causes also include
a number of communicable diseases beyond the lower respiratory
infections one would expect, such as HIV/AIDS, tuberculosis, and
diarrheal diseases. The importance of road injuries, self-harm, and
interpersonal violence is also striking for this group. The leading
causes of DALYs in this country income group look quite similar to
those for low-income countries but also include dietary iron
deficiency.
The leading causes of deaths in upper middle-income countries
suggest some important shifts compared to low- and lower middle-
income countries. Like in the lower middle-income countries, the
leading causes of death in this country income group include
HIV/AIDS, interpersonal violence, and self-harm. However, in this
country income group we also see the importance of cancers, as
well as falls. The leading causes of DALYs in this country income
group are similar to those for the lower middle-income country
group.
The leading causes of death in the high-income countries suggest
substantial shifts from the lower-income groups. Self-harm, road
injuries, ischemic heart disease, and stroke are important in this
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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group, as in lower middle-income and upper middle-income
countries. However, we also see here the emergence of breast,
lung, and colorectal cancers, as well as drug use and alcohol use
disorders. The leading causes of DALYs in the high-income
countries do include ischemic heart disease and road injuries, as
one might expect. However, the prominence of several mental
disorders, including depressive disorders and anxiety disorders, as
well as drug use disorders and self-harm, is striking.
Causes of Deaths and DALYs by Sex
It is also important to examine deaths and DALYs by sex, as
shown in TABLE 3-8.
TABLE 3-8 Leading Causes of Deaths and DALYs by Sex, by
World Bank Country Income Group, 2016
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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When considering the leading causes of deaths and DALYs for
females, it is important to remember that much of the global health
literature on females focuses on reproductive health. While this is
an important matter, it is essential to view female health more
broadly. Every maternal death is unacceptable, but the leading
cause of female death globally is ischemic heart disease, with
stroke also being an important cause of death. We can also see
that HIV/AIDS and TB remain important causes of female death in
lower-income countries. As country income levels rise, diabetes,
chronic obstructive pulmonary disease (COPD), a range of
cancers, chronic kidney disease, and Alzheimer’s disease become
increasingly important causes of death.
Because these data are for all age groups, we see a range of
neonatal conditions as important causes of DALYs in the low-
income country group, as well as nutritional issues. However, as
country incomes rise, the leading causes of DALYs cluster
increasingly around a number of noncommunicable causes, plus
depressive disorders.
The leading causes of death among men of all ages do not differ
greatly from the leading causes of death for women of all ages.
However, COPD, road injuries, self-harm, and liver cancers are
more important causes of death for men than for women, as, of
course, is prostate cancer. The causes of DALYs for males of all
ages follow a pattern similar to that for females.
In this case, too, diabetes, COPD, sense organ diseases, and skin
diseases become increasingly important as country income levels
rise. For males, however, road injuries and interpersonal violence
are much more important causes of deaths and DALYs than for
females.
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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PHOTO 3-3 An indigenous woman in Guatemala is shown
here being examined by healthcare workers in a local clinic.
What are the most important burdens of disease for women like
the one shown? What are the most important risk factors for
those burdens? Why is it so important to consider the health of
women broadly and not just focus on their reproductive health?
Courtesy of Mark Tuschman.
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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▶ The Burden of Deaths and Disease Within
Countries
As you consider causes of death and the burden of disease
globally and by country income group, region, age, and sex, it is
also important to consider how deaths and DALYs vary within
countries by gender, ethnicity, and socioeconomic status, among
other things. Generally speaking, the following statements are
true:
■ Rural populations will be less healthy than urban populations.
■ Disadvantaged ethnic minorities will be less healthy than
majority populations.
■ Females will suffer a number of conditions that relate to their
relatively disadvantaged social positions.
■ Lower-income people will be less healthy than better-off
people.
■ Uneducated people will be less healthy than better-educated
people.
In addition, people of lower socioeconomic status will have higher
rates of communicable diseases, illness, and death related to
maternal causes and malnutrition than will people of higher status.
People of lower socioeconomic status will also suffer from a larger
burden of disease related to smoking, alcohol, and poor diet than
would be the case for better-off people. These points are
fundamental to understanding global health.
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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▶ Risk Factors
As we discuss the determinants of health and how health status is
measured, there will be many references to risk factors for
various health conditions. A risk factor is “an aspect or personal
behavior or life-style, an environmental exposure, or an inborn or
inherited characteristic, that, on the basis of epidemiologic
evidence, is known to be associated with health-related
condition(s) considered important to prevent.” Risks that
relate to health can also be thought of as “a probability of an
adverse outcome, or a factor that raises this probability.” We
are all familiar with the notion of risk factors from our own lives and
from encounters with health services. When we answer questions
about our health history, for example, we are essentially helping to
identify the most important risk factors that we face ourselves. Do
our parents suffer from any health conditions that might affect our
own health? Are we eating in a way that is conducive to good
health? Do we get enough exercise and enough sleep? Do we
smoke or drink alcohol excessively? Are there any special
stresses in our life? Do we wear seat belts when we drive?
If we extend the idea of risk factors to people with fewer
resources, especially in low- and lower middle- income countries,
then we might add some other questions that relate more to the
ways that they live. Does the family have safe water to drink? Do
their house and community have appropriate sanitation? Does the
family cook indoors in a way that makes the house smoky? Do the
parents work in places that are safe environmentally? We might
also have to ask if there is war or conflict in the country, because
they are also important risk factors for illness, death, and disability.
If we are to understand how the health status of people can be
enhanced, then it is very important that we understand the risk
18(p51)
19(p7)
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factors to which their health problems relate. TABLE 3-9 shows
the relative importance of different risk factors to deaths and
DALYs for different country income groups. The burden of disease
studies generally refer to these risks in three categories,
behavioral, environmental and occupational, and metabolic, and it
is valuable to keep this in mind as one considers risk factors.
TABLE 3-9 Leading Risk Factors for Deaths and DALYs by World
Bank Country Income Group, 2016
16
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There are two points that stand out as one looks at risk factors by
country income group. First, consistent with the pattern of deaths
and DALYs, the low- income countries continue to face a number
of risks related to Group I causes, such as the lack of safe water
and sanitation, household air pollution, low birthweight, and child
growth failure. Beyond this, however, there is a noteworthy
convergence of key risks for deaths and DALYs across the country
income groups. These risks overwhelmingly relate to high blood
pressure, smoking, ambient particulate matter, and dietary risks
associated with overweight and obesity.
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PHOTO 3-4 The lack of access to safe water remains a major
risk factor for ill health in many low- and lower middle-income
countries. This picture shows a woman in India retrieving water
for household use from an open source. What risks does this
pose to the woman, her family, and her community? What is
likely to be the most cost-effective way of addressing those risks
in the kind of community in which this woman lives?
Courtesy of Mark Tuschman.
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▶ Demography and Health
There are a number of points related to population that are
extremely important to people’s health. These are among the most
important:
■ Population growth
■ Population aging
■ Urbanization
■ The demographic divide
■ The demographic transition
These factors are briefly discussed next, along with their
implications for health. Other important matters related to
population, such as the relationship between fertility and the health
of women and children, are discussed in other chapters.
Population Growth
The population of the world was estimated in August 2018 to be
about 7.6 billion and is still growing. As shown in FIGURE 3-4, it
is estimated that by 2050 the population of the world will be about
9.9 billion.
20
20
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FIGURE 3-4 World Population 1950 to 2100
Modified from United Nations, Department of Economic and Social Affairs, Population
Division. (2017). World population prospects: The 2017 revision, key findings and
advance tables (Working Paper No. ESA/P/WP/248). New York, NY: United Nations.
Retrieved from
https://esa.un.org/unpd/wpp/Publications/Files/WPP2017_KeyFindings
As also shown in Figure 3-4, the overwhelming majority of
population growth in the future will occur in low- and middle-
income countries, especially in sub-Saharan Africa. This reflects
the fact that fertility is falling slowly in many countries that have
had high fertility rates historically, whereas many of the high-
income countries already have very low fertility. In fact, some high-
income countries are below replacement fertility. At a minimum,
we should expect that increasing population growth in low-income
countries will put substantial pressure on the environment, with its
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https://esa.un.org/unpd/wpp/Publications/Files/WPP2017_KeyFindings
attendant risks for health. It will also mean that infrastructure, such
as water supply and sanitation, will have to be provided to an
increasing number of people in the countries that have the largest
service gaps and can least afford to expand such services. This
could cause these countries to face substantial impacts on health
as a result. Increasing population will also make it more difficult for
low-income countries to provide education and health services,
with additional consequences for the health of their people in the
future.
Population Aging
As shown in TABLE 3-10, the population of the world is aging.
TABLE 3-10 Percentage of the Population Over 65 Years of Age,
by WHO Regions and Globally, 2015, 2030, and 2050
This is especially true in high-income countries that have low
fertility, but this is occurring in other countries as well. One impact
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of population aging is that it changes the ratio between the number
of people that are 15 to 64 years of age, compared with the
number that are 65 years of age or older. This is called the elderly
support ratio. In Niger, with high fertility and a growing
population, only 5 percent of the population in 2017 was over 65
years of age. By contrast, in Japan, with very low fertility and a
shrinking population, 28 percent of the population was over 65 in
2017, as shown in Table 3-11.
Population aging and the shift in the elderly support ratio have
profound implications for the burden of disease and for health
expenditures and how they will be financed. In the simplest terms,
people will live longer and experience more years with morbidities
and disabilities, largely related to noncommunicable diseases.
This will raise the costs of health care. In addition, the large
numbers of older adults for every working person will make it
difficult for countries to finance that health care.
21
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PHOTO 3-5 An older woman in India is shown in this photo.
Which countries are aging the fastest? What impact is aging
likely to have on the burden of disease and why?
Courtesy of Mark Tuschman.
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Urbanization
In the last 15 years, the majority of the world’s population has lived
in urban areas for the first time in world history. People are
continuing to move from rural to urban areas, especially in low-
and middle-income countries in which important shares of the
population have continued to live in rural areas until recently.
Continuing urbanization will also put enormous pressure on urban
infrastructure, such as water and sanitation, schools, and health
services, which are already in short supply in many countries.
Gaps in such infrastructure, as well as the development of
crowded and low-standard housing, for example, could have
substantial negative consequences for health.
The Demographic Divide
Despite some convergence, there is an exceptional difference in
the demographic indicators and future demographic paths of the
best-off and the least-well-off countries, as suggested in the two
previous sections. The highest-income countries generally have
very low fertility, declining populations, and aging populations. By
contrast, fertility in the lowest-income countries is generally still
high, although it is declining slowly. In addition, the population is
still growing in these countries and will continue to grow for some
time. There is also an enormous difference in the health
circumstances of the high- and low-income countries. TABLE 3-11
portrays the demographic divide.
TABLE 3-11 The Demographic Divide: The Example of Nigeria
and Japan
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The Demographic Transition
One important demographic trend of importance is called the
demographic transition. Simply put, this is the shift from a
pattern of high fertility and high mortality to low fertility and low
mortality, with population growth occurring in between.
When we look back historically at the countries that are now high-
income, we can see that they had long periods when fertility was
high, mortality was high, and population growth was, therefore,
relatively slow, or might even have declined in the face of
epidemics. Beginning around the turn of the 19th century,
however, mortality in those countries began to decline as hygiene
and nutrition improved and the burden of infectious diseases
lessened. In most cases, this decline in mortality started before
much decline in fertility. As mortality declined, the population
increased and the share of the population of younger ages also
increased. Later, fertility began to decline and, as births and
deaths became more equal, population growth slowed. As births
and deaths stayed more equal, the share of the population that
was of older ages increased. There are now some countries, as
mentioned earlier, in which death rates exceed birth rates and the
population is declining.
There are a number of ways to depict the demographic transition,
one of which is shown in Figure 3-5.
22
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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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FIGURE 3-5 The Demographic Transition
Data from PopulationPyramid.net. (n.d.). Population pyramids of the world from 1950
to 2100. Retrieved from https://www.populationpyramid.net/world/2017/
The first “population pyramid” reflects a country with high fertility
and high mortality, such as the low-income, high-fertility countries
in sub-Saharan Africa. The second population pyramid is
indicative of a country in which mortality has begun to decline but
fertility remains high. This would be similar to the demographics
one would find, for example, in a number of countries in sub-
Saharan Africa that are undergoing demographic transition, or
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https://www.populationpyramid.net/world/2017/
Haiti, as noted. The third pyramid reflects a population in which
fertility has been reduced for a substantial period of time, in which
fertility is continuing to decline, and in which there is a much larger
share of older people in the population than in the first and second
pyramids. This would be similar to the demographics in a number
of low-fertility, aging populations in the upper middle- and high-
income countries. The fourth pyramid illustrates a country, such as
Japan, Russia, or Australia, in which mortality rates are low and
fertility rates are very low and the population shrinks in the
absence of immigration.
The Epidemiologic Transition
The epidemiologic transition is closely related to the
demographic transition, as suggested throughout the previous
discussion. Historically there has been a shift in the patterns of
disease that follows these trends:
■ First, high and fluctuating mortality, related to very poor health
conditions, epidemics, and famine
■ Then, progressive declines in mortality as epidemics become
less frequent
■ Finally, further declines in mortality, increases in life
expectancy, and the predominance of noncommunicable
diseases
FIGURE 3-6 shows the distribution of deaths by groups of causes,
by World Bank country income group. FIGURE 3-7 shows the
distribution of DALYs.
23
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FIGURE 3-6 Distribution of Deaths by Cause Group, for World
Bank Country Income Groups
Data from Institute of Health Metrics and Evaluation (IHME). (n.d.). GBD Compare:
Viz Hub. Retrieved from https://vizhub.healthdata.org/gbd-compare/
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https://vizhub.healthdata.org/gbd-compare/
FIGURE 3-7 Distribution of DALYs by Cause Group, for World
Bank Country Income Groups
Data from Institute of Health Metrics and Evaluation (IHME). (n.d.). GBD Compare:
Viz Hub. Retrieved from https://vizhub.healthdata.org/gbd-compare/
You can see in Figures 3-6 and 3-7 how the pattern of deaths and
DALYs differs between the low-, middle-, and high-income
countries. You can also see the changes that will occur over time,
as the burden of disease in lower-income countries moves from
Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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https://vizhub.healthdata.org/gbd-compare/
one with a substantial share of communicable diseases to one in
which noncommunicable diseases are predominant.
The pace of the epidemiologic transition in different societies
depends on a number of factors related to the determinants of
health that were discussed earlier. In its early stages, the transition
appears to depend primarily on improvements in hygiene,
nutrition, education, and socioeconomic status. Some
improvements also stem from advances in public health and in
medicine, such as the development of new vaccines and
antibiotics.
Most of the countries that are now high-income went through
epidemiologic transitions that were relatively slow, with the
exception of Japan. Most low- and middle-income countries have
already begun their transition; however, it is still far from complete
in many of them.
In fact, most low-income countries are in an ongoing epidemiologic
transition, and many of them, therefore, face significant burdens of
communicable and noncommunicable diseases and injuries at the
same time. This strains the capacity of the health system of many
of these countries. It is also expensive for countries that are
resource-poor to address a substantial burden of all three of these
types of conditions simultaneously.
24
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▶ Progress in Health Status
There has been substantial progress in improving health and
raising life expectancy in all parts of the world. However, those
gains have not been uniform across regions or countries. Rather,
life expectancy in sub-Saharan Africa and South Asia continues to
substantially lag behind that in other regions. In addition, for
countries that had a life expectancy in 1960 of less than 50 years,
the pace of improvements in life expectancy in sub-Saharan Africa
has been much slower than in any other region.
TABLE 3-12 shows life expectancy in 1960, 1990, and 2016 by
World Bank region. The table also shows the percentage gain in
life expectancy over three different periods, 1960 to 2016, 1960 to
1990, and 1990 to 2016.
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TABLE 3-12 Life Expectancy and Percentage Gain in Life
Expectancy, by World Bank Region, 1960-2016
Life expectancy grew over each period in each region; however,
the increases in Europe and Central Asia were small in the period
from 1990 to 2016, largely reflecting the social and economic
consequences of the breakup of the former Soviet Union and the
impact of changes on the health system as well. The slowdown in
progress in improving life expectancy in sub-Saharan Africa
between 1990 and 2016, although still very substantial, mostly
reflects the negative impact on life expectancy of the HIV/AIDS
epidemic, as well as slow economic progress in some countries
and political conflict. The slow increase in life expectancy in the
last period in North America reflects not only the high base from
which it started but also the impact on life expectancy of an
epidemic of substance abuse in the United States. By contrast, the
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dramatic increases in life expectancy from 1960 to 2016 in much
of the low- and middle-income world reflects the rapid pace of
economic development in many low- and middle-income countries,
usually accompanied by improvements in infrastructure, nutrition,
education, and health.
The factors that lead to improvements in health are complex.
Additional comments are made at the end of this chapter about
these factors, including the role, for example, of nutrition,
education, political stability, and scientific improvements. Many
other chapters also include comments on the progress in
improving the health of women and children and in addressing
particular causes of illness, disability, and death.
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▶ The Burden of Disease: Looking Forward
The burden of disease in the future will be influenced by a number
of factors that will continue to change. Some of these will relate to
the determinants of health. Some will relate to the demographic
forces just discussed, including population growth, population
aging, and migration. The burden of disease in the future will also
be driven by, among other things, the following factors:
■ Economic development
■ Scientific and technological change
■ Climate change
■ Political stability
■ Emerging and re-emerging infectious diseases
These are discussed very briefly in the following sections.
Economic Development
The economies of low-income countries will need to grow if those
countries are to generate the income they need to invest in
improving people’s health and well-being. The impact of economic
development on health will depend partly on the extent to which
economic growth is equitable across population groups. It will also
depend on the extent to which countries are able—or choose—to
use their increased income to invest in other areas that improve
health, such as water, sanitation, hygiene, food security, and
education. The extent and appropriateness of their investments in
health, such as in low-cost, high-yielding efforts, will also be
critical.
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Scientific and Technological Change
Scientific and technological change has had an enormous impact
on health and will continue to have an impact in the future. This is
easy to understand, as one considers the development of
vaccines or new drugs, such as antibiotics or antiretroviral therapy.
The development of improved diagnostics for TB, for example,
would have an substantial impact on the health of the world, as
would the development of a vaccine against HIV or malaria. The
impact of scientific and technological change on the low-income
countries of today will depend to a large extent on the pace at
which they are able to effectively adopt any improvements when
they are developed.
Climate Change
The full extent of the impact of climate change on health is not
clear; however, it is anticipated that climate change and its
attendant impact on weather and rising sea levels could directly
and indirectly have an important impact on health. On the indirect
side, climate change could alter the nature of the food crops that
can be grown in different places and food security and lead to
migration from some places to others that are deemed more
habitable. On the more direct side, climate change could lead to
weather changes and adverse weather that harm people’s health.
It could also lead to the disappearance of disease vectors in some
places as the weather is no longer hospitable to them, while
allowing the emergence or re-emergence of disease vectors in
other places.
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Political Stability
In low-income countries, political stability appears to be necessary
for achieving long-term gains in health. There is substantial
evidence, for example, that the lack of political stability was a
major impediment to progress in achieving the Millennium
Development Goals in a number of countries. It is not hard to
imagine, for example, how conflicts that occurred in Liberia, Sierra
Leone, and the Democratic Republic of the Congo could set back
health status for many years. These conflicts led directly to
substantial illness, disability, and death. In addition, by causing a
breakdown in infrastructure, such as water, sanitation, and
electricity, as well as the erosion of health services, they also had
enormous indirect impacts on health.
Emerging and Re-emerging Infectious
Diseases
It is not possible to predict if and when new diseases will emerge
or diseases already known will re-emerge. It is also not possible to
know how well individual countries and the world will do in
recognizing such problems as they arise and addressing them
quickly and effectively. What is clear is that pandemic flu, for
example, could have a major impact on future disease patterns. It
is also clear, for example, that if the growth of drug resistance for,
say, malaria, outpaced our ability to produce safe and effective
drugs to fight malaria, this, too, could have a substantial impact on
the burden of disease.
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▶ The Development Challenge of Improving
Health
One of the key development challenges facing policymakers in
low-income countries is how they can speed the demographic and
epidemiologic transitions at the lowest possible cost. How can
Niger, for example, improve its health status as rapidly as
possible, at the least possible cost, and in the fairest ways? Will it
be possible for the people of Niger to enjoy the health status of a
middle-income country, even if Niger remains a low-income
country?
FIGURE 3-8 shows national income of a sample of countries,
plotted against life expectancy at birth for females in those
countries. From this figure, one can see that, generally, the health
of a country does increase as national income rises. However, one
can also see that there are some countries, such as Bangladesh,
Jordan, Peru, China, and Malaysia, that have achieved higher
average life expectancies at birth for females than one would have
predicted for countries at their level of income. At the same time,
one has to ask why a country like Pakistan, with a similar per
capita national income to Bangladesh and Cambodia, has lower
female life expectancy than those countries have.
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FIGURE 3-8 Gross Domestic Product per Capita and Female
Life Expectancy at Birth, Selected Countries
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Data from The World Bank. (n.d.). Life expectancy at birth, female (years) and GDP
per capita (current US$). Retrieved from https://data.worldbank.org/
To a large extent, countries that have done better than one might
expect in increasing life expectancy at birth for females (and
males) achieved their health gains as a result of the following:
■ Investing effectively and efficiently in areas that address key
risk factors and determinants of health, including water,
sanitation and hygiene, nutrition, and education
■ Investing effectively and efficiently in relatively low-cost but
high-impact health services, such as vaccination and the
control of communicable diseases
■ Taking a community-based approach to primary health care
Indeed, in the long run, economic progress will help to bring down
fertility, reduce mortality from communicable diseases, and help to
produce a healthier population. However, at the present rates of
progress in improving health in most low-income countries, these
changes will take a very long time to occur. One considerable
public policy challenge for these countries and their governments,
therefore, is how they can short-circuit this process and reach
reduced levels of fertility, lower mortality, and better health for their
people, even as they remain relatively low-income.
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https://data.worldbank.org/
▶ Case Study
One case study follows. It deals with an effort, called the Million
Death Study, to gather valid data on deaths in India at a
sustainable cost and in ways that are replicable.
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The Aims of the Million Death Study
The Centre for Global Health Research, at the University of
Toronto, Canada, is carrying out the Million Deaths Study in India
in conjunction with the Registrar General of India. This study is
one of the largest research efforts ever undertaken on the causes
of premature mortality. Led by Professor Prabhat Jha, the study
aims to help India improve the documentation of the underlying
causes and risk factors of mortality as a basis for enhancing
investments in health, reducing premature death, and improving
the health of India’s people.
Vital statistics, such as fertility and mortality data, are crucial for
identifying major health issues, identifying new health problems as
they arise, making cost-effective public health investments, and
evaluating the progress of public health interventions. Yet reliable
mortality statistics are rare. As much as 75 percent of global
deaths occur in low- and middle-income countries, and the
majority of these lack medical supervision and official certification
of cause of death. In India, for example, 70 percent of deaths go
unreported or misclassified. Previous mortality estimates for
India were largely based on data from the limited spectrum of
deaths that occur in hospitals and were consequently biased
toward causes of death that affect urban populations more than
rural populations. They were also biased toward conditions that
are more urgent and lead to hospitalization, rather than taking
sufficient account of chronic health problems. Moreover, in India
and in many other middle- and low-income countries, there is a
general dearth of knowledge around the causes of death,
especially for middle-aged adults, and the corresponding risk
factors leading to premature death.
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The Study Approach
The Million Death Study seeks to assess the causes of death of 1
million people in India through monitoring 2.4 million households
over two time periods: 1998 to 2003 and 2004 to 2014. The study
is based on an approach called “verbal autopsy.” The study uses
India’s Sample Registration System as its sampling framework.
Twice a year, trained surveyors conduct surveys in order to identify
households in which a death occurred. They then interview
household members about the deaths in their families and record
information on the events leading to death and the symptoms of
the deceased. The verbal autopsies are sent to two independent
physicians to be analyzed and ascertain the underlying cause of
those deaths. By early 2015, 600,000 deaths had been surveyed
and 400,000 deaths had been fully coded.
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Key Findings to Date
The study thus far has exposed some mortality estimates and
trends that deviate from those previously recognized. First, the
study has suggested that the top four causes of death in India are
cardiovascular disease, chronic respiratory disease, TB, and
cancer. Second, one of the most striking findings is related to the
effects of tobacco. The average Indian smoker starts smoking later
in life than in many other countries and often smokes hand-rolled
locally manufactured cigarettes called bidis, which have a lower
concentration of cancer-causing agents than commercially
manufactured cigarettes. Nonetheless, this study showed that in
India, smoking is as much a risk factor for premature death as in
Europe and the United States. Moreover, study findings suggest
that smoking is a risk factor for TB in India and that 40 percent of
all TB deaths in middle-aged men in India can be attributed to
smoking. Third, the study suggests that some estimates of the
burden of disease might be quite different from what was
previously thought and that the burden of disease pattern varies
greatly across the country. This study, for example, estimates that
total malaria deaths are 10 times greater than the World Health
Organization estimates, with over half of malaria deaths occurring
in people ages 15 to 69 and the state of Odisha accounting for a
quarter of India’s annual malaria deaths. On the other hand, the
study suggests that mortality associated with HIV-related
infections is lower than UNAIDS estimates, although the rural
areas around Mumbai have a particularly high concentration of
HIV-related deaths, with an annual death rate of 56 per
100,000. The study has also led to revised estimates of the
number of girls who are “missing” due to sex-selective abortion
and suggested that most suicides are among young adults, rather
than among adult farmers, as had previously been thought.
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Lessons of Experience
The Million Death Study may offer a model for improving mortality
information that is reliable, high impact, low cost, and replicable in
other countries. The ideal system to measure mortality would
depend on a well-functioning system of vital registration. However,
in the absence of such comprehensive registration programs, this
study suggests that verbal autopsies can reduce inaccurate data
by correctly classifying the underlying causes of 90 percent of the
deaths occurring before age 70, an order of magnitude better than
the limited cause of death data previously available. This can
help derive the probable cause of death when one has not been
reported and help us to understand the leading causes of death.
Importantly, this approach has also been shown to be cost-
effective. India added recording the causes of death and risk
factors to a low-cost, preexisting sample registration system, at a
cost of less than $2 per household.
The long-term goal will always be universal civil registration of
deaths with medical certification in order to minimize
misclassification and misrepresentation. However, approaches
such as those applied in the Million Death Study offer an interim
solution for better statistics on mortality for many low- and middle-
income countries.
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▶ Main Messages
To understand and address the most important global health
issues, we must understand the burden of disease, the risk factors
for that burden, and how those vary among different population
groups. Over the last several decades, the global burden of
disease studies have provided the most comprehensive
information on these matters.
These studies have also developed an important metric for
assessing the burden of disease, the DALY. The DALY goes
beyond measuring only deaths to provide an understanding of the
amount of healthy life years lost due to both premature death and
to years lived with disability. It is easy to understand the
importance of the DALY when we consider causes of ill health that
do not necessarily lead to death but that can lead to many years of
disability, such as depressive disorders, musculoskeletal
disorders, and the neglected tropical diseases.
The leading cause of death worldwide for both sexes and all age
groups is ischemic heart disease, followed by stroke. All of the
other 10 leading causes of death globally, except lower respiratory
infections, HIV/AIDS, and TB, are noncommunicable diseases.
The leading cause of DALYs for both sexes and all age groups
globally is also ischemic heart disease when looking at both sexes
combined and all age groups combined. However, the 10 leading
causes of DALYs also include several diseases that especially
affect large numbers of children in lower-income countries, such
as diarrhea and malaria. The leading causes of DALYs also
include road traffic injuries and low back pain.
The burden of disease is predominantly noncommunicable in all
regions of the world except sub-Saharan Africa, and South Asia
also continues to have a substantial burden of communicable
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disease. Over the last several decades, the burden of disease
within regions and globally has continued to shift more and more
toward a pattern dominated by noncommunicable diseases.
Barring major outbreaks of communicable disease, this trend will
continue, especially in the face of populations that are aging. This
movement from a pattern of disease that is largely communicable
to one that is largely noncommunicable is called the epidemiologic
transition.
It is also important to understand the most important risk factors
that are associated with deaths and DALYs. In the low-income
countries, some of the most important risk factors include a range
of nutritional issues, the lack of safe water or safe sanitation,
indoor and ambient particulate matter pollution, and tobacco
smoking. Poor diets that relate to obesity, high blood pressure,
high cholesterol, and cardiovascular disease are becoming
increasingly important problems as well, even in low-income
countries. In the higher-income countries, the key risk factors for
deaths and DALYs are overwhelmingly behavioral and have to do
with what people eat, their levels of physical activity, and if they
smoke tobacco, engage in excessive alcohol use, and drive safely.
Ambient particulate matter pollution is also an important risk factor
in the higher-income countries.
An understanding of basic demographic trends is also very helpful
to understanding and addressing key global health issues. The
three demographic trends that will have the most important
impacts on health are the continuing increase in the global
population, almost all from increases in low- and lower middle-
income countries; the universal aging of populations; and the
increasing urbanization of the world. Another fundamental concept
that it is important to understand is the demographic transition.
This refers to the movement over time from a pattern of high
mortality and high fertility to one of low mortality and low fertility.
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Study Questions
1. If you could pick only one indicator to describe the health
status of a low-income country, which indicator would you
use and why?
2. Why is it valuable to have composite indicators like the
DALY to measure the burden of disease?
3. As countries develop economically, what are the most
important changes that occur in their burden of disease?
4. Why do these changes occur?
5. How might the burden of disease differ from one region to
another in a large and diverse country such as India or
Nigeria?
6. How do we expect the burden of disease to evolve globally
over the next 20 to 30 years?
7. What is the epidemiologic transition?
8. What is the demographic transition?
9. What are the leading causes of death of young children in
low-income countries?
10. What are the leading causes of death in high-income
countries, and how are they similar to and different from
the causes in low-income countries?
References
1. Worldometers. (n.d.). Bangladesh population. Retrieved from
http://www.worldometers.info/world-
population/bangladesh-population/
2. Preamble to the Constitution of the World Health Organization
as adopted by the International Health Conference, New
York, 19–22 June, 1946; signed on 22 July 1946 by the
representatives of 61 States (Official Records of the World
Health Organization, no. 2, p. 100) and entered into force on
7 April 1948.
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http://www.worldometers.info/world-population/bangladesh-population/
3. Merson, M. H., Black, R. E., & Mills, A. J. (2000). International
public health: Diseases, programs, systems, and policies.
Gaithersburg, MD: Aspen.
4. Institute of Health Metrics and Evaluation (IHME). (n.d.).
Frequently asked questions. What is HALE? Retrieved from
http://www.healthdata.org/gbd/faq#What%20is%20HALE?
5. Institute for Health Metrics and Evaluation (IHME). (2013).
The global burden of disease: Generating evidence, guiding
policy. Seattle, WA: Author. Retrieved from
http://www.healthdata.org/sites/default/files/files/policy_report/2013/GBD_GeneratingEvidence/IHME_GBD_GeneratingEvidence_FullReport
6. World Health Organization (WHO). (n.d.). Health status
statistics: Mortality. Healthy life expectancy (HALE). Retrieved
from http://www.who.int/healthinfo/statistics/indhale/en/
7. Institute of Health Metrics and Evaluation (IHME). (n.d.).
Global Burden of Disease Study 2016 (GBD 2016) data
resources: GBD 2016 reference life table. Retrieved from
http://ghdx.healthdata.org/gbd-2016
8. Salomon, J. A, Haagsma, J. A., Davis, A., de Noordhout, C.
M., Polinder, S., Havelaar, A. H., . . . Vos, T. (2015). Disability
weights for the Global Burden of Disease 2013 study. Lancet
Global Health, 3(11), e712–e723.
9. GBD 2016 Disease and Injury Incidence and Prevalence
Collaborators. (2017). Global, regional, and national
incidence, prevalence, and years lived with disability for 328
diseases and injuries for195 countries, 1990–2016: A
systematic analysis for the Global Burden of Disease Study
2016. The Lancet 390(10100):1227.
10. Voigt, K., & King, N. B. (2014). Disability weights in the global
burden of disease 2010 study: two steps forward, one step
back? Bulletin of the World Health Organization 92: 226–228.
11. GBD 2016 Collaborators. (2017). The Global Burden of
Disease Study 2016. The Lancet 390(10100):1083–1464.
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Skolnik, Richard. Global Health 101, Jones & Bartlett Learning, LLC, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/indianatech-ebooks/detail.action?docID=5894023.
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