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than a quarter of the total disease burden. In contrast, in
Latin America and the Caribbean, these diseases accounted
for 8% of disease burden. However, this region also had high
levels of diabetes and endocrine disorders compared with
other regions. Violence was the third leading cause of burden
in Latin America and Caribbean countries, but did not reach
the top 10 in any other region.
HIV/AIDS was the leading cause of burden of disease in
sub-Saharan Africa, followed by malaria. Seven other Group
I causes also appear in the top 10 causes for this region, with
road traffic accidents being the only non-Group I cause.
Group I, II, and III causes all appear among the top 10
causes of the disease burden for the Middle East and North
Africa. Of particular note, road traffic accidents were the third
leading cause and congenital anomalies were the seventh
leading cause.
Group I causes of disease burden remained dominant in
South Asia, and this burden fell particularly on children, but
noncommunicable diseases such as IHD, stroke, and chronic
obstructive pulmonary disease also featured in the list of top
10 causes.
In East Asia and the Pacific, stroke was the leading cause
of disease burden in 2001, with IHD in fourth place,
although Group I causes such as conditions arising during
the perinatal period, TB, lower respiratory infections, and
diarrhoeal diseases remained important.
Conclusions
The analysis presented has confirmed some of the
conclusions of the original GBD study about the importance
of including nonfatal outcomes in a comprehensive
assessment of global population health, and has also
confirmed the growing importance of noncommunicable
diseases in low- and middle-income countries. However, it
has also documented some dramatic changes in population
health in some regions since 1990. The key findings include
the following:
✜ HIV/AIDS is now the fourth leading cause of the burden
of disease globally and the leading cause in sub-Saharan
Africa.
✜ In low- and middle-income countries, the
epidemiological transition has resulted in a 20%
reduction in the per capita disease burden due to Group
I causes since 1990. Without the HIV/AIDS epidemic,
this reduction would have been closer to 30%. Several
of the “traditional” infectious diseases, such as TB and
malaria, have not declined, in part because of weak
public health services and the increased numbers of
people with immune systems weakened by HIV/AIDS.
✜ The per capita disease burden in Europe and Central
Asia increased by nearly 40% during 1990–2001,
meaning that this region now has worse health than all
other regions except South Asia and sub-Saharan Africa.
The unexpected increase in the disease burden, and the
concomitant reduction in life expectancy, in countries of
this region appear to be related to such factors as
alcohol abuse, suicide, and violence, which seem to be
associated with societies facing social and economic
disintegration. The rapidity of these declines has
dramatically changed our perceptions of the time frames
within which substantial changes in the burden of
chronic disease can occur and of the potential for such
adverse health trends to occur elsewhere.
✜ Adults under the age of 70 in low- and middle-income
countries face a substantially greater risk of death from
noncommunicable diseases than adults of the same age
in high-income countries.
✜ In Europe and Central Asia, Latin America and the
Caribbean, and the Middle East and North Africa, more
than 30% of the entire disease burden among male
adults age 15 to 44 is attributable to injuries, including
road traffic accidents, violence, and self-inflicted injuries.
In addition, injury deaths are noticeably higher for
women in some parts of Asia and the Middle East and
North Africa than in other regions, partly because of
high levels of suicide and violence. Combined with
higher rates of infant and child mortality for girls, this
results in a narrower differential between male and
female healthy life expectancy than in any other region. ❏
Alan Lopez is Professor of Medical Statistics and Population
Health and Head of the School of Population Health at the
University of Queensland. Prior to joining the University in January
2003, he worked at the World Health Organization (WHO) in
Geneva, Switzerland, for 22 years where he held a series of
technical and senior managerial posts including Chief
Epidemiologist in WHO’s Tobacco Control Program (1992–95),
Manager of WHO’s Program on Substance Abuse (1996–98),
Director of the Epidemiology and Burden of Disease Unit
(1999–2001), and Senior Science Advisor to the Director-General
(2002).
Colin Mathers is Coordinator of the Country Health Information
team in the Evidence and Information for Policy Cluster at the
World Health Organization (WHO) in Geneva, Switzerland. He is
responsible for WHO reassessments of the global burden of
disease, and in the development of software tools to support
burden of disease analysis at country level.
174 ✜ Global Forum Update on Research for Health Volume 4