Decision-makingGlobal <strong>and</strong> regional mortality in 2001Slightly more than 56 million people died in 2001, 10.5million, or nearly 20%, of whom were children younger thanfive. Of <strong>the</strong>se child deaths, 99% occurred in low- <strong>and</strong> middleincomecountries. Those age 70 <strong>and</strong> over accounted for 70%of deaths in high-income countries, compared with 30% ino<strong>the</strong>r countries. Thus a key point is <strong>the</strong> comparatively largenumber of deaths among <strong>the</strong> young <strong>and</strong> <strong>the</strong> middle-aged inlow- <strong>and</strong> middle-income countries. In <strong>the</strong>se countries, 30% ofall deaths occur at ages 15 <strong>to</strong> 59, compared with 15% inhigh-income countries. The causes of death at <strong>the</strong>se ages, aswell as in childhood, are thus important in assessing public<strong>health</strong> priorities.Trends in mortality levelsThe 1990s were characterized by significant economic gainsin most regions, with growth in gross national product percapita ranging from 18% in South Asia <strong>and</strong> sub-SaharanAfrica <strong>to</strong> more than 100% in East Asia <strong>and</strong> <strong>the</strong> Pacific <strong>and</strong><strong>the</strong> Middle East <strong>and</strong> North Africa. Overall, gross nationalproduct per capita grew by about 33% in low- <strong>and</strong> middleincomecountries during <strong>the</strong> decade. One would expect this<strong>to</strong> have led <strong>to</strong> a significant improvement in life expectancy,<strong>and</strong> this indeed occurred in most regions with <strong>the</strong> notableexception of Europe <strong>and</strong> Central Asia <strong>and</strong>, in particular, sub-Saharan Africa (Table 1a <strong>and</strong> 1b). In <strong>the</strong> former region, lifeexpectancy was largely unchanged at around 72.5 years over<strong>the</strong> decade, primarily because of <strong>the</strong> massive rise in adultmortality in countries such as Russia <strong>and</strong> its neighboursduring <strong>the</strong> first part of <strong>the</strong> decade, which negated <strong>the</strong> declinesin child mortality. Much of this extraordinary increase in adultmortality, which rose by about 50% between 1987 <strong>and</strong>1994, has been attributed <strong>to</strong> alcohol abuse, particularlyamong men (Leon et al. 1997).Economic development <strong>and</strong> better coverage of <strong>the</strong>population with essential child <strong>health</strong> services have ensuredcontinued declines in levels of child mortality, as measured by<strong>the</strong> risk of death from birth <strong>to</strong> age five, in all regions. Thenotable exception is sub-Saharan Africa, where childmortality among girls remained unchanged at around 165per 1000, with only a modest decline (5%) in <strong>the</strong> risk ofdeath for boys. The absence of significant declines in childmortality in <strong>the</strong> 1990s in sub-Saharan Africa is most likelylargely due <strong>to</strong> <strong>the</strong> impact of HIV/AIDS. Overall, <strong>the</strong> risk ofchild death declined from 90 per 1000 in 1990 <strong>to</strong> 80 per1000 in 2001, with <strong>the</strong> risk being remarkably similar formales <strong>and</strong> females (Table 1a <strong>and</strong> 1b); however, <strong>the</strong> differentialin child mortality between <strong>the</strong> world’s richest <strong>and</strong> poorestpopulations is stark, with a newborn in sub-Saharan Africafacing 25 times <strong>the</strong> risk of death before <strong>the</strong> age of five than anewborn in a high-income country.Despite <strong>the</strong> much greater uncertainty in relation <strong>to</strong> levels ofadult mortality compared with those for children, <strong>the</strong>estimates shown in Table 1a <strong>and</strong> 1b none<strong>the</strong>less indicatesubstantially different trends in adult mortality across differentregions between 1990 <strong>and</strong> 2001. For most regions, <strong>the</strong> riskof death between ages 15 <strong>and</strong> 60 fell by about 10 <strong>to</strong> 17%over <strong>the</strong> decade. This was not <strong>the</strong> case in Europe <strong>and</strong> CentralAsia, where policy shifts, particularly in relation <strong>to</strong> alcohol,<strong>to</strong>ge<strong>the</strong>r with broader <strong>social</strong> change, have largely beenresponsible for <strong>the</strong> 15% rise in adult male mortality <strong>and</strong> <strong>the</strong>6% increase in <strong>the</strong> risk of death for women. Note that <strong>the</strong>seestimates mask <strong>the</strong> large cyclical fluctuations in adultmortality in Russia, in particular, that characterized <strong>the</strong>region’s mortality trends in <strong>the</strong> 1990s.Table 1 also reveals <strong>the</strong> large increase in adult mortality insub-Saharan Africa, which was due primarily <strong>to</strong> <strong>the</strong> unfoldingof <strong>the</strong> HIV/AIDS epidemic in sou<strong>the</strong>rn Africa. Notwithst<strong>and</strong>ing<strong>the</strong> substantial uncertainty surrounding <strong>the</strong>se estimates, <strong>the</strong>epidemic appears <strong>to</strong> have been of proportionately greaterconsequence for women, with <strong>the</strong> rise in <strong>the</strong>ir risk of death(67%) being twice that of males, among whom o<strong>the</strong>r causesof death such as violence were more common. If <strong>the</strong>seestimates are correct, <strong>the</strong>n 52% of African males <strong>reach</strong>ingage 15 <strong>and</strong> 44% of females will die before <strong>the</strong>ir 60thbirthdays, compared with, for instance, 6.5% of women inhigh-income countries, who despite <strong>the</strong>ir already low riskenjoyed a fur<strong>the</strong>r 11% decline in mortality during <strong>the</strong> 1990s.These reversals in mortality decline have effectively negatedgains elsewhere, with <strong>the</strong> results that <strong>the</strong> global risk of adultdeath has remained essentially unchanged for males, <strong>and</strong>may even have risen slightly for females.Taken <strong>to</strong>ge<strong>the</strong>r, <strong>the</strong> probability of death up <strong>to</strong> <strong>the</strong> age of five<strong>and</strong> between <strong>the</strong> ages of 15 <strong>and</strong> 60 are a better reflection of<strong>the</strong> risk of premature death than ei<strong>the</strong>r alone, although bothhave particular public <strong>health</strong> implications. Some argue that<strong>health</strong> policy should be equally concerned with keepingadults alive in<strong>to</strong> old age as it is with keeping children alivein<strong>to</strong> adulthood. A convenient metric <strong>to</strong> measure this is <strong>the</strong> riskof death between birth <strong>and</strong> age 60 (Table 1a <strong>and</strong> 1b). Inhigh-income countries, given 2001 mortality rates, onlyabout 7% of females <strong>and</strong> 13% of males would be dead byage 60, compared with 55 <strong>to</strong> 62% in sub-Saharan Africa.Significant improvements in this summary measure ofpremature death can be observed in all regions except Europe<strong>and</strong> Central Asia <strong>and</strong> sub-Saharan Africa. Worldwide, <strong>the</strong>index appears <strong>to</strong> have changed slightly for males <strong>and</strong> not atall for females.O<strong>the</strong>r features of global mortality summarized in Table 1a<strong>and</strong> 1b are worth highlighting. First is <strong>the</strong> impressiveevidence of a continued decline in mortality among older agegroups in high-income countries that began in <strong>the</strong> early1970s. The risk of a 60-year-old dying before age 80declined by about 15% for both men <strong>and</strong> women in highincomecountries so that at 2001 rates, fewer than 33% ofwomen who <strong>reach</strong> age 60 will be dead by age 80, as will lessthan 50% of men. Second, crude death rates in East Asia <strong>and</strong><strong>the</strong> Pacific, Latin America <strong>and</strong> <strong>the</strong> Caribbean, <strong>and</strong> <strong>the</strong> MiddleEast <strong>and</strong> North African region are lower than in high-incomecountries, reflecting <strong>the</strong> impact of <strong>the</strong> older age structure ofrich countries, <strong>and</strong> are particularly low in Latin America <strong>and</strong><strong>the</strong> Caribbean. Third, <strong>the</strong> proportion of deaths that occurbelow age five, while declining in all regions, variesenormously across <strong>the</strong>m, from just over 1% in high-incomecountries <strong>to</strong> 44% in sub-Saharan Africa. In some low- <strong>and</strong>middle-income regions, particularly East Asia <strong>and</strong> <strong>the</strong> Pacific,166 ✜ Global Forum Update on Research for Health Volume 4
Decision-makingGroup IGroup IIGroup III6%7%Group IGroup IIGroup III36%54%87%10%Low- <strong>and</strong> middle-income countriesHigh-income countriesFigure 1: Deaths by broad cause group, 2001 Source: Ma<strong>the</strong>rs et al. 2006Europe <strong>and</strong> Central Asia, <strong>and</strong> Latin America <strong>and</strong> <strong>the</strong>Caribbean, <strong>the</strong> proportion is well below 20%. The net effec<strong>to</strong>f <strong>the</strong>se changes in age-specific mortality since 1990 hasbeen <strong>to</strong> increase global life expectancy at birth by 0.7 yearsfor females <strong>and</strong> by about twice this for males: a modestscorecard.Distribution of deaths by major cause groupWorldwide, one death in every three is from a Group I cause.This proportion remains almost unchanged from 1990 withone big difference: whereas HIV/AIDS accounted for only 2%of Group I deaths in 1990, it accounted for 14% of Group Ideaths in 2001. Excluding HIV/AIDS, Group I deaths fell from33% of <strong>to</strong>tal deaths in 1990 <strong>to</strong> less than 20% in 2001.Virtually all of <strong>the</strong> Group I deaths are in low- <strong>and</strong> middleincomecountries. Just under 10% are from Group III causes(injuries) <strong>and</strong> almost 60% of deaths are from Group II causes(noncommunicable diseases). Figure 1 shows <strong>the</strong>proportional distribution of <strong>the</strong>se major cause groups for low<strong>and</strong>middle-income countries <strong>and</strong> high-income countries.Group I causes remain <strong>the</strong> leading cause of child deaths inall regions, although <strong>the</strong>y are now responsible for fewer childdeaths than Group II <strong>and</strong> Group III combined in high-incomecountries (Figure 2). In contrast, Group II causes are nowresponsible for more than 50% of deaths in adults age 15 <strong>to</strong>59 in all regions except South Asia <strong>and</strong> sub-Saharan Africa,where Group I causes, including HIV/AIDS, remainresponsible for 33 <strong>and</strong> 67% of deaths, respectively. Foradults age 15 <strong>to</strong> 59, death rates from Group II causes arehigher for all low- <strong>and</strong> middle-income regions than for highincomecountries, <strong>and</strong> in Europe <strong>and</strong> Central Asia are almostdouble <strong>the</strong> rate for <strong>the</strong> high-income countries. These resultsshow that premature mortality from noncommunicablediseases is higher in populations with high mortality <strong>and</strong> lowincomes than in <strong>the</strong> high-income countries.Leading causes of deathTable 2 shows <strong>the</strong> <strong>to</strong>p 10 disease <strong>and</strong> injury causes of deathin 2001 for low- <strong>and</strong> middle-income countries <strong>and</strong> for highincomecountries. Ischaemic Heart Disease (IHD) <strong>and</strong>cerebrovascular disease (stroke) were <strong>the</strong> leading causes ofdeath in both groups of countries in 2001, responsible for 12million deaths globally, or almost one quarter of <strong>the</strong> global<strong>to</strong>tal. Only 1.4 million of <strong>the</strong> 7.1 million who died of IHDwere in <strong>the</strong> high-income countries. Stroke killed 5.4 million,of whom less than 1.0 million were in high-income countries.Whereas lung cancer, predominantly due <strong>to</strong> <strong>to</strong>baccosmoking, remains <strong>the</strong> third leading cause of death in highincomecountries reflecting high levels of smoking in previousyears, <strong>the</strong> increasing prevalence of smoking in low- <strong>and</strong>middle-income countries has not yet driven lung cancer in<strong>to</strong><strong>the</strong> <strong>to</strong>p 10 causes of death for <strong>the</strong>se countries. HIV/AIDS is<strong>the</strong> fourth leading cause of death in low- <strong>and</strong> middle-incomecountries, <strong>and</strong> HIV/AIDS death rates are projected <strong>to</strong> continue<strong>to</strong> rise, albeit at a slower pace, despite recent increasedefforts <strong>to</strong> improve access <strong>to</strong> antiretroviral drugs.Lower respira<strong>to</strong>ry infections, conditions arising during <strong>the</strong>perinatal period, <strong>and</strong> diarrhoeal diseases remain among <strong>the</strong><strong>to</strong>p 10 causes of death in low- <strong>and</strong> middle-income countries.In 2001, <strong>the</strong>se three causes of death <strong>to</strong>ge<strong>the</strong>r accounted fornearly 60% of child deaths globally.Table 3 shows <strong>the</strong> 10 leading causes of death in low- <strong>and</strong>middle-income countries by sex in 2001. Leading causes ofdeath are generally similar for males <strong>and</strong> females, althoughroad traffic accidents appear in <strong>the</strong> <strong>to</strong>p 10 only for males <strong>and</strong>diabetes appears only for females.Leading causes of death in childrenInfectious <strong>and</strong> parasitic diseases remain <strong>the</strong> major killers ofchildren in <strong>the</strong> developing world. Although notable successhas been achieved in certain areas, for example, polio,communicable diseases still account for 7 out of <strong>the</strong> <strong>to</strong>p 10causes <strong>and</strong> are responsible for about 60% of all child deaths.Overall, <strong>the</strong> 10 leading causes in low- <strong>and</strong> middle-incomecountries represent 80% of all child deaths in thosecountries, <strong>and</strong> also worldwide (Table 4).Many Latin American <strong>and</strong> some Asian <strong>and</strong> Middle Easterncountries have shifted somewhat <strong>to</strong>wards <strong>the</strong> cause of deathpattern observed in developed countries. In <strong>the</strong>se countries,conditions arising during <strong>the</strong> perinatal period, including birthasphyxia, birth trauma, <strong>and</strong> low birth weight, have replacedinfectious diseases as <strong>the</strong> leading cause of death <strong>and</strong> are nowGlobal Forum Update on Research for Health Volume 4 ✜ 167