Combining health and social protection measures to reach the ultra ...

Decision-makingthan a quarter of the total disease burden. In contrast, inLatin America and the Caribbean, these diseases accountedfor 8% of disease burden. However, this region also had highlevels of diabetes and endocrine disorders compared withother regions. Violence was the third leading cause of burdenin Latin America and Caribbean countries, but did not reachthe top 10 in any other region.HIV/AIDS was the leading cause of burden of disease insub-Saharan Africa, followed by malaria. Seven other GroupI causes also appear in the top 10 causes for this region, withroad traffic accidents being the only non-Group I cause.Group I, II, and III causes all appear among the top 10causes of the disease burden for the Middle East and NorthAfrica. Of particular note, road traffic accidents were the thirdleading cause and congenital anomalies were the seventhleading cause.Group I causes of disease burden remained dominant inSouth Asia, and this burden fell particularly on children, butnoncommunicable diseases such as IHD, stroke, and chronicobstructive pulmonary disease also featured in the list of top10 causes.In East Asia and the Pacific, stroke was the leading causeof disease burden in 2001, with IHD in fourth place,although Group I causes such as conditions arising duringthe perinatal period, TB, lower respiratory infections, anddiarrhoeal diseases remained important.ConclusionsThe analysis presented has confirmed some of theconclusions of the original GBD study about the importanceof including nonfatal outcomes in a comprehensiveassessment of global population health, and has alsoconfirmed the growing importance of noncommunicablediseases in low- and middle-income countries. However, ithas also documented some dramatic changes in populationhealth in some regions since 1990. The key findings includethe following:✜ HIV/AIDS is now the fourth leading cause of the burdenof disease globally and the leading cause in sub-SaharanAfrica.✜ In low- and middle-income countries, theepidemiological transition has resulted in a 20%reduction in the per capita disease burden due to GroupI causes since 1990. Without the HIV/AIDS epidemic,this reduction would have been closer to 30%. Severalof the “traditional” infectious diseases, such as TB andmalaria, have not declined, in part because of weakpublic health services and the increased numbers ofpeople with immune systems weakened by HIV/AIDS.✜ The per capita disease burden in Europe and CentralAsia increased by nearly 40% during 1990–2001,meaning that this region now has worse health than allother regions except South Asia and sub-Saharan Africa.The unexpected increase in the disease burden, and theconcomitant reduction in life expectancy, in countries ofthis region appear to be related to such factors asalcohol abuse, suicide, and violence, which seem to beassociated with societies facing social and economicdisintegration. The rapidity of these declines hasdramatically changed our perceptions of the time frameswithin which substantial changes in the burden ofchronic disease can occur and of the potential for suchadverse health trends to occur elsewhere.✜ Adults under the age of 70 in low- and middle-incomecountries face a substantially greater risk of death fromnoncommunicable diseases than adults of the same agein high-income countries.✜ In Europe and Central Asia, Latin America and theCaribbean, and the Middle East and North Africa, morethan 30% of the entire disease burden among maleadults age 15 to 44 is attributable to injuries, includingroad traffic accidents, violence, and self-inflicted injuries.In addition, injury deaths are noticeably higher forwomen in some parts of Asia and the Middle East andNorth Africa than in other regions, partly because ofhigh levels of suicide and violence. Combined withhigher rates of infant and child mortality for girls, thisresults in a narrower differential between male andfemale healthy life expectancy than in any other region. ❏Alan Lopez is Professor of Medical Statistics and PopulationHealth and Head of the School of Population Health at theUniversity of Queensland. Prior to joining the University in January2003, he worked at the World Health Organization (WHO) inGeneva, Switzerland, for 22 years where he held a series oftechnical and senior managerial posts including ChiefEpidemiologist 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 Informationteam in the Evidence and Information for Policy Cluster at theWorld Health Organization (WHO) in Geneva, Switzerland. He isresponsible for WHO reassessments of the global burden ofdisease, and in the development of software tools to supportburden of disease analysis at country level.174 ✜ Global Forum Update on Research for Health Volume 4