Prof. Hsien-Ho Lin Mar Unless noted, the course materials are licensed under Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Taiwan (CC BY-NC-SA 3.0 )Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Taiwan (CC BY-NC-SA 3.0 )

If you were a multi-billionaire and wanted to save the world… What would be the single indicator of health you most wanted to improve? Why? Life expectancy Child mortality Maternal mortality HIV mortality

Key indicators in population health Life expectancy Infant mortality rate Neonatal mortality rate Under five mortality rate Maternal mortality ratio

Life expectancy The average number of years of life at a given age in a population if the current mortality experience were to continue – “at a given age” – So, it varies by age The generally quoted indicator “life expectancy” refers to life expectancy at birth, which applies to the newborns

Gapminder GAPMINDER

$ 2000 $ 200 $ Income per person (comparable dollars per year) Life expectancy (years) 50 years Burundi 81 years Sweden GAPMINDER

$ 2000 $ 200 $ Income per person (comparable dollars per year) Age (years) Life expectancy (years) 50 years Burundi National Taiwan University Hsien-Ho Lin

The life expectancy at birth in Burundi is 50 years (1) We will rarely see elderly people (>65) in Burundi (2) We will still see a bunch of elderly people in Burundi

$ 2000 $ 200 $ Income per person (comparable dollars per year) Age (years) Life expectancy (years) 50 years Burundi Look at the expected life of five newborn Burundians… GAPMINDER

Age (years) SarahAnnJeanLizPierre …if conditions remain as in Burundi in 2007 during their whole lifetime? How long will they live… GAPMINDER

Age (years) SarahAnnJeanLizPierre GAPMINDER

Age (years) SarahAnnJeanLizPierre child adult old So yes, 2 of 5 get old in Burundi GAPMINDER

Age (years) SarahAnnJeanLizPierre This is the Life Expectancy 50 years Calculate the mean… = 50 GAPMINDER

The life expectancy at age 30 in Burundi (1) 50 (2) >20, <50 (3) 20 (4) <20

The life expectancy at birth in Sweden is 81 years So, do most Swedes live 31 years longer than Burundians? (1) Yes (2) No

Age (years) SaraAntonJanLisaPer How long will they live… …if conditions remain as in Sweden in 2007 during their whole lifetime? GAPMINDER

Age (years) SaraAntonJanLisaPer =81 81 years Calculate the mean… GAPMINDER

Age (years) But “dying young” in Sweden is very different from “dying young” in Burundi So, no, all Burundians do not live 31 years shorter than Swedes “To live long” in Sweden is almost the same as “to live long” in Burundi GAPMINDER

Death (mortality) in children Will substantially affect the measured life expectancy Three related measures: Neonatal mortality rate: <28 days Infant mortality rate: < 1 year Under five mortality rate (child mortality rate): < 5 years NakedNepal

Situation in Burundi, 2010 Neonatal mortality rate (1 m): 42 per 1,000 live births Infant mortality rate (12 m): 88 per 1,000 live births Under five mortality rate (5 y): 142 per 1,000 live births Any pattern observed?

Global distribution of neonatal mortality rate World birth aid

Related MDG targets UN – MDG

How are we doing? Lawn et al, Lancet 2005 Joy E Lawn, Anthony Costello, Charles Mwansambo, David Osrin

What are the causes of neonatal death? Lawn et al, Lancet

Clean delivery kit From: delivery-kits.html Photo took by:

To what extent can the use of clean delivery kit reduce neonatal mortality? (1) By 10% (2) By 30% (3) By 50%

The use of clean delivery kit was associated with a 48% reduction in neonatal mortality in the three countries (India, Bangladesh, Nepal) Seward et al, PLoS Med 2012 Association between Clean Delivery Kit Use, Clean Delivery Practices, and Neonatal Survival: Pooled Analysis of Data from Three Sites in South Asia

The cost of a kit (1) <5 USD (2) <1 USD (3) <50 cent USD (4) < 20 cent USD

Maternal mortality ratio Number of women who die as a result of pregnancy and childbirth complications per 100,000 live births Usually less likely to happen than infant and child deaths

Maternal mortality ratio and GDP per capita, 2009 Gapminder

Related MDG targets UN – MDG

How are we doing? MDG report, United Nations 2010 Declines in maternal mortality ratio across all developing regions Trend in maternal mortality, by UNICEF regions, Source: Trends in Maternal Mortality WHO, UNICEF, UNFPA and The World Bank. Unicef-Childinfo

If you were a multi-billionaire and wanted to save the world… What would be the single indicator of health you most wanted to improve? Why? Life expectancy Child mortality Maternal mortality HIV mortality

Global burden of disease (GBD) project Prof. Christopher MurrayProf. Alan Lopez flickr Sandeep Naik

Leading causes of death, 2002 Mathers et al, 2006 The Burrill Report

What about middle- and low-income countries? 1.Similar pattern with mostly chronic diseases 2.Infectious diseases 3.Both

Leading causes of death, 2002 Mathers et al, 2006 Middle-Income CountriesLow-Income Countries The Burrill Report

Caveat: not all deaths are equal “Premature” death deserves special attention Years of Life Lost (YLL) due to premature death Flickr Martin Pettitt

Leading causes of Years of Life Lost (YLL) 1.Heart disease 2.HIV/AIDS 3.Lower respiratory infection 4.Perinatal conditions

Leading causes of YLL Mathers et al, 2006

More caveat: death is not the only thing that matters Years of healthy life Lost due to Disability (YLD)

Leading causes of YLD in low and middle-income countries? 1.Cancer 2.Stroke 3.HIV/AIDS 4.Depression

Leading causes of YLD Mathers et al, 2006

Disability-Adjusted Life Year (DALY) A summary measure of population health that combines years of life lost from premature death (YLL) and years of life lived in less than full health (YLD) DALY = YLL + YLD

Leading causes of DALY in low and middle- income countries?? 1.Depression 2.Lower respiratory infection 3.HIV/AIDS 4.Perinatal conditions

Leading causes of DALY, 2001 Mathers et al, 2006

More importantly… We want to prevent the causes of diseases

Leading risk factors of DALYs, 2001 Ezzati et al, 2006

Global Burden of Disease study 2010 Coming soon…

Progress report Life expectancy Neonatal/infant/child mortality rate Maternal mortality ratio Global burden of disease Disability-Adjusted Life Year (DALY)

Definition Epidemiology ≠ infectious disease Epidemiology: the study of the occurrence, frequency, and distribution of diseases in a given population

Smallpox

Robert Fisher

Insanity?

Smallpox vaccination

Eradication

Not a threat any more? “Most of the infectious diseases have now yielded up their secrets. Many illnesses have been exterminated: others have been brought under control.” (H. Sigerist in 1931) “It is time to close the book on infectious diseases.” (Surgeon general WH Stewart in 1969)

SARS outbreak, 2003 Wikimedia Maximilian Dörrbecker (Chumwa)

Questions of interest on infectious diseases How transmissible is it? How serious will the epidemic be? What needs to be done to contain it? – What is the coverage of the intervention that is needed? Will it come back again?

Next week Bring your laptop for in-class exercise Make sure the battery can last for more than one hour Read the paper on Ceiba course site Mobile Phone Text Messaging: Tool for Malaria Control in Africa By Dejan Zurovac, Ambrose O. Talisuna, Robert W. Snow

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COPYRIGHT DECLARATION PAGEWORKLICENSEAUTHOR/SOURCE 22 UN – MDG /05/31 visited This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET. 23 Joy E Lawn, Anthony Costello, Charles Mwansambo, David Osrin. Arch Dis Child 2007;92: /07/31 visited This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET. 25 David Gregersen Original photo took by: This work is licensed by David Gregersen for the use of “Essentials of Global Health” ONLY. The copyright belongs to the above mentioned creator(s) and GET does not have the authorization right. 30 GAPMINDER /05/31 visited

COPYRIGHT DECLARATION PAGEWORKLICENSEAUTHOR/SOURCE 31 UN – MDG This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET. 2012/05/31 visited 32 Unicef-Childinfo This work is used subject to the fair use doctrine of Unicef- Childinfo. 35 Flickr World Economic Forum/Sandeep Naik / 2012/05/31 visited 35 University of Queensland, Brisbane, Australia tmlhttp:// tml This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET. 2012/07/16 visited. 36 The Burrill Report This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET. 2012/07/16 visited.

COPYRIGHT DECLARATION PAGEWORKLICENSEAUTHOR/SOURCE 38 The Burrill Report This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET. 2012/07/16 visited. 39 Flickr Martin Pettitt /05/31 visited 41 Prof Alan D Lopez PhD, Colin D Mathers PhD, Majid Ezzati PhD, Dean T Jamison PhD, Christopher JL Murray MD The Lancet, Vol. 367 No pp , May 27, 2006 This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET. 42 Flickr Nationaal Archief 7/sizes/z/in/photostream/ 2012/05/31 visited 44 Mathers et al ch3 This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET. Lancet

COPYRIGHT DECLARATION PAGEWORKLICENSEAUTHOR/SOURCE 47 Prof Alan D Lopez PhD, Colin D Mathers PhD, Majid Ezzati PhD, Dean T Jamison PhD, Christopher JL Murray MD The Lancet, Vol. 367 No pp , May 27, 2006 This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copright Act by GET. 49 Prof Alan D Lopez PhD, Colin D Mathers PhD, Majid Ezzati PhD, Dean T Jamison PhD, Christopher JL Murray MD The Lancet, Vol. 367 No pp , May 27, 2006 This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET. 53 Wiki user GrahamColm /05/31 visited 54 “Guns, Germs, and Steel” (author: Jared Diamond ) cover es/m/in/photostream/ This work is licensed by W.W. Norton & Company, Inc. for the use of “Essentials of Global Health” ONLY. The copyright belongs to the above mentioned creator(s) and GET does not have the authorization right. 54 Flickr Robert Fisher This work is licensed by Robert Fisher for the use of “Essentials of Global Health” ONLY. The copyright belongs to the above mentioned creator(s) and GET does not have the authorization right.

COPYRIGHT DECLARATION PAGEWORKLICENSEAUTHOR/SOURCE 55 Wikimedia commons James Gillray (1756–1815)/Library of Congress, Prints & Photographs Division /05/31 visited 56 Wikimedia commons James Gathany/CDC tion.jpg?uselang=zh-tw 2012/05/31 visited 57 Wikimedia commons CDC mallpox_Eradication_Program.jpg 2012/05/31 visited 59 Wikimedia commons Maximilian Dörrbecker (Chumwa) /05/31 visited