1. Prof. Hsien-Ho Lin Mar-09-2012 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 )

2. 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

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

4. 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

5. Gapminder GAPMINDER

6. 20 000 $ 2000 $ 200 $ Income per person (comparable dollars per year) 100 80 60 40 20 0 Life expectancy (years) 50 years Burundi 81 years Sweden GAPMINDER

7. 20 000 $ 2000 $ 200 $ Income per person (comparable dollars per year) 100 80 60 40 20 0 Age (years) Life expectancy (years) 50 years Burundi National Taiwan University Hsien-Ho Lin

8. 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

9. 20 000 $ 2000 $ 200 $ Income per person (comparable dollars per year) 100 80 60 40 20 0 Age (years) Life expectancy (years) 50 years Burundi Look at the expected life of five newborn Burundians… GAPMINDER

10. 100 80 60 40 20 0 Age (years) SarahAnnJeanLizPierre …if conditions remain as in Burundi in 2007 during their whole lifetime? How long will they live… GAPMINDER

11. 100 80 60 40 20 0 Age (years) SarahAnnJeanLizPierre 84 72 57 36 1 GAPMINDER

12. 100 80 60 40 20 0 Age (years) SarahAnnJeanLizPierre 84 72 57 36 1 child adult old So yes, 2 of 5 get old in Burundi GAPMINDER

13. 100 80 60 40 20 0 Age (years) SarahAnnJeanLizPierre 84 72 57 36 1 This is the Life Expectancy 50 years Calculate the mean… 1+36+57+72+84 5 = 50 GAPMINDER

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

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

16. 100 80 60 40 20 0 Age (years) SaraAntonJanLisaPer How long will they live… …if conditions remain as in Sweden in 2007 during their whole lifetime? GAPMINDER

17. 100 80 60 40 20 0 93 Age (years) SaraAntonJanLisaPer 63 77 84 88 63+77+84+88+93 5 =81 81 years Calculate the mean… GAPMINDER

18. 100 80 60 40 20 0 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

19. 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

20. 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?

21. Global distribution of neonatal mortality rate World birth aid

22. Related MDG targets UN – MDG

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

24. What are the causes of neonatal death? Lawn et al, Lancet 2005 www.sciencedirect.com

25. Clean delivery kit From: http://dlgregersen.blogspot.tw/2010/04/clean- delivery-kits.html Photo took by: http://www.zambiamission.org/

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

27. 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

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

29. 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

30. Maternal mortality ratio and GDP per capita, 2009 Gapminder

31. Related MDG targets UN – MDG

32. 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, 1990-2010 Source: Trends in Maternal Mortality 1990-2010. WHO, UNICEF, UNFPA and The World Bank. Unicef-Childinfo

34. 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

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

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

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

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

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

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

41. Leading causes of YLL Mathers et al, 2006

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

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

44. Leading causes of YLD Mathers et al, 2006

45. 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

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

47. Leading causes of DALY, 2001 Mathers et al, 2006

48. More importantly… We want to prevent the causes of diseases

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

50. Global Burden of Disease study 2010 Coming soon… http://www.globalburden.org/

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

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

53. Smallpox

54. Robert Fisher

55. Insanity?

56. Smallpox vaccination

57. Eradication

58. 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)

59. SARS outbreak, 2003 Wikimedia Maximilian Dörrbecker (Chumwa)

60. 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?

61. 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

62. PAGEWORKLICENSEAUTHOR/SOURCE 5 GAPMINDER http://www.gapminder.org/ 2012/05/31 visited 6 GAPMINDER http://www.gapminder.org/desktop/ 2012/05/31 visited 7National Taiwan University Hsien-Ho Lin 7 GAPMINDER http://www.gapminder.org/desktop/ 2012/05/31 visited 9 GAPMINDER http://www.gapminder.org/desktop/ 2012/05/31 visited 10 GAPMINDER http://www.gapminder.org/downloads/life-expectancy-ppt/ 2012/05/31 visited 11 GAPMINDER http://www.gapminder.org/downloads/life-expectancy-ppt/ 2012/05/31 visited 12 GAPMINDER http://www.gapminder.org/downloads/life-expectancy-ppt/ 2012/05/31 visited COPYRIGHT DECLARATION

63. PAGEWORKLICENSEAUTHOR/SOURCE 13 GAPMINDER http://www.gapminder.org/downloads/life-expectancy-ppt/ 2012/05/31 visited 16 GAPMINDER http://www.gapminder.org/downloads/life-expectancy-ppt/ 2012/05/31 visited 17 GAPMINDER http://www.gapminder.org/downloads/life-expectancy-ppt/ 2012/05/31 visited 18 GAPMINDER http://www.gapminder.org/downloads/life-expectancy-ppt/ 2012/05/31 visited 19 NakedNepal http://nakednepal.com/?p=237 2012/05/31 visited 21 This work is from: World birth aid http://worldbirthaid.org/about/overview/ This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET. 2012/07/17 visited

64. COPYRIGHT DECLARATION PAGEWORKLICENSEAUTHOR/SOURCE 22 UN – MDG http://www.unmillenniumproject.org/goals/gti.htm 2012/05/31 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;92:551-556 http://adc.bmj.com/content/92/6/551.full 2012/07/31 visited This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET. 24 www.sciencedirect.com http://www.sciencedirect.com/science/article/pii/S01460005100 01175 This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET. 25 David Gregersen http://dlgregersen.blogspot.tw/2010/04/clean-delivery-kits.html Original photo took by: http://www.zambiamission.org/http://www.zambiamission.org/ 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 http://www.gapminder.org/desktop/ 2012/05/31 visited

65. COPYRIGHT DECLARATION PAGEWORKLICENSEAUTHOR/SOURCE 31 UN – MDG http://www.unmillenniumproject.org/goals/gti.htm 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 http://www.childinfo.org/maternal_mortality.html This work is used subject to the fair use doctrine of Unicef- Childinfo. 35 Flickr World Economic Forum/Sandeep Naik http://www.flickr.com/photos/worldeconomicforum/30144 58205/ 2012/05/31 visited 35 University of Queensland, Brisbane, Australia http://www.uq.edu.au/uqresearchers/researcher/lopezad.h tmlhttp://www.uq.edu.au/uqresearchers/researcher/lopezad.h 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 http://www.burrillreport.com/printer_article-634.html This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET. 2012/07/16 visited.

66. COPYRIGHT DECLARATION PAGEWORKLICENSEAUTHOR/SOURCE 38 The Burrill Report http://www.burrillreport.com/printer_article-634.html 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 http://www.flickr.com/photos/mdpettitt/2854765060/ 2012/05/31 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. 9524 pp 1747-1757, 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 http://www.flickr.com/photos/nationaalarchief/419274867 7/sizes/z/in/photostream/ 2012/05/31 visited 44 Mathers et al 2006 http://www.dcp2.org/pubs/GBDhttp://www.dcp2.org/pubs/GBD ch3 This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET. Lancet

67. 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. 9524 pp 1747-1757, 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. 9524 pp 1747-1757, 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 http://commons.wikimedia.org/wiki/File:Aztec_smallpox_victims.jpg?uselang=zh-tw 2012/05/31 visited 54 “Guns, Germs, and Steel” (author: Jared Diamond ) cover http://www.flickr.com/photos/57979595@N06/5330846394/siz 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 http://www.flickr.com/photos/gothicknight2/6636391019/ 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.

68. COPYRIGHT DECLARATION PAGEWORKLICENSEAUTHOR/SOURCE 55 Wikimedia commons James Gillray (1756–1815)/Library of Congress, Prints & Photographs Division http://commons.wikimedia.org/wiki/File:The_cow_pock.jpg 2012/05/31 visited 56 Wikimedia commons James Gathany/CDC http://commons.wikimedia.org/wiki/File:Smallpox_vaccine_injec tion.jpg?uselang=zh-tw 2012/05/31 visited 57 Wikimedia commons CDC http://commons.wikimedia.org/wiki/File:Directors_of_Global_S mallpox_Eradication_Program.jpg 2012/05/31 visited 59 Wikimedia commons Maximilian Dörrbecker (Chumwa) http://commons.wikimedia.org/wiki/File:SARS_map.svg 2012/05/31 visited