1. Harvard University Initiative for Global Health Global Health Challenges Social Analysis 76: Lecture 4

2. Harvard University Initiative for Global Health Epidemiological Diversity Trends in Child Mortality Adult Mortality Trends The Epidemiological Transition and Causes of Death The Global Burden of Diseases, Injuries and Risk Factors

3. Harvard University Initiative for Global Health

4. Epidemiological Diversity Trends in Child Mortality Adult Mortality Trends The Epidemiological Transition and Causes of Death The Global Burden of Diseases, Injuries and Risk Factors

5. Harvard University Initiative for Global Health 1. 1.Slow steady decline in child mortality over 200 years in developed countries. 2. 2.Rapid declines post-WWII in many developing countries. 3. 3.Increasing divergence in trends since 1990, some countries have increasing child mortality while most continue to decline. Three Key Patterns

6. Harvard University Initiative for Global Health

9. 40% increase No Data

10. Epidemiological Diversity Trends in Child Mortality Adult Mortality Trends The Epidemiological Transition and Causes of Death The Global Burden of Diseases, Injuries and Risk Factors

11. Harvard University Initiative for Global Health 1. 1.Slow steady decline in adult female mortality over 125 years in developed countries. 2. 2.Male mortality falling behind females sometime between 1950-1980 in most developed countries. 3. 3.Consistent and variable rise in adult mortality in Eastern Europe and Former Soviet Union since 1965. 4. 4.Dramatic increases in adult mortality in HIV affected regions since 1990. Key Patterns

12. Harvard University Initiative for Global Health

15. Epidemiological Diversity Trends in Child Mortality Adult Mortality Trends The Epidemiological Transition and Causes of Death The Global Burden of Diseases, Injuries and Risk Factors

16. Harvard University Initiative for Global Health Term used to describe the developed country transition from high mortality and high fertility rates to low mortality and low fertility rates. This shift leads to a dramatic change in population age structure from a pyramid to a cylinder. Demographic Transition

17. Harvard University Initiative for Global Health

19. Omran proposed the concept of the epidemiological transition to capture characteristic changes in cause of death structure. He defined three Ages: Age of Pestilence and Famine Age of Receding Pandemics Age of Degenerative and Man-Made Diseases Epidemiological Transition

20. Harvard University Initiative for Global Health Epidemiological Transition in Chile

21. Harvard University Initiative for Global Health Potential Factors Explaining the Epidemiological Transition 1.Population Aging 2.Rising age-specific non-communicable disease rates

22. Harvard University Initiative for Global Health Non-Communicable Disease Death Rates Rise with Age

23. Harvard University Initiative for Global Health Exposure to infections during early childhood may be risk factors for non-communicable diseases as adults. Known examples include Hepatitis B and liver cancer, human papilloma virus and cervical cancer, and H.pylori and ulcers. Barker hypothesis: fetal nutritional deficiencies increase risk of adult non-communicable diseases. Potential Explanations for Declining Age-Specific NCD Death Rates

24. Harvard University Initiative for Global Health Epidemiological Diversity Trends in Child Mortality Adult Mortality Trends The Epidemiological Transition and Causes of Death The Global Burden of Diseases, Injuries and Risk Factors

25. Harvard University Initiative for Global Health GBD Goals GBD v5.6 Decouple epidemiological assessment and advocacy Inject non-fatal health outcomes into health policy debate Use a common metric for burden of disease assessment and cost-effectiveness analysis 1. 2. 3.

26. Harvard University Initiative for Global Health GBD Objectives GBD v5.6 Internally consistent estimates of mortality by age, sex and region for 107 causes Internally consistent estimates of incidence, prevalence, case-fatality and duration by age, sex, and region for 483 disabling sequelae Estimates of the burden of disease attributable to 10 major risk factors Project burden of disease 1990-2020 1. 2. 3. 4.

27. Harvard University Initiative for Global Health DALY = YLL + YLD i i i

28. Harvard University Initiative for Global Health Group I includes communicable, maternal, and perinatal causes and nutritional deficiencies. During the epi transition, these causes decline at a faster rate than all cause mortality. Group II includes the non-communicable causes including cancers, diabetes, cardiovascular disorders and chronic respiratory diseases. During the epi transition, these causes decline at a slower rate than all cause mortality. Group III includes unintentional and intentional injuries. Groups I, II and III

29. Harvard University Initiative for Global Health Leading Causes of Mortality 2002 Percent 1.Ischaemic heart disease 12.6 2.Cerebrovascular disease 9.7 3.LRI 6.8 4.HIV/AIDS 4.9 5.COPD 4.8 6.Perinatal conditions 4.3 7.Diarrhoeal diseases 3.2 8.Tuberculosis 2.7 9.Lung Cancer 2.2 10.Malaria 2.2 Source: World Health Report, 2004

30. Harvard University Initiative for Global Health Status of the Epidemiological Transition across Subregions, 2002 Source: World Health Report, 2004

31. Harvard University Initiative for Global Health Global Burden of Disease by Major Cause, 2002 Source: World Health Report, 2004

32. Harvard University Initiative for Global Health Leading Causes of the Global Burden of Disease, 2002 % 1.Perinatal conditions 6.5 2.Lower respiratory infections 6.1 3.HIV/AIDS 5.7 4.Depression 4.5 5.Diarrhoeal diseases 4.2 6.Ischaemic heart disease 3.9 7.Cerebrovascular disease 3.3 8.Malaria 3.1 9.Road traffic accidents 2.6 10.Tuberculosis 2.3 Source: World Health Report, 2004

33. Harvard University Initiative for Global Health Attributable Disease Burden of 20 Risk Factors