Chapter 002. Global Issues in Medicine (Part 4) docx

Chapter 002. Global Issues in Medicine
(Part 4)

Nearly 20% (10.6 million) of the 56 million dead in 2001 were children <5
years of age who died of acute respiratory infections, measles, diarrhea, malaria,
and HIV/AIDS (Fig. 2-1). Of these deaths, 99% occurred in middle- and low-
income countries, and fully 40% occurred in sub-Saharan Africa.
If stillbirths are counted, the number of childhood deaths rises to 13.5
million worldwide (~25% of all deaths worldwide), of which more than half (i.e.,
one-eighth of all deaths) occurred before the first birthday. Between 1990 and
2001, under-five childhood mortality dropped by 30% in high-income countries,
Latin America, the Caribbean, the Middle East, North Africa, and the middle- and
low-income countries of Europe and Central Asia. Notably, the total number of
deaths from diarrheal diseases dropped from 2.4 million in 1990 to 1.6 million in
2001, probably as a result of the increased use of oral rehydration therapy in poor
countries. Malaria and HIV infection were the only two conditions for which
childhood death rates increased between 1990 and 2001.
Among persons 15–59 years of age (Fig. 2-2), noncommunicable diseases
accounted for more than half of all deaths in all regions except South Asia and
sub-Saharan Africa, where communicable diseases, maternal and perinatal
conditions, and nutritional deficiencies together accounted for one-third and two-
thirds of all deaths, respectively.
The 15- to 59-year-olds with noncommunicable conditions in low- and
middle-income countries faced a 30% greater risk of death from their conditions
than did their peers in high-income countries. In this age group, injuries accounted
for 25% of all deaths; Europe and Central Asia registered even higher rates, with
injuries accounting for one-third of all deaths.
Overall, death rates in this age group declined between 1990 and 2001 in
all regions except Europe and Central Asia, where cardiovascular diseases and
injuries have caused increased mortality, and sub-Saharan Africa, where the
impact of HIV/AIDS in this age cohort has been particularly devastating.

Noncommunicable diseases accounted for almost 60% of all deaths in 2001
but, because of the later onset of these diseases, accounted for only 40% of years
of life lost.
In contrast, because they occur more often in younger people, injuries
accounted for 12% of years of life lost but for only 9% of deaths. Overall, males
had an 11% higher death rate than females as well as a 15% higher rate of years of
life lost; these figures reflect the earlier age of death of males worldwide.
Notably, almost half of the disease burden in middle- and low-income
countries in 2001 derived from noncommunicable disease—an increase of 10%
since 1990.
Compared with years of life lost, there is greater uncertainty in calculating
years of life lived with disability for specific conditions. Best estimates from 2001
reveal that, while the prevalence of diseases common in older populations (e.g.,
dementia and musculoskeletal disease) was higher in high-income countries, the
disability experienced as a result of cardiovascular diseases, chronic respiratory
diseases, and the long-term impact of communicable diseases was greater in low-
and middle-income countries.
Thus, predictably, in most low- and middle-income countries, people both
lived shorter lives and experienced disability and poor health for a greater
proportion of their lives. Indeed, 45% of the overall burden of disease occurred in
South Asia and sub-Saharan Africa, which together comprise only one-third of the
global population.
In its analysis of risk factors for ill health, the GBD project found that
undernutrition was the leading cause of loss of DALYs in both 1990 and 2001. In
an era that has seen obesity become a major health concern in so many developed
countries, the persistence of undernutrition is surely cause for great consternation.
Our inability to feed the hungry indicts many years of failed development
projects and must be addressed as a problem of the highest priority. Indeed, no
health care initiative, however generously funded and scientifically justified, will
be effective without adequate nutrition.

The GBD analysis was used as the basis for the second edition of Disease
Control Priorities in Developing Countries (DCP2). Published in 2006, DCP2 is a
document of stunning breadth and ambition, providing cost-effectiveness analyses
for >100 interventions and including 21 chapters focused on strategies for
strengthening health systems.
Cost-effectiveness analyses that compare two relatively equal interventions
and facilitate the best choices under constraint are important; however, as both
resources and ambitions for global health grow, cost-effectiveness analyses
(particularly those based on past conditions) must not hobble the increased
worldwide commitment to provide resources and accessible services to all who
need them.
To illustrate this point, we turn in greater detail to AIDS, which has
become, in the course of the last three decades, the world's leading infectious
cause of death during adulthood.