Chapter 002. Global Issues in Medicine (Part 4)

Nearly 20% (10.6 million) of the 56 million dead in 2001 were children
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Chapter 002. Global Issues in Medicine (Part 4) Chapter 002. Global Issues in Medicine (Part 4) Nearly 20% (10.6 million) of the 56 million dead in 2001 were children Among persons 15–59 years of age (Fig. 2-2), noncommunicable diseasesaccounted for more than half of all deaths in all regions except South Asia andsub-Saharan Africa, where communicable diseases, maternal and perinatalconditions, 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- andmiddle-income countries faced a 30% greater risk of death from their conditionsthan did their peers in high-income countries. In this age group, injuries accountedfor 25% of all deaths; Europe and Central Asia registered even higher rates, withinjuries accounting for one-third of all deaths. Overall, death rates in this age group declined between 1990 and 2001 inall regions except Europe and Central Asia, where cardiovascular diseases andinjuries have caused increased mortality, and sub-Saharan Africa, where theimpact of HIV/AIDS in this age cohort has been particularly devastating. Noncommunicable diseases accounted for almost 60% of all deaths in 2001but, because of the later onset of these diseases, accounted for only 40% of yearsof life lost. In contrast, because they occur more often in younger people, injuriesaccounted for 12% of years of life lost but for only 9% of deaths. Overall, maleshad an 11% higher death rate than females as well as a 15% higher rate of years oflife lost; these figures reflect the earlier age of death of males worldwide. Notably, almost half of the disease burden in middle- and low-incomecountries in 2001 derived from noncommunicable disease—an increase of 10%since 1990. Compared with years of life lost, there is greater uncertainty in calculatingyears of life lived with disability for specific conditions. Best estimates from 2001reveal that, while the prevalence of diseases common in older populations (e.g.,dementia and musculoskeletal disease) was higher in high-income countries, thedisability experienced as a result of cardiovascular diseases, chronic respiratorydiseases, 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 bothlived shorter lives and experienced disability and poor health for a greaterproportion of their lives. Indeed, 45% of the overall burden of disease occurred inSouth Asia and sub-Saharan Africa, which together comprise only one-third of theglobal population. In its analysis of risk factors for ill health, the GBD project found thatundernutrition was the leading cause of loss of DALYs in both 1990 and 2001. Inan era that has seen obesity become a major health concern in so many developedcountries, the persistence of undernutrition is surely cause for great consternation. Our inability to feed the hungry indicts many years of failed developmentprojects and must be addressed as a problem of the highest priority. Indeed, nohealth care initiative, however generously funded and scientifically justified, willbe effective without adequate nutrition. The GBD analysis was used as the basis for the second edition of DiseaseControl Priorities in Developing Countries (DCP2). Published in 2006, DCP2 is adocument of stunning breadth and ambition, providing cost-effectiveness analysesfor >100 interventions and including 21 chapters focused on strategies forstrengthening health systems. Cost-effectiveness analyses that compare two relatively equal interventionsand facilitate the best choices under constraint are important; however, as bothresources and ambitions for global health grow, cost-effectiveness analyses(particularly those based on past conditions) must not hobble the increasedworldwide commitment to provide resources and accessible services to all whoneed them. To illustrate this point, we turn in greater detail to AIDS, which hasbecome, in the course of the last three decades, the worlds leading infectiouscause of death during adulthood.