Elsevier

The Lancet

Volume 349, Issue 9063, 17 May 1997, Pages 1436-1442
The Lancet

Articles
Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study

https://doi.org/10.1016/S0140-6736(96)07495-8Get rights and content

Summary

Background

Prevention and control of disease and injury require information about the leading medical causes of illness and exposures or risk factors. The assessment of the public-health importance of these has been hampered by the lack of common methods to investigate the overall, worldwide burden. The Global Burden of Disease Study (GBD) provides a standardised approach to epidemiological assessment and uses a standard unit, the disability-adjusted life year (DALY), to aid comparisons.

Methods

DALYs for each age-sex group in each GBD region for 107 disorders were calculated, based on the estimates of mortality by cause, incidence, average age of onset, duration, and disability severity. Estimates of the burden and prevalence of exposure in different regions of disorders attributable to malnutrition, poor water supply, sanitation and personal and domestic hygiene, unsafe sex, tobacco use, alcohol, occupation, hypertension, physical inactivity, use of illicit drugs, and air pollution were developed.

Findings

Developed regions account for 11·6% of the worldwide burden from all causes of death and disability, and account for 90·2% of health expenditure worldwide. Communicable, maternal, perinatal, and nutritional disorders explain 43·9%; non-communicable causes 40·9%; injuries 15·1%; malignant neoplasms 5·1%; neuropsychiatric conditions 10·5%; and cardiovascular conditions 9·7% of DALYs worldwide. The ten leading specific causes of global DALYs are, in descending order, lower respiratory infections, diarrhoeal diseases, perinatal disorders, unipolar major depression, ischaemic heart disease, cerebrovascular disease, tuberculosis, measles, road-traffic accidents, and congenital anomalies. 15·9% of DALYs worldwide are attributable to childhood malnutrition and 6·8% to poor water, and sanitation and personal and domestic hygiene.

Interpretation

The three leading contributors to the burden of disease are communicable and perinatal disorders affecting children. The substantial burdens of neuropsychiatric disorders and injuries are under-recognised. The epidemiological transition in terms of DALYs has progressed substantially in China, Latin America and the Caribbean, other Asia and islands, and the middle eastern crescent. If the burdens of disability and death are taken into account, our list differs substantially from other lists of the leading causes of death. DALYs provide a common metric to aid meaningful comparison of the burden of risk factors, diseases, and injuries.

Introduction

In this, the third of a four-article series on the Global Burden of Disease Study (GBD) (see Lancet 1997; 349: 1269–76 and 1347–52, and the next issue) the primary indicator used to summarise the burden of premature mortality and disability (including temporary disability) is the disability-adjusted life year (DALY). The burden of 107 disorders is compared with the burden attributable to ten major risk factors and to selected diseases as risk factors for other conditions. More extensive detail on the estimation of causes of death and development of epidemiological profiles of each disabling sequela have been published.1

DALYs are the sum of life years lost due to premature mortality and years lived with disability adjusted for severity. The value choices incorporated into DALYs and the basis of their selection have been extensively debated and discussed.2, 3, 4 In this article we give more details on the methods used to estimate attributable burden.

Section snippets

Estimation of attributable burden

For the GBD, assessments of the burden attributable to each of the ten major risk factors were made by specialists on each topic: tobacco,5 alcohol,6 illicit drugs,7 occupation,8 air pollution,9 poor water supply, sanitation, and personal and domestic hygiene,10 hypertension,11 physical inactivity,12 malnutrition,13 and unsafe sex.14 Attributable burden in this study has been defined (for a specific risk factor, population, and time) as “the difference between currently observed burden and the

Results

We calculated the regional distribution of the burden of disease and health expenditure worldwide (figure 1). In 1990, nearly 90% of the worldwide burden of disease occurred in devloping regions, where only 10% of health-care funds were spent.23 In terms of overall worldwide burden of disease, sub-Saharan Africa and India had the largest proportions (21·4% and 20·9%, respectively) but very small proportions (0·7% and 1·0%) of health expenditure. Established market economies accounted for 7·2%

Discussion

Three findings from the GBD should be emphasised. First, despite dramatic improvements in child health conditions in the developing world, the three leading contributors to the burden of disease are lower respiratory infections, diarrhoeal diseases, and perinatal disorders. Together with measles, the eighth largest cause of burden, these childhood diseases account for 25% of the whole burden of premature mortality and disability in developing regions. Two important risk factors that contribute

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