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Introduction to Global Health Challenges

Introduction to Global Health Challenges. Christopher W. Woods, MD, MPH August 27, 2013. To Do…. Sign in on attendance sheet Pick up copies of Thursday ’ s readings Koplan et al. Murray and Lopez Pick up copy of Syllabus Review for top 3 selections of class to help lead/discuss

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Introduction to Global Health Challenges

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  1. Introduction to Global Health Challenges Christopher W. Woods, MD, MPH August 27, 2013

  2. To Do….. • Sign in on attendance sheet • Pick up copies of Thursday’s readings • Koplan et al. • Murray and Lopez • Pick up copy of Syllabus • Review for top 3 selections of class to help lead/discuss • Note TA grouping

  3. Introductions: GLHLTH 701 • Chris Woods • Teaching Assistants • Mirna Hodzic Mun • Ben Silverberg • Students • The Course….

  4. Fun with data • http://www.ted.com/talks/hans_rosling_shows_the_best_stats_you_ve_ever_seen.html • http://www.gapminder.org/

  5. The Emergence of “Global Health” • As a notion • The state of global health • As an objective • Aiming for a condition of global health • A world of healthy people • As a mix of scholarship, research, and practice • Multidisciplinary issues • Hypotheses/questions • Participants Koplan et al, Lancet 2009, p. 1993

  6. Global Health is… • An area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care. Koplan et al., 2009

  7. Defining Global Health

  8. Millennium Development Goals http://www.un.org/millenniumgoals/

  9. AND in 2012 • Discover biomarkers of disease • Discover new ways to achieve healthy birth, • growth, and development http://www.grandchallenges.org/Pages/BrowseByGoal.aspx

  10. Estimating Global Burden of Disease Christopher W. Woods, MD, MPH August 29, 2013

  11. Reliable health data and statistics are the foundation of health policies, strategies, and evaluation and monitoring…….Evidence is also the foundation for sound health information for the general public. Margaret Chan 2007If you are going to work, work on something important William Foege, 2006

  12. Objectives • Summarize Measures of Population Health • Describe the Global Burden of Disease Project • Burden of Disease • Burden of Risk • The future is here

  13. World Population Levels in History

  14. Defining Health • “A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” WHO Charter, 1948

  15. Measuring Health and Disease • Rationale (Why) • Assess health status over time • Reduce disease consequence • Application of evidence-based public health practice* • Burden (How) • Frequency (incidence or prevalence) • Severity (premature mortality and extent of disability) • Type of people affected (gender, age)..disparities • Consequences (health, social, economic)

  16. Life Expectancy at Birth, US 1900-2000 • Common metric • Measures average expected age at birth • No measure of quality of life • Strongly affected by infant and childhood mortality Nature Medicine 10, S82 - S87 (2004) www.WorldLifeExpectancy.com

  17. Life Expectancy around the World

  18. Comparing Life Expectancies and Under-Five Mortality Across Countries http://www.nytimes.com/2010/08/15/world/asia/15japan.html?_r=1&scp=1&sq=japan%20elderly&st=cse Source: World Health Report 2008 and World Development Group Indicators

  19. Historical Perspective • As nations become wealthier, they also become healthier, and vice versa. Source: Marmot M. Health in an Unequal World. The Lancet 2006;368:2081-94. Swaziland However, this relationship is not linear! In fact, there is a clear inflection point in the curve at US$5000 per capita.

  20. Demographic Transition Transition from traditional to modern society • Decline in mortality (primarily in under 5) • Lagging decline in fertility • http://www.worldlifeexpectancy.com/world-population-pyramid

  21. The Epidemiologic Transition • Underlying reasons for the demographic transition • Change in disease pattern • Reduction in malnutrition and communicable diseases

  22. US Crude Mortality Rates for All Causes, Noninfectious Causes, and Infectious Diseases Armstrong et al, JAMA, 1999.

  23. Components of Public Health Success • Clean water supply • Sanitary sewage disposal • Food inspection • Disease surveillance • Maternal-child health • Nutrition-free lunch/milk • Housing regulations • Worker safety, ages, hours

  24. Vital statistics: Mortality • Deaths defined by the Manual of International Statistical Classification of Diseases, Injuries, and Cause of Death, 10th edition (ICD-10) • Mortality at national and sub-national levels • Fact of death unreliable in 26% of countries (age, sex, place) • Cause is unreliable (even in parts of US) • Supplement with surveys and verbal autopsies Murray et al, 2001

  25. Quality of Death Information Mathers et al., Bulletin of the World Health Organization, March 2005

  26. Measuring disability • Morbidity • Case Disability Ratio • Proportion of those diagnosed with a disease who have disability • CDR=1 for most diseases • Latent infection or genetic marker may be <1 • Extent or severity of disability • Usually rank 0 to 1 • Duration • Onset until cure and recovery or death • May have continuing permanent disability

  27. Composite Measures of Population Health • Health Expectancy=A+f(B) • Disability-free Life Expectancy (DFLE) • Health Adjusted Life Expectancy (HALE). • Health Gap (Healthy Life Lost)=C+g(B) • Healthy Life Years (HeaLY) • Disability Adjusted Life Year C B % Surviving A AGE

  28. Disability Adjusted Life Years (DALY) • DALY=YLL + YLD (One lost year of healthy life) • YLL=Years of life lost to premature mortality • YLD=Equivalent years of healthy life lost due to disability • Ranges from 0 to 1 • Uses Life Expectancy table • compare with Japan (80 y male, 82.5 female) • Uses health professional expert groups to define values • Discount rates for future life • Weight for life lived at different ages • Disability Weights

  29. DALY: Years of Life Lost (YLL) • YLL = N x Lx YLL=Years of life lost to premature mortality • N=Number of deaths in the population • Lx =Standard life expectancy at age of death • X=Age of Death • Example: • 10 deaths at 50 = 10 x Lx=10 x 34=340 YLL

  30. Years Lived with Disability • YLD = I x DW x d • YLD=Years of life lived with disability • I = Number of incident cases in the population • DW = Disability Weight • Scale 0 (perfect health) to 1 (death) • d = Duration of disability (years) • 10 cases of mental retardation due to lead at birth: • 10 x 0.36 x 80 years = 288 YLD

  31. Value Choices for the DALY • Time discounting: 3% • Falling mortality • Increasing costs • Age weighting • non uniform weights • less weight to years lived at younger and older ages • Disability weights • Largely based on GBD 1990 study with some revisions. • For local prioritization, may adjust to suit cultural preferences % Surviving AGE

  32. Criticisms of the DALY (Policy Perspective) • Expert vs. community/patient value of health • Discriminates against young and the old • Disabilities additive in nature and could exceed “1” • More than dead? • No priority (weight) given to worse off • No prioritization for people with limited treatment potential • Does not assess qualitative difference in outcomes • No Male-Female difference in length of life • Discounting future health outcomes (3% vs. 7%) Adapted from GHEC Module 21 http://globalhealthedu.org/modules/Documents/21/player.html

  33. Quantified Health effects for 107 diseases and injuries in 8 regions in 1990 Comprehensive and consistent estimates of morbidity and mortality by age, sex, and region Introduced the DALY YLL from premature death and years lived in less than full health Global Burden of Disease Study Murray and Lopez, 1996

  34. Global Burden of Disease Goals • Measure loss of health due to comprehensive set of disease injury and risk factor causes in a comparable way • Decouple epidemiological assessment from advocacy • Inject non-fatal health outcomes into health policy debate • Use a common metric for burden of disease assessment using summary measure for population health and cost-effectiveness analysis WHO Global Burden of Disease 2004 Report

  35. GBD Philosophy • Quantities of interest are total events or states at population levels • Best available data used to make estimates • Corrections for major known biases to improve cross-population compatibility • Comprehensive set of disease and injury causes • nothing is left out in principle • No blanks in the tables, only wider uncertainty intervals • Internal consistency used as a tool to improve validity WHO Global Burden of Disease 2004 Report

  36. GBD Data Sources • Mortality • Death registration, sample registration systems, household surveys, surveillance systems, epidemiological studies, population laboratories • Morbidity/Disability • Disease registers, population-based studies, longitudinal studies, health facility data (injuries)

  37. YLL update by age, sex, and cause for 192 states YLD estimates for 52 causes UNAIDS, UNICEF, RBM, IARC, WHO surveillance Addition of “refractory errors” Revision of “angina pectoris” and CVA estimates GBD 2004 Update (2008)

  38. Approximate number of data sources, GBD 2004 WHO Global Burden of Disease 2004 Report

  39. Number of datasets by region, GBD 2004 WHO Global Burden of Disease 2004 Report

  40. Methods and data for cause-of-death for 2004, by Region WHO Global Burden of Disease 2004 Report

  41. Global Cause of Death by Category • Group I • Communicable plus maternal, perinatal and nutritional conditions • Group II • Non-communicable conditions (eg, heart disease, stroke, cancer) • Group III • Injuries including motor vehicle accidents, homicide, and suicide 58.8 million deaths, 2004 Murray and Chen, 1995

  42. GBD 2004: Leading Causes of Death by Income WHO Global Burden of Disease 2004 Report

  43. Disease Burden Measured in DALY

  44. 2010 Updates 291 diseases and injuries 67 risk factors 1,160 sequelae (non-fatal health consequences) 21 regions 20 age groups 187 countries Improved methods for the estimation of disability weights No discounting or Age-weighting

  45. Global BOD 1990 vs. 2010

  46. http://www.healthmetricsandevaluation.org/gbd/multimedia/video/gbd-compare-tutorialhttp://www.healthmetricsandevaluation.org/gbd/multimedia/video/gbd-compare-tutorial • http://www.thelancet.com/themed/global-burden-of-disease

  47. Disease Risk Factors

  48. Leading Causes of GBD, 2004 to 2030 WHO Global Burden of Disease 2004 Report

  49. Assess demographics Cause of Death Define disability by cause with input Assess reliability/validity Define social preferences for age weighting, discounting, life expectation Est HLL for each condition and by group Perform sensitivity analysis Consider other variations (region, age, sex) Review policy implications Modify as necessary for setting For policy considerations Est effectiveness of each intervention under consideration. Work out costs of interventions Develop Cost-effectiveness ratios to maximize return on healthy life per expenditure Review expected gains of healthy life by age, sex, geographic area and adjust as necessary* Implementing a BOD study

  50. Risks Quantified in GBD

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