Global Burden of Disease –
where does arthritis fit?
Associate Professor Fiona Blyth
MBBS (Hons) FAFPHM, PhD
In this talk
› Introduction – how epidemiology contributes to advocacy
› History: from stigma and judgment to human rights
› The big picture of Global Health
› GBD
› Some important considerations across the lifespan
› Advocacy
In this talk
› Introduction – how epidemiology contributes to advocacy
› History: from stigma and judgment to human rights
› The big picture of Global Health
› GBD
› Some important considerations across the lifespan
› Advocacy
Why we need good information about arthritis in
the population
› To get visibility as a health care problem
› To compete with other more ‘established’ conditions for
limited health resources
› To highlight areas of unmet need
› To have the opportunity to learn about those who are
‘doing well’ with arthritis
What do epidemiologists have to do with it?
› We look at the size, patterns, causes and consequences
of health problems in population groups
› This can help to lobby for extra resources by providing a
shape and form for health problems
› It can help gauge how advances developed in
specialised settings might translate “out there” in the
community
Putting it together…
adapted from Blyth 2010
ARTHRITIS-FOCUSSED
STUDIES
GENERAL HEALTH
SURVEYS
Shape
RISK FACTORS/
BURDEN
WITHIN
SPECIFIED
POPULATIONS
Place
Voice
HOW COMMON/
SEVERE IS
ARTHRITIS
COMPARED WITH
OTHER
CONDITIONS?
Giving arthritis and musculoskeletal problems a
voice
In this talk
› Introduction – how epidemiology contributes to advocacy
› History: from stigma and judgment to human rights
› The big picture of Global Health
› GBD
› Some important considerations across the lifespan
› Advocacy
History has some lessons for us-1
The Lancet, 1932
Sound familiar?
 ‘The reasons for dealing with chronic rheumatism
systematically on a national scale include the
following…
 The disease at present causes a large loss in
money, and an immense amount of preventable
suffering and crippledom.
 Nothing systematic is at present being done in
England, whereas, other countries e.g. Germany
and Sweden – find it worth their while to tackle
the problem.
 Lay opinion is in favour of action, but lacks
medical guidance, while research, which is very
desirable in this group of diseases, could be
stimulated and rendered possible on a larger
scale than at present.’ Copeman, Lancet 1932
Hmmm…
 ‘Research is an urgent need in this branch of
medicine. The subject of chronic rheumatism
has never, until recently, inspired enthusiasm,
except in few individuals, and is therefore
most neglected’ Copeman, Lancet 1932
Here comes the competition!
 Lastly, it is suggested that possibly other
diseases should also be singled out for
special treatment.
 But such a scheme is necessary only in the
case of a chronic disease which occurs on a
scale large enough to merit the title of a social
menace.

These diseases are four in number
Copeman, Lancet 1932
1.
Tuberculosis – Efficient scheme already in force.
2.
Venereal diseases – Efficient scheme already in force.
3.
Cancer – Owing to dramatic appeal of this disease
adequate voluntary effort is forthcoming.
4.
Chronic rheumatism – The most costly of the three (to
the country), but lacking in dramatic appeal because it
is not fatal. Scheme suggested Copeman, Lancet 1932.
History has some lessons for us-2
 1944
 25 soldiers with backache/no organic signs
 British army hospital in Italy
 ‘Biopsychosocial’ assessment
British Medical Journal
1946
Psychological assessment
Paulet, BMJ 1946
 “Four patients had an immature personality; they were
shy mother-fixated emotionally adolescent male
virgins”
 “Of the 25 patients, 20 had an inadequate personality.
Those who habitually interpret their failures as due to
circumstances unjustly thrust upon them, may reach a
quasi-paranoid state, losing the self-criticism that is
essential for social harmony”
Paulet, BMJ 1946
“it is hard for a simple-minded hypochondriac
to adopt any other attitude than that he has
been unjustly accused of malingering. If he
had no psychological disability before this
event, he would certainly have one after it”
“The mechanism of low back pain remains
obscure”
Stigmatized and judged
2010 Declaration of Montreal
In this talk
› Introduction – how epidemiology contributes to advocacy
› History: from stigma and judgment to human rights
› The big picture of Global Health
› GBD
› Some important considerations across the lifespan
› Advocacy
Why is the Global Burden of Disease
important?
 Changing global demography
 Changing global economy
 Changing patterns of disease and disability
 Need for a comprehensive and systematic
revision of global burden of disease
estimates
The World by land area
(Worldmapper http://www.worldmapper.org/)
The world sized by population aged over 65 years
(Worldmapper)
The world sized by global burden of diabetes
(Worldmapper)
The world sized by global spending on public health
(Worldmapper)
The funding hasn’t followed this rapid change...Stuckler et al,
Lancet 2008
Chronic
diseases
Chronic
diseases
In this talk
› Introduction – how epidemiology contributes to advocacy
› History: from stigma and judgment to human rights
› The big picture of Global Health
› GBD
› Some important considerations across the lifespan
› Advocacy
Burden of Disease
› Burden of Disease is a way of measuring and
ranking the effects of diseases on the health of
populations
› Two parts to this: death and disability (and both
combined)
27
Impact of previous GBD findings
› Highly influential
› Stimulated national burden of disease studies
› informed governmental and non-governmental
priorities for research, development, policies and
healthcare funding
28
GBD 2010 Overall Aims
 To produce new, robust, and reliable
estimates of burden for all major diseases,
injuries, and risks that are widely
disseminated, understood, and easily
used by policymakers, researchers,
funders and practitioners.
GBD 2010
 GBD 2010 started in 2008
 Major findings published in December 2012 in The
Lancet
 More than 175 diseases and injuries, 20 risk
factors
 More than 400 experts around the world involved
GBD 2010
globalburden.org
Key collaborators:
 Johns Hopkins University
 Harvard University
 University of Queensland*
 Institute for Health Metrics and Evaluation
at the University of Washington
 World Health Organization
Musculoskeletal conditions in GBD:
evolution over time
•
•
•
•
•
•
Osteoarthritis (GBD 1990, 2000, 2010)
Rheumatoid arthritis (GBD 1990, 2000,2010)
Low Back pain ( LBP in GBD 2000, 2010)
Neck Pain (GBD 2010)
Gout (GBD 2010)
Other MSK (GBD 2010)
Brief overview of what was done
› Each expert group found all the relevant studies in their disease area over
a fixed time period around the world and assessed them (quality, main
findings)
› Each group then had to work out the main common patterns of this
disease from the available studies (e.g. acute, chronic, mild, severe, shortterm, long-term, mortality)
› The next task was to measure how much disability occurred with these
common patterns: DIFFICULT!
› All this information was put together (very complicated!) by a central
coordinating team based in the USA (the Core Team) to produce rankings
of diseases according to deaths caused, disability caused and combined
death and disability (=BURDEN OF DISEASE)
33
How was disability measured?
› For each common pattern of each disease:
A simple (lay) description of what a person in this state would experience
was developed
People in different countries were asked to make comparisons between
two descriptions for two conditions – these were used to assess how
disabling all patterns of all diseases were (‘disability weights’)
34
Building a lay description from the Health
State Checklist
The first set of questions asks about capacity in different areas of
functioning. Indicate by checking either ‘yes’ or ‘no’ whether a
person would be able to perform the following functions.
Rising: Rise from lying position on the ground (Yes/No); Rise
from sitting position on the ground (Yes/No)
Building a lay description from the Health
State Checklist
The second set of questions asks about specific symptoms or
problems. Indicate by checking either ‘yes’ or ‘no’ whether a person
would experience the symptom or problem, and indicate average
duration and/or frequency where relevant
Feeling worried or anxious (Yes/No; # days per week;# hours per
day)
Quite a process!
WHY BOTHER?
 Final versions had to be concise
 Modified after feedback from
GBD central team which had
oversight of all disease groups
 Major restrictions on both
length and content
The final lay descriptions - LBP
 ACUTE BACK PAIN WITH LEG PAIN
- “person with severe back and leg pain”
This person has severe back and leg pain, which causes difficulty
dressing, sitting, standing, walking, and lifting things. The person
sleeps poorly and feels worried.
 CHRONIC LOW BACK PAIN WITH LEG PAIN
- “person with constant back and leg pain”
This person has constant back and leg pain, which causes difficulty
dressing, sitting, standing, walking, and lifting things. The person
sleeps poorly, is worried, and has lost some enjoyment in life.
Osteoarthritis
Lay Definitions
• MILD OA
-
“the person with the mild pain and stiffness in the legs”
This person has moderate pain and stiffness in the legs which causes
difficulty running, walking long distances and getting up and down.
•
MODERATE OA - “the person with the moderate pain in the hips &/or knees”
This person has moderate pain in the leg, which makes the person
limp, and causes some difficulty walking, standing, lifting or carrying
heavy things and getting up and down and sleeping.
•
SEVERE OA - “the person with the severe constant pain in the hips &/or knees”
This person has severe pain in the leg, which makes the person limp
and causes a lot of difficulty walking, standing, lifting and carrying
heavy things, getting up and down, and sleeping.
39
Survey webpage http://gbdsurvey.org/
New and important addition to this process
› People in developing countries were also asked to do the same ratings in
household surveys (Bangladesh, Indonesia, Peru, South Africa, Tanzania;
USA to compare)
› Interestingly, the results were quite similar across countries
› Previous GBD studies had relied on experts
43
‘Democratization of data’
 Open access data visualisation tools rapidly
made available on Institute of Health Metrics
Evaluation website:
 http://www.healthmetricsandevaluation.org/g
bd/visualizations/country
http://www.healthmetricsandevaluation.org/gbd/visualizations/country
Musculoskeletal conditions
 Widespread recognition of the huge disability
burden globally and locally related to MSK
conditions (NB low back pain, neck pain)
 Surprisingly low disability weights for osteoarthritis
 Significant gaps in basic information from many
countries
 Lack of consistent data needs to be addressed in
the future (eg, severity and length of episodes)
In this talk
› Introduction – how epidemiology contributes to advocacy
› History: from stigma and judgment to human rights
› The big picture of Global Health
› GBD
› Some important considerations across the lifespan
› Advocacy
Musculoskeletal problems matter early in life
 Key findings from epidemiological studies of pain in childhood
and adolescence
›
Pain is common in childhood and adolescents, shows evidence of
common underpinnings, and seems to have distinctive
trajectories over time
 Key findings from birth cohort studies of experiences early life
influence later health in adulthood
›
Broad, subtle and pervasive effects on musculoskeletal health
happen early in life
 Big potential for gains in years lived without pain disability
Key findings
 Working age people with long-term back problems
were more than two and a half times more likely
not to be in the labour force

With three or more additional conditions, this goes
up substantially – more than nine times more likely
not to be in the labour force
 Early retirement due to back problems will
substantially reduce accumulated wealth
The bigger picture of health and ageing
›
National GP survey
›
GP consultations
›
GP assessment of morbidities (CIRS)
›
Common patterns of multimorbidity
What about arthritis?
Britt et al, MJA 2008
In this bigger picture, how important are
MSK conditions?
Very!
Greatest impact

“In light of the variability in methods of prior
studies, it is striking that previous studies have
also ranked musculoskeletal disorders and
major depression as the conditions associated
with the largest number of disability days at both
the individual and population levels.”
(Merikangas et al, 2008)
Comorbidity and Multimorbidity occurs
in older people but…
What do we REALLY know about the
ageing process and how it relates to
diseases, their causes and
consequences?
“A glass of sherry a day keeps me going”
quoted 103 year old Daphne Timms.
The Warrnambool Standard, VIC, Aust.
Eva follows the “risk factor script”...
Eva McConnell, 110,
is now Australia’s
oldest person. Eva
attributes her
longevity “to hard
work and plain
tucker.” Eva was still
living on her own,
cooking for herself
and chopping wood
when she turned 100.
Ulladulla Times, NSW, Aust.
Uh-oh...
Lorna Gobey, a 100-year
old woman says drink and
cigarettes keep her young.
She has smoked over half a
million cigarettes and still
smokes 20 cigarettes a day.
“I like my smokes, a drop of
whiskey and Guinness and
I still love to play skittles”.
She attributes her longevity
to her fun-loving lifestyle.
The Telegraph, U.K.
In this talk
› Introduction – how epidemiology contributes to advocacy
› History: from stigma and judgment to human rights
› The big picture of Global Health
› GBD
› Some important considerations across the lifespan
› Advocacy
Conclusion
 A clearer picture is emerging of the heavy
global and national toll of MSK conditions
 Important that it is used to argue for
resources
 Also important to keep up the ‘back room’
efforts to improve how this burden is
measured
What do we need to do?
›
Train for a marathon and not a sprint
›
Improve measures, measurement and surveillance at population
levels
›
Think about risk and prevention as well as treatment
›
Think about risk in relation to all levels of prevention
›
Think globally and act collaboratively
›
Advocate