Prof. Hsien-Ho Lin
Mar-09-2012
Unless noted, the course materials are licensed under Creative Commons
Attribution-NonCommercial-ShareAlike 3.0 Taiwan (CC BY-NC-SA 3.0)
If you were a multi-billionaire and wanted to
save the world…
• What would be the single indicator of health you
most wanted to improve? Why?
•
•
•
•
Life expectancy
Child mortality
Maternal mortality
HIV mortality
Key indicators in population health
•
•
•
•
•
Life expectancy
Infant mortality rate
Neonatal mortality rate
Under five mortality rate
Maternal mortality ratio
Life expectancy
• The average number of years of life at a given age in
a population if the current mortality experience were
to continue
– “at a given age”
– So, it varies by age
• The generally quoted indicator “life expectancy”
refers to life expectancy at birth, which applies to the
newborns
Gapminder
GAPMINDER
100
Sweden
Life expectancy
81 years
80
60
50 years
Burundi
(years)
40
Population 1
(millions) 100
20
1000
0
200 $
2000 $
20 000 $
GAPMINDER
Income per person (comparable dollars per year)
Life Age
expectancy
(years)
100
80
60
Burundi
(years)
50
years
40
Population 1
(millions) 100
20
1000
0
200
2000 $
National Taiwan University Hsien-Ho Lin
$
20 000
$
Income per person (comparable dollars per year)
The life expectancy at birth in Burundi is 50 years
(1) We will rarely see elderly people (>65) in Burundi
(2) We will still see a bunch of elderly people in Burundi
Life Age
expectancy
(years)
100
80
60
50 years
Look at the expected
life of five newborn
Burundians…
Burundi
(years)
40
20
Population 1
(millions) 100
1000
0
GAPMINDER
200 $
2000 $
20 000 $
Income per person (comparable dollars per year)
100
How long will
they live…
Age (years)
80
60
…if conditions remain as
in Burundi in 2007
during their whole
lifetime?
40
20
0
Pierre
GAPMINDER
Liz
Jean
Ann
Sarah
100
84
Age (years)
80
72
57
60
36
40
20
1
0
Pierre
GAPMINDER
Liz
Jean
Ann
Sarah
100
old
Age (years)
80
adult
60
40
child
Pierre
57
So yes, 2 of 5
get old in Burundi
1
GAPMINDER
72
36
20
0
84
Liz
Jean
Ann
Sarah
Age (years)
100
Calculate the mean…
This is the Life
80
Expectancy
1+36+57+72+84
= 50
5
60
84
72
57
50 years
36
40
20
1
0
Pierre
GAPMINDER
Liz
Jean
Ann
Sarah
The life expectancy at age 30 in Burundi
(1) 50
(2) >20, <50
(3) 20
(4) <20
The life expectancy at birth in Sweden is 81 years
So, do most Swedes live 31 years longer than
Burundians?
(1) Yes
(2) No
100
How long will
they live…
Age (years)
80
60
…if conditions remain as
in Sweden in 2007
during their whole
lifetime?
40
20
0
Per
GAPMINDER
Lisa
Jan
Anton
Sara
100
77
Age (years)
81 years
80
84
88
93
63
60
40
Calculate the mean…
20
63+77+84+88+93 =81
5
0
Per
GAPMINDER
Lisa
Jan
Anton
Sara
100
“To live long” in Sweden
is almost the same as
80
Age (years)
“to live long” in Burundi
60
40
20
But “dying young”
in Sweden
So, no,
0
is very different
all Burundians
do not live 31
fromyears
“dyingshorter
young”than
in Burundi
Swedes
GAPMINDER
Death (mortality) in children
Will substantially affect the measured life expectancy
Three related measures:
• Neonatal mortality rate: <28 days
• Infant mortality rate: < 1 year
• Under five mortality rate (child mortality rate): < 5
years
NakedNepal
Situation in Burundi, 2010
• Neonatal mortality rate (1 m): 42 per 1,000 live
births
• Infant mortality rate (12 m): 88 per 1,000 live births
• Under five mortality rate (5 y): 142 per 1,000 live
births
• Any pattern observed?
Global distribution of neonatal mortality rate
World birth aid
Related MDG targets
UN – MDG
How are we doing?
Joy E Lawn, Anthony Costello, Charles
Mwansambo, David Osrin
What are the causes of neonatal death?
www.sciencedirect.com
Clean delivery kit
From: http://dlgregersen.blogspot.tw/2010/04/cleandelivery-kits.html
Photo took by: http://www.zambiamission.org/
To what extent can the use of clean delivery kit
reduce neonatal mortality?
(1) By 10%
(2) By 30%
(3) By 50%
Association between Clean Delivery Kit Use,
Clean Delivery Practices, and Neonatal Survival:
Pooled Analysis of Data from Three Sites in
South Asia
Seward et al, PLoS Med 2012
The use of clean delivery kit was associated with
a 48% reduction in neonatal mortality in the
three countries (India, Bangladesh, Nepal)
The cost of a kit
(1) <5 USD
(2) <1 USD
(3) <50 cent USD
(4) < 20 cent USD
Maternal mortality ratio
• Number of women who die as a result of pregnancy
and childbirth complications per 100,000 live births
• Usually less likely to happen than infant and child
deaths
Maternal mortality ratio and GDP per capita, 2009
Gapminder
Related MDG targets
UN – MDG
How are we doing?
Declines in maternal mortality ratio across all developing regions
Trend in maternal mortality, by UNICEF regions, 1990-2010
Source: Trends in Maternal Mortality 1990-2010. WHO, UNICEF,
UNFPA and The World Bank.
Unicef-Childinfo
If you were a multi-billionaire and wanted to
save the world…
• What would be the single indicator of health you
most wanted to improve? Why?
•
•
•
•
Life expectancy
Child mortality
Maternal mortality
HIV mortality
Global burden of disease (GBD) project
Prof. Christopher Murray
flickr Sandeep Naik
Prof. Alan Lopez
Leading causes of death, 2002
The Burrill Report
What about middle- and low-income countries?
1. Similar pattern with mostly chronic diseases
2. Infectious diseases
3. Both
Leading causes of death, 2002
Middle-Income Countries
Low-Income Countries
The Burrill Report
Caveat: not all deaths are equal
• “Premature” death deserves special attention
• Years of Life Lost (YLL) due to premature death
Flickr Martin Pettitt
Leading causes of Years of Life Lost (YLL)
1.
2.
3.
4.
Heart disease
HIV/AIDS
Lower respiratory infection
Perinatal conditions
Leading causes of YLL
Mathers et al, 2006
More caveat: death is not the only thing that
matters
• Years of healthy life Lost due to Disability
(YLD)
Leading causes of YLD in low and middle-income
countries?
1.
2.
3.
4.
Cancer
Stroke
HIV/AIDS
Depression
Leading causes of YLD
Mathers et al, 2006
Disability-Adjusted Life Year (DALY)
• A summary measure of population health that
combines years of life lost from premature
death (YLL) and years of life lived in less than
full health (YLD)
• DALY = YLL + YLD
Leading causes of DALY in low and middleincome countries??
1.
2.
3.
4.
Depression
Lower respiratory infection
HIV/AIDS
Perinatal conditions
Leading causes of DALY, 2001
Mathers et al, 2006
More importantly…
• We want to prevent the causes of diseases
Leading risk factors of DALYs, 2001
Ezzati et al, 2006
Global Burden of Disease study 2010
• Coming soon…
• http://www.globalburden.org/
Progress report
•
•
•
•
•
Life expectancy
Neonatal/infant/child mortality rate
Maternal mortality ratio
Global burden of disease
Disability-Adjusted Life Year (DALY)
Definition
• Epidemiology ≠ infectious disease
• Epidemiology: the study of the occurrence,
frequency, and distribution of diseases in a given
population
Smallpox
Robert Fisher
Insanity?
Smallpox vaccination
Eradication
Not a threat any more?
• “Most of the infectious diseases have now
yielded up their secrets. Many illnesses have
been exterminated: others have been brought
under control.”
(H. Sigerist in 1931)
• “It is time to close the book on infectious
diseases.”
(Surgeon general WH Stewart in 1969)
SARS outbreak, 2003
Wikimedia Maximilian Dörrbecker (Chumwa)
Questions of interest on infectious diseases
•
•
•
How transmissible is it?
How serious will the epidemic be?
What needs to be done to contain it?
–
•
What is the coverage of the intervention that is
needed?
Will it come back again?
Next week
• Bring your laptop for in-class exercise
• Make sure the battery can last for more than one
hour
• Read the paper on Ceiba course site
Mobile Phone Text Messaging:
Tool for Malaria Control in Africa
By Dejan Zurovac, Ambrose O. Talisuna, Robert W. Snow
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NakedNepal
http://nakednepal.com/?p=237
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This work is from: World birth aid
http://worldbirthaid.org/about/overview/
This work is used subject to the fair use doctrine of Article
52, 65 Taiwan Copyright Act by GET.
2012/07/17 visited
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UN – MDG
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Joy E Lawn, Anthony Costello, Charles Mwansambo, David Osrin.
Arch Dis Child 2007;92:551-556
http://adc.bmj.com/content/92/6/551.full
2012/07/31 visited
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www.sciencedirect.com
http://www.sciencedirect.com/science/article/pii/S01460005100
01175
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David Gregersen
http://dlgregersen.blogspot.tw/2010/04/clean-delivery-kits.html
Original photo took by: http://www.zambiamission.org/
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Unicef-Childinfo
http://www.childinfo.org/maternal_mortality.html
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Flickr World Economic Forum/Sandeep Naik
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University of Queensland, Brisbane, Australia
http://www.uq.edu.au/uqresearchers/researcher/lopezad.h
tml This work is used subject to the fair use doctrine of
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The Burrill Report
http://www.burrillreport.com/printer_article-634.html
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Flickr Martin Pettitt
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Prof Alan D Lopez PhD, Colin D Mathers PhD, Majid Ezzati
PhD, Dean T Jamison PhD, Christopher JL Murray MD
The Lancet, Vol. 367 No. 9524 pp 1747-1757, May 27, 2006
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Mathers et al 2006
http://www.dcp2.org/pubs/GBD ch3
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Lancet
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Prof Alan D Lopez PhD, Colin D Mathers PhD, Majid Ezzati PhD,
Dean T Jamison PhD, Christopher JL Murray MD
The Lancet, Vol. 367 No. 9524 pp 1747-1757, May 27, 2006
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Prof Alan D Lopez PhD, Colin D Mathers PhD, Majid Ezzati PhD,
Dean T Jamison PhD, Christopher JL Murray MD
The Lancet, Vol. 367 No. 9524 pp 1747-1757, May 27, 2006
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“Guns, Germs, and Steel” (author: Jared Diamond ) cover
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Wikimedia commons CDC
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Wikimedia commons Maximilian Dörrbecker (Chumwa)
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