>> GLOOD MORNING, EVERYONE. I'M FRANCIS COLLINS, THE DIRECTOR OF NIH. IT'S MY PLEASURE TO WELCOME YOU TO A VERY SPECIAL PRESENTATION BY A SPECIAL GUEST, DR. CHRISTOPHER MURRAY. DR. MURRAY IS CURRENTLY PROFESSOR OF GLOBAL HEALTH AT THE UNIVERSITY OF WASHINGTON AND DIRECTOR OF THE INSTITUTE FOR HEALTH METRICS AND EVALUATION, IHME, AT THAT INSTITUTION. MORE THAN ANYONE ELSE, DR. MURRAY HAS BEEN ASSOCIATED WITH CAREFUL QUANTITATIVE ANALYSIS OF THE GLOBAL BURDEN OF DISEASE OVER THE COURSE OF A NUMBER OF YEARS AND PARTICULARLY RELEVANT NOW, CULMINATING MOST RECENTLY IN A MAJOR PUBLICATION IN THE LANCET, WHICH I HOPE YOU PICKED A COPY OF ON YOUR WAY IN, IF YOU DIDN'T, THERE ARE M MORE COPIES ON THE TABLE. DR. MURRAY AND HUNDREDS OF COLLABORATORS GATHERED INFORMATION TO TRY TO ADDRESS WHAT THE TRENDS ARE, WHAT THE ACTUAL CIRCUMSTANCES ARE RIGHT NOW THAT ARE FACED BY THE BILLIONS OF PEOPLE ON THIS PLANET. THIS IS, AS YOU CAN IMAGINE, AN ABSOLUTELY ENORMOUSLY CHAL CHALLENGING TASK, AND TO BE ABLE TO PUT FORWARD A REPORT OF THIS SORT REPRESENTS REALLY A REMARKABLE ACHIEVEMENT. DR. MURRAY HAS PLAYED MAJOR ROLES FOR A NUMBER OF YEARS IN THIS SPACE, THE DISABILITY ADJUSTED LIFE YEAR OR THE DALY WE ALL REFER TO AS A MEANS OF ASSESSING HEALTH OF INDIVIDUALS IN THE POPULATION IS SOMETHING HE WAS VERY STRONGLY RESPONSIBLE FOR DEVELOPING BACK FOR THE 1996 VERSION FORT GLOBAL BURDEN OF DE, AND NOW WIT -- DISEASE, AND NOW WITH THIS MOST RECENT UPDATE, WE SEE THE TRENDS WHICH ARE IN MANY WAYS ENCOURAGING, IN OTHER WAYS WE HAVE A LONG WAY TO GO, AND I'M SURE HE WILL TALK TO YOU ABOUT SOME OF THOSE ACTIONS THAT WE MIGHT CONSIDER TAKING AWAY FROM THIS. CHRIS WILL ALSO TELL YOU SOMETHING ABOUT WHERE WE GO FROM HERE AS FAR AS THE COLLECTION AND THE MAKING THE DATA AVAILABLE GOING FORWARD, BAW OBVIOUSLY IN THE CURRENT ERA RAILROAD EVERYTHING IS MORE ELECTRONIC, IT WOULD BE WONDERFUL TO HAVE THE OPPORTUNITY IF IT CAN BE ARRANGED TO HAVE AN ONGOING SNAPSHOT OF THE WORLD'S HEALTH AS OPPOSED TO SOMETHING THAT COMES ALONG ONCE EVERY DECADE OR MORE. HIS ACADEMIC HISTORY, UNDER DWRAD WATT WORK AT HARVARD, B.A. IN BIOLOGY FOLLOWED BY A DOCTORATE FROM OXFORD UNIVERSITY, FOLLOWED BY AN M.D. BACK AT HARVARD MEDICAL SCHOOL. HE WORKED AT THE WORLD HEALTH ORGANIZATION FOR A NUMBER OF YEARS AS THE EXECUTIVE DIRECTOR IN THE EVIDENCE AND INFORMATION FOR POLICY CLUSTER, AND THEN WAS AT HARVARD FROM 2003 TO 2007. 2007, HE MOVED ACROSS THE COUNTRY TO THE WEST COAST, WHERE HE CONTINUES TO SERVE AS PROFESSOR OF GLOBAL HEALTH AT THE UNIVERSITY OF WASHINGTON. PROUD TO SAY HE HAS BEEN AN NIH GRANTEE FOR MUCH OF HIS PROFESSIONAL CAREER. WE'RE ALWAYS PLEASED TO BE ABLE TO CLAIM CREDIT FOR INDIVIDUALS OF THIS SORT WHO HAVE CONTRIBUTED SO ENORMOUSLY TO BIOMEDICAL RESEARCH. SO I'D AGAIN LIKE TO WELCOME ALL OF YOU TO WHAT I THINK IS GOING TO BE AN ABSOLUTELY STIMULATING PRESENTATION. WE'VE ALLOWED AN HOUR AND A HALF FOR THIS BECAUSE WE DIDN'T WANT TO CONSTRAIN THE DISCUSSION. DR. MURRAY WILL MAKE A PRESENTATION ABOUT SOME OF THE THINGS THAT HE THOUGHT THIS AUDIENCE WOULD BE MOST INTERESTED IN REGARDING THIS REPORT ON THE GLOBAL BURDEN OF DISEASE AND THEN WE SHOULD HAVE PLENTY OF TIME FOR QUESTIONS, BECAUSE THIS IS A WEBCAST EVENT, WHEN WE GET TO THE QUESTIONS, WE'LL ASK PEOPLE TO MOVE TO THE MICROPHONES THAT ARE IN THE AISLES SO THAT YOUR QUESTIONS CAN BE HEARD. SO WITHOUT FURTHER ADO, PLEASE JOIN ME IN WELCOMING TO THE PODIUM OUR SPECIAL PRESENTER, CHRISTOPHER MURRAY. THANK YOU. [APPLAUSE] >> WELL, THANK YOU VERY MUCH. SO WHAT I'D LIKE TO DO IN THIS PRESENTATION IS GO THROUGH A LITTLE BIT OF THE BACKGROUND OF THE CBD, FIVE KEY GLOBAL RESULTS, GIVE YOU A FLAVOR OF THE REGIONAL AND NATIONAL VARIATION AND THE RESULTS, I WANT TO GIVE YOU A TASTE OF U.S. RESULTS, THEY HAVEN'T BEEN PUBLISHED YET BUT THEY'RE EMBEDDED IN THIS STUDY, TALK ABOUT SOME OF THE MANY LIMITATIONS OF THE STUDY FOR WHICH I THINK FUTURE RESEARCH CAN ADDRESS SOME OF THEM, AND THEN TALK ABOUT WHAT DR. COLLINS MENTIONED JUST A MOMENT AGO, THAT OUR PLANS TO TURN THE GBD INTO A CONTINUOUSLY UPDATED GLOBAL PUBLIC GOOD. SO FIRST THE GLOBAL BURDEN OF DISEASE, WHAT IS IT? WE LIKE TO THINK OF IT AS A SYSTEMATIC SCIENTIFIC EVIDENT TO QUANTIFY THE COMPARATIVE MAGNITUDE OF HEALTH LOSS, NOT WELL-BEING, NOT MONEY, BUT HEALTH DUE TO DISEASES, INJURIES AND RISK BY AGE, BY SEX, IN THIS CASE BY COUNTRY, AND OVER TIME. FIRST DONE 20 YEARS AGO, OR STARTED IN 1991, INITIATED BY THE WORLD BANK, INTERESTINGLY, TO DRIVE OR FUEL THEIR POLICY ANALYSIS IN THE 1993 WORLD DEVELOPMENT REPORT. WHO TOOK ON THE TASK OF UPDATING IT AROUND THE YEAR 2000, AND THERE HAVE BEEN MORE THAN 37 PUBLISHED NATIONAL BURDEN OF DISEASE STUDIES USING THIS TYPE OF APPROACH. THE GBD 2010 IS AN ATTEMPT TO DO THIS IN A DRAMATICALLY EXPANDED SCOPE AND AMBITION. IT'S AT THE COUNTRY LEVEL AS OPPOSED TO THE REGIONAL LEVEL. IT IS USING THE SAME METHODS FOR TWO POINTS IN TIME, 1990 AND 2010, ALSO 2005 IN THE BACKGROUND. A LARGER LIST OF DISEASES, 291 DISEASES AND INJURIES, FOR WHICH WE QUANTIFY THE PREVALENCE OF 1,160 DIFFERENT SEQUELAE RELATED TO THOSE DISEASES. AND WE ALSO, IN THE RISK FACTOR ASSESSMENT, HAVE EXPANDED THE LIST OF RISKS. WE COVER 67 RISKS OR CLUSTERS OF RISKS. NOW, BULLET THREE HERE SAYS IN A SENTENCE WHAT HAS TAKEN YEARS TO ACHIEVE IN THIS STUDY, AND THAT IS FOR THE FIRST TIME, WE ACTUALLY TRIED TO BRING THE SORT OF RAISED BAR OF MODERN MEASUREMENT TO THIS TASK, AND QUANTIFY EVERY QUANTITY IN THE STUDY WITH UNCERTAINTY. AND THAT'S FORCED US TO MAKE MANY METHODOLOGICAL ENHANCEMENTS ALONG THE WAY. THE STUDY STARTED IN 2007 FUNDED IN THE CORE COMPONENT BY THE BILL AND MELINDA GATES FOUNDATION, BUT BECAUSE THE STUDY IS A GIANT COLLABORATIVE WITH 486 AUTHORS FROM 300-PLUS INSTITUTIONS IN 50 COUNTRY, MANY OF THEM HAVE BEEN SUCCESSFUL IN GETTING THEIR OWN FUNDING TO COVER THEIR SALARY TIME AND SOME OTHER TYPES OF WORK, SO THE TOTALITY OF THE FUNDING COMES FROM MANY SOURCES. AS DR. COLLINS MENTIONED, DECEMBER 15TH, THERE WAS A FIRST-EVER DEDICATED TRIPLE ISSUE OF THE LANCET TO THIS STUDY AND THERE'S MORE THAN 200 PUBLICATIONS IN SUBMISSION OR IN PREPARATION THAT WILL BE COMING IN THE NEXT YEAR OR TWO. JUST TO POINT OUT WHERE OUR COLLABORATORS COME FROM, WHILE HIGHLY CONCENTRATED IN HIGH INCOME COUNTRIES, MORE THAN HALF ARE ACTUALLY FROM LOW AND MIDDLE INCOME COUNTRIES, WHICH I THINK IS AN IMPORTANT ILLUSTRATION OF HOW AT LEAST THE SCIENCE AROUND EPIDEMIOLOGY HAS TRULY BECOME GLOBAL IN NATURE. NOW, WE CAN SPEND A LOT OF TIME ON METHODS, BUT WHAT I'M GOING TO DO IS ONLY GIVE YOU TWO SLIDES ABOUT METHODS. AND HOPEFULLY IN THE Q AND A OR IN FURTHER INTERACTION, WE CAN GO THROUGH THOSE METHODS IN MORE DETAIL. THIS SLIDE SHOWS THE DIFFERENT COMPONENTS OF THE STUDY AND HOW THEY'RE INTERRELATED. IT'S SORT OF COLOR-CODED. SO ON THE TOP BOX NUMBER TWO IS THE DEMOGRAPHIC ANALYSIS, AND MY COLLEAGUE WHO LED THE ANALYSIS WITH ALAN LOPEZ IS HERE, WHERE THE PURPOSE WAS TO PRODUCE LIFE TABLES FOR EVERY COUNTRY OVER TIME, USING ALL THE AVAILABLE DATA SOURCES. THE GREEN BOXES ARE THE CAUSE OF DEATH ANALYSIS, AND THERE'S A WHOLE SERIES OF VERY IMPORTANT THINGS THAT GO ON TO ENHANCE THE COMPARABILITY OF CAUGHT OF DEATH DATA, SO IT'S NOT ENOUGH TO SIMPLY HAVE VITAL REGISTRATION DATA, BUT THERE'S CONSIDERABLE VARIATION IN LOCAL CERTIFICATION PRACTICE AND WE TRY TO ADDRESS THAT. THAT MAKES A BIG DIFFERENCE TO SOME OF THE RESULTS, FOR EXAMPLE, THE FRENCH PARADOX MAY NOT BE AS MUCH A PARADOX AS MANY PEOPLE THINK ONCE YOU TAKE INTO ACCOUNT HOW THEY FILL OUT DEATH CERTIFICATES IN FRANCE. THERE'S A WHOLE COMPONENT AROUND THE MODELING OF CAUSE OF DEATH IN BOXES FOUR AND FIVE WHERE DATA ARE INCOMPLETE. THE BLUE BOXES ARE THE SYSTEMATIC ASSESSMENT OF THE WORLD'S EVIDENCE ON THE PREVALENCE AND INCIDENCE OF THE DISABLING SEQUELAE FROM DIFFERENT CONDITIONS, AND THAT ENTAILS ALSO AN EXPLICIT ATTEMPT TO MODEL CO-MORBIDITY IN EACH COUNTRY, AGE AND SEX GROUP, AND IN THE Q AND A, YOU CAN CERTAINLY COME BACK TO THAT. WE HAVEN'T PUT A LOT BASED ON THE CO-MORBID IT RESULTS IN THE LANCET ISSUE. THERE WILL BE MORE TO COME ON THAT, BUT I THINK IT'S AN IMPORTANT DEVELOPMENT IN THESE METHODS. THE PINK BOX IS THE NEW DISABILITY WEIGHT STUDY THAT JOSH SOLOMON LED AT HARVARD, WHO IS ALSO HERE. AND THEN THE SALMON-COLORED BOXES ON THE LEFT ARE THE ANALOGOUS WORK AROUND RISKS, LOOKING AT RISK FACTOR EXPOSURE, CYST AT THE ME ADVERTISING THE DATA, DOING METAANALYSES OF PUBLISHED STUDIES TO GET RELATIVE RISKS AND THEN ESTIMATING THE ATTRIBUTABLE BOTH BURDEN FROM PREMATURE MORTALITY AND DISABILITY. NOW, HERE'S A MORE DETAILED SLIDE ON THE BLUE BOX PART, THAT IS ASSESSING THE COMPONENTS, STILL IN THE LANCET ISSUE, SO IF YOU WANT TO LOOK IN DETAIL, PLEASE HAVE A LOOK THERE, OF ASSESSING THE PREVALENCE OF THE 1,160 DISABLING SEQUELAE. I JUST WANT TO NOTE THAT NOW, IN THE BURDEN OF DISEASE, IN THE PAST, THERE WAS A VERY SUBJECTIVE ELEMENT OF ANALYSTS LOOKING AT THE AVAILABLE DATA SOURCES AND SAYING, WELL, I THINK THIS IS THE BEST SOURCE AND I WILL USE IT TO FIGURE OUT THE PREVALENCE OF OSTEOARTHRITIS. WE'VE NOW SHIFTED TO A MUCH MORE FORMALIZED METAREGRESSION APPROACH USING A TOOL CALLED DISMOD-MR DEVELOPED EXPLICIT FOR THE DVD AND THERE IS A BOOK COMING ON THE METHODOLOGICAL BEHIND THIS, AND IT'S PRIMARILY THE WORK OF ABRAHAM FLAXMAN AT THE UNIVERSITY OF WASHINGTON OVER THE LAST FIVE YEARS. NOW, SOME TERMINOLOGY. THOSE OF YOU WHO ARE FAMILIAR WITH DALYs, THIS WILL BE OLD BUT LET MET MAKE SURE WE'RE ON THE SAME PAGE. THEIYOU TAKE DEATH AT AGE -- REFERENCE LIFE TABLE LIFE EXPECTANCY AT AGE X. OUR RIRCHES LIFE TABLE IS 86. IT'S BASED ON LOOKING AROUND THE WORLD AND IDENTIFYING THE LOWEST AGE-SPECIFIC DEATH RATE THAT IS OBSERVED IN 2010 AND CONSTRUCTING A LIFE TABLE FROM THAT. YEARS LIVED WITH DISABILITY IS ALSO VERY SIMPLE. IT'S PREVALENCE OF DIFFERENCE CAUSES OF DISABILITY OR THE 1,160 DISABLING SEQUELAE TIMES THE DISABILITY WEIGHT FOR THAT CONDITION. NOW, IN THE PAST, WE HAVE USED AGE WEIGHTING AND DISCOUNTING, WE HAVE NOT DONE THAT THIS TIME, BASED ON A BROAD CONSULTATION OF VARIOUS GROUPS INVOLVED IN THE STUDY, AS WELL AS REFLECTING THE MORE THAN 400 PAPERS IN THE LITERATURE ABOUT WHETHER AGE-WEIGHTING AND DISCOUNTING IS A GOOD IDEA. AND WE CONVENED A CONFERENCE OF PHILOSOPHERS AND ETHICISTS AS PART OF THIS STUDY AND CAME UP WITH THE CONCLUSION THAT WE WOULD NOT DO THAT. SO NOW WHILE THESE ARE REALLY QUITE SIMPLE, PREVALENCE TIMES SEVERITY WEIGHT AND THEN WE SUM THAT ACROSS SEQUELAE. SO THAT'S ALL I'M GOING TO SAY ABOUT METHODS AND CONTEXT. OF COURSE THERE'S AN INCREDIBLE ARRAY OF WORK THAT'S BEING DONE, AND I'M VERY HAPPY TO TRY TO FIELD QUESTIONS TO THE EXTENT I CAN OR DIRECT YOU TO THOSE WHO CAN ANSWER THEM BETTER. WHAT I'D LIKE TO DO IS START WITH THE END RESULT, AND THEN WORK BACKWARDS AS TO HOW DID WE GET HERE. THIS IS SORT OF MY SENSE OF THE END RESULT. IT IS IN THE LANCET PAPER ON DALYs AND IT SHOWS ON THE LEFT-HAND SIDE THE RANK ORDER OF DISEASES IN 1990, AND THE RANK ORDER OF DISEASES IN 2010 ON THE RIGHT-HAND SIDE. IT ALSO GIVES YOU UNCERTAINTY IN THE RANKS BECAUSE WE DO HAVE UNCERTAINTY IN EVERYTHING AND IN THE FAR RIGHT COLUMN, IT GIVES YOU THE PERCENT CHANGE IN ABSOLUTE TERMS. COMMUNICABLE MATERNAL NEONATAL CAUSES ARE IN RED, THE NON-COMMUNICABLE CAUSES ARE IN BLUE, AND THE INJURIES ARE IN GREEN. AND SO YOU CAN SEE THE EPITRANSITION SORT OF HAPPENING AT THE GLOBAL SCALE. AT THE TOP CONDITIONS NOW ARE ISCHEMIC HEART DISEASE UP FROM RANK FOUR TO NUMBER ONE, STROKE IS NUMBER THREE, YOU HAVE A DISABLING CONDITION, NOT A KILLER, AT NUMBER SIX, LOW BACK PAIN. CHRONIC OBSTRUCTIVE PULMONARY DISEASE IS NUMBER NINE. ANOTHER NCD, MAJOR DEPRESSION AT NUMBER 11, AND INTERSPERSED WITH THOSE ARE THE SORT OF STILL REMAINING CLASSIC GLOBAL HEALTH CHALLENGES. PNEUMONIA NUMBER TWO, DIARRHEA FOUR, HIV/AIDS FROM 33RD TO FIFTH, MALARIA HOLDING CONSTANT IN TERMS OF BURDEN IN THIS RANK ORDER, AND THEN CAN YOU SEE DROPS FOR THINGS LIKE PRETERM BIRTH COMPLICATIONS OR TUBERCULOSIS OR PROTEIN ENERGY MALNUTRITION THAT HAVE GONE DOWN SUBSTANTIALLY. A GLOBAL HEALTH SUCCESS STORY, FOR EXAMPLE, IS MEASLES, WHICH HAS GONE FROM 16TH TO 56TH OVER THIS TIME PERIOD. SO THERE'S A LOT BEHIND THIS TRANSITION OF THE DISEASES AND THE CRISSCROSSING LINES SORT OF TELL YOU ABOUT HOW MUCH CHANGE THERE IS IN THE WORLD AROUND US. DIABETES, FOR EXAMPLE, GOING FROM 21ST TO 14TH, GLOBAL BURDEN GOING UP BY ALMOST 70% IN THE TWO DECADES. SO HOW DO WE UNPACK THESE CHANGES THAT ARE PRETTY WELL DESCRIBED, I THINK, IN THE PAPER ON DALYs? THE WAY I WOULD DO THAT IS TO STEP BACK TO FOUR HIGH LEVEL MESSAGES THAT DRIVE THAT PATTERN. DEMOGRAPHIC CHANGE, A WELL CHARACTERIZED BUT RATHER RAPID CAUSE OF DEATH TRANSITION, A SHIFT THAT'S LESS WELL RECOGNIZED THAT INCREASINGLY BURDEN IS COMING FROM CHRONIC DISABILITY AND NOT PREMATURE MORTALITY, AND THEN THE TRANSITION IN RISK FACTORS FROM RISKS DOMINATED BY RISKS OF POOR CHILDREN IN POOR COUNTRIES TO RISKS THAT ARE RELATED TO THINGS LIKE TOBACCO, ALCOHOL, OR OTHER ASPECTS OF DIET AND BEHAVIOR. SO EACH A LITTLE BIT IN MORE DETAIL. FIRST, THE DEMOGRAPHIC CHANGE. WE HAVE SEEN REAL PROGRESS AT THE GLOBAL LEVEL IN REDUCING MORTALITY. THIS IS SHOWING PERCENT DECLINE IN THE GLOABLG AGE SPECIFIC DEATH RATES FOR MALES AND FEMALES, MALES IN GREEN, AND IN KIDS, THERE HAS BEEN DECLINES OF 60 TO 70%, AND IN MOST OF THE ADULT FEMALE AGE GROUPS, ABOUT A 40% DECLINE IN AGE-SPECIFIC RATES. FOR MALE MALES, THE DECLINES ARE SMALLER AND YOU'LL NOTICE THAT THERE IS MUCH LESS OF A DECLINE IN THE AGE GROUPS 20 TO 35. AND THAT IS NOT H.I.V. BECAUSE H.I.V. IS ABOUT EQUALLY DISTRIBUTED BETWEEN MALES AND FEMALES AT THE GLOBAL LEVEL. THAT'S ACTUALLY VERY LITTLE PROGRESS AROUND THE NUMBER OF INJURIES IN THOSE AGE GROUPS, AS WELL AS LITTLE PROGRESS ON DEATHS RELATED TO DRUG USE. NOW, A BETTER WAY TO UNDERSTAND THE DEMOGRAPHIC CHANGE THAT'S UNDERWAY IN THE WORLD IS WITH ONE SINGLE METRICS, SO IF YOU NEED TO KNOW ONE NUMBER ABOUT A COUNTRY AND GUESS WHAT THE BURDEN OF DISEASE WOULD BE IT WOULD BE KNOWING THE MEAN AGE OF DEATH. IT TURNS OUT TO BE HIGHLY PREDICTIVE OF THE ENTIRE PROFILE OF BURDEN OF DISEASE. THIS SHOWS THE MEAN AGE OF DEATH, WHICH IS A JOINT METRIC OF BOTH DE DEMOGRAPHIC AND EPIDEMIOLOGICAL CHANGE. ON THE X AXIS IS THE MEAN AGE OF DEATH IN 2010, AND ON THE Y AXIS IS THE MEAN AGE OF DEATH IN 1970, AND THE TRIANGLES ARE THE 21 REGIONS IN THE STUDY. AND IN A PLACE LIKE TROPICAL LATIN AMERICA SHOWING OVER ON THE RIGHT HERE, PARAGUAY AND BRAZIL, THERE THE MEAN AGE OF DEATH IN A 40 YEAR PERIOD HAS GONE UP BY ALMOST 33 YEARS. THAT'S AN INCREDIBLE PACE OF DEMOGRAPHIC CHANGE, TRANSFORMING THE TYPES OF DISEASES IN INDIVIDUALS COMING INTO HOSPITALS AND TO CLINICS AND THE PROFILE OF BURDEN IN A COUNTRY, AND THE PACE OF THAT CHANGE, I BELIEVE, IS SO FAST THAT MANY SYSTEMS, BOTH IN THE WAY THEY TRAIN, HEALTHCARE PROFESSIONALS AND IN THE WAY EVEN MINISTRIES OF HEALTH ARE ORGANIZED HAVE CHALLENGES IN JUST KEEPING UP WITH THE PACE OF CHANGE. I THINK IT'S WORTH DISCUSSING JUST WHAT MIGHT BE DONE ABOUT THAT LOOKING FORWARD. THE NET EFFECT OF THAT IS THAT THERE'S A SUBSTANTIAL SHIFT IN THE AGE DISTRIBUTION OF THE BURDEN AS SHOWN ON THIS DIAGRAM, WHICH SHOWS PERCENT OF DALYs BY AGE AT WHICH THEY OCCUR FROM DOMINATED IN CHILDREN UNDER AGE 5 IN 1990 SHOWN IN GREEN, TO STILL A LOT OF AVOIDABLE BURDEN IN CHILDREN, BUT INCREASINGLY SHIFTING INTO YOUNG AND MIDDLE AGED ADULTS AT THE GLOBAL SCALE. OKAY. SO THE CAUSE OF DEATH TRANSITION, I THINK IS PROBABLY FAMILIAR TO YOU. THAT IS THE NOTION THAT WE'RE SHIFTING FROM COMMUNICABLE DISEASES TO A WORLD MORE DOMINATED BY NON-COMMUNICABLE CAUSES OF DEATH, PARTICULARLY CARDIOVASCULAR DISEASE AND CANCER, AND HERE'S TWO WAYS OF SEEING THAT. THESE ARE SNAPSHOTS OF A LIVE TOOL THAT'S AVAILABLE ONLINE. IT'S ON OUR WEBSITE, I THINK IT'S ON THE LANCET WEBSITE, IT WAS ALSO AVAILABLE ON OTHER PLACES THAT HAVE GIVEN LINKS TO IT. AND IT SHOWS ON THE TOP LEFT THE ACTUAL DISTRIBUTION OF DEATH NUMBERS BY AGE AT THE GLOBAL SCALE. AND IT'S BROKEN DOWN BY 21 BROAD CAUSE GROUPS. THE LIGHT BLUE IS CANCER, THE DARK BLUE IS CARDIOVASCULAR DISEASE, AND YOU CAN JUST SEE AT THE SORT OF GROSS GLOBAL LEVEL HOW MANY OF THE DEATHS IN THE WORLD ARE STILL FROM THOSE CAUSES. THE BOTTOM RYAN PANEL I RIGHT PANEL IS EAC H AGE GROUP INFLATED UP TO 100%, SO YOU CAN DRILL DOWN AND LOOK AT THE CAUSE COMPOSITION BY AGE AND SEE FOR EXAMPLE IN YOUNGER AGE GROUPS THE PREDOMINANT ROLE OF INJURIES AS WELL AS H.I.V. AT THE GLOBAL SCALE AS CAUSING SUBSTANTIAL NUMBERS OF DEATHS IN THE AGE GROUPS FROM 15 TO 40. BUT IN GENERAL, WE FIND THAT THE PACE OF THE CAUSE OF DEATH TRANSITION IS QUITE FAST. WHAT THAT MEANS, SHOWING HERE IN THESE SORT OF ARROW DIAGRAMS AGAIN IN THE LEADING CAUSES OF DEATH, NOT PREMATURE MORTALITY, THIS IS JUST DEATH COUNT, SO A DEATH AT AGE 80 COUNTS THE SAME AT THE DEATH AT AGE 5, THAT ET LEADING CAUSE OF DEATH WE'RE SEEING SOME SUBSTANTIAL SHIFTS. CLEARLY H.I.V. WENT UP, BUT BARRING THAT, YOU SEE THE BLUE CAUSES, THINGS LIKE LUNG CANCER GOING FROM THE EIGHTH CAUSE TO THE FIFTH CAUSE, THE RISE OF DIABETES, THE RISE OF HYPERTENSIVE HEART DISEASE AS CAUSE OF DEATH, A STRING OF CANCERS IN ADDITION TO LUNG CANCER THAT ARE IN THE TOP 20, LIVER CANCER, STOMACH, CHRONIC KIDNEY DISEASE, RISING SUBSTANTIALLY, COLORECTAL CANCER ALSO RISING IN ABSOLUTE DEATH NUMBERS. SO THE CAUSE OF DEATH TRANSITION REALLY QUITE DEVELOPED AND FAR ALONG AT THE GLOBAL SCALE. WHAT THAT MEANS IS THAT THE FRACTION OF THE BURDEN OF DISEASE SHOWN HERE AT THE COUNTRY LEVEL THAT'S DUE TO NON-COMMUNICABLE DISEASES IS CHANGING REMARK PLI QUICKLY IN LATIN AMERICA, NORTH AFRICA, SOUTH ASIA, EAST ASIA AND SOUTHEAST ASIA. SO THIS IS THE CHANGE IN THE ABSOLUTE PERCENTAGE POINTS OF DALYs. IT'S NOT RELATIVE CHANGE, IT'S ABSOLUTE CHANGE. THE RED COLORS ARE ALL INCREASES IN THE FRACTION DUE TO NCDs AND THE DARK REDS ARE INCREASES OF 20 PERCENTAGE POINTS. SO REALLY SUBSTANTIAL SHIFTS IN THE FRACTION OF THE BURDEN THAT'S ATTRIBUTABLE TO NCDs AT THE GLOBAL LEVEL. NOW THE EXCEPTION, OF THAT, OF COURSE IS IN AFRICA WHERE THERE ARE SHIFTS BUT THEY'RE SUBSTANTIALLY SMALLER AND THERE'S A HANDFUL OF PLACES WHERE BECAUSE OF THE H.I.V. EPIDEMIC, THERE'S ACTUALLY BEEN A DECLINE IN THE FRACTION OF THE BURDEN RELATED TO NCDs DUE TO THE RISE OF H.I.V. NOW, THOSE SHIFTS FROM 1990 TO 2010 LEAD US TO THIS PICTURE OF THE FRACTION OF DALYs DUE TO NCDs AT THE GLOBAL SCALE. SO ALL OF THE COUNTRIES IN GREEN AND THE LIGHTER SHADE OR DARKER SHADE OF YELLOW, 50% OR MAR ARE NCDs. SO WE LIVE IN A WORLD WHERE OUTSIDE OF AFRICA, NCDs IS REALLY THE AGENDA, EVEN IN SOUTH ASIA. SO REALLY QUITE SUBSTANTIAL TRANSITION, WE'RE FAR ALONG IN THE EPITRANSITION, EXCEPT IN SUBIS A HAIRSUBISSAHARA AFRICA. ONE WAY TO UNDER STAT THE UNDERSTAND THE DISABILITY TRANSITION IS THIS ANALYSIS THAT DRAWS ON THE PAPER IN THE SERIES ON HEALTHY LIFE EXPECTANCY. AND THIS SHOWS HEALTHY YEARS LOST DUE TO DISABILITY, THAT'S THE DIFFERENCE BETWEEN LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY ON THE Y AXIS, AND LIFE EXPECTANCY ON THE X AXIS, AND EACH COUNTRY IS SHOWN AS A BLUE AND A RED DOT. THE BLUE DOT IS 1990, THE RED DOT IS 2010, AND THEY'RE CONNECTED BY A LINE. IT'S OUR ATTEMPT TO SHOW IN ONE PICTURE BOTH CROSS-SECTIONAL AND TIME SERIES DATA, AND WHAT IT GENERALLY SAYS IS THAT AS LIFE EXPECTANCY INCREASES, WHICH FORTUNATELY IS HAPPENING IN MOST PLACES IN THE WORLD, HEALTHY LIFE EXPECTANCY ALSO INCREASES, BUT THAT INCREASE IS SMALLER THAN THE INCREASE IN LIFE EXPECTANCY, IN OTHER WORDS, PEOPLE LIVE MORE YEARS WITH ONE OR SEVERAL CHRONIC CONDITIONS. PERHAPS NOT SURPRISING, GIVEN THE AGE STRUCTURE OF THOSE CONDITIONS. NOW, WHAT THAT TRANSLATES TO IN DALY TERMS IS THAT THE FRACTION OF THE BURDEN OF DISEASE THAT'S RELATED TO DISABILITY, OR CHRONIC DISABILITY, IS GOING UP. SO ON THIS GRAPH, WE LINE UP THE 21 REGIONS FROM LEFT TO RIGHT. MOST DEMOGRAPHICALLY AND EPIDEMIOLOGICALLY ADVANCED ON THE LEFT, LEAST ON THE RIGHT, 1990 ON THE LEFT PANEL, YOU SEE THE PREMATURE MORTALITY IN GREEN, AND YOU SEE DISABILITY IN ORANGE, AND IN 2010, YOU CAN SEE IN EVERY REGION, EXCEPT THE CARIBBEAN, WHICH IS DUE TO THE HAITI EARTHQUAKE, BUT IN EVERY OTHER REGION, YOU SEE A SHIFT TOWARDS A LARGER FRACTION OF THE BURDEN FROM DISABILITY, AND IN THE ADVANCED REGION, FOR EXAMPLE, NORTH AMERICA, YOU SEE WE'VE REACHED THE 50/50-POINT WHERE HALF THE BURDEN OF DISEASE IS CHRONIC DISABILITY AND NOT PREMATURE MORTALITY. MORE ON THAT. THE COUNTRY LEVEL, YOU CAN SEE, IN FACT, THERE'S A NUMBER OF PLACES NOW WHERE THE BURDEN OF DISEASE IS OVER 50% DUE TO DISABILITY, BUT IN SUB-SAHARAN AFRICA, THE AGENDA IS ENTIRELY OR LARGELY DOMINATED BY THE COMPONENT THAT'S RELATED TO PREMATURE MORTALITY. WHAT'S GOING ON HERE? HOW DO WE EXPLAIN THAT SHIFT TOWARDS DISABILITY? AND I THINK THE WAY TO UNDERSTAND IT IS GOING BACK TO THAT SLIDE I SHOWED IN HEALTHY LIFE EXPECTANCY. THIS IS ANOTHER WAY TO THINK ABOUT IT. WE'VE MADE REAL PROGRESS GLOBALLY ON REDUCING PREMATURE MORTALITY. HEART DISEASE PARTICULARLY BUT ALSO FOR SOME CANCERS AND A NUMBER OF OTHER CHRONIC CONDITIONS. ON THE OTHER HAND, THE PREVALENCE OF DISABILITY AT THE GLOBAL LEVEL, HERE SHOWN BY AGE, SHOWED FOR 1990 AND 2010, 1990 IS THE DASHED LINE, 20 TIN 10:IS THE SOLID LINE, HAS BARELY CHANGED. SO THE PREVALENCE HAS GONE DOWN SLIGHTLY BY AGE, SO WHEN YOU COMBINE ABOUT ALMOST NO PROGRESS ON REDUCING THE PREVALENCE OF CHRONIC DISABILITY WITH PEOPLE LIVING INTO LATER YEARS OF LIFE WHERE THE PREVALENCE IS HIGHER, THAT'S HOW YOU GET THIS SHIFT TOWARDS DISABILITY. HERE ARE THE NUMBERS. I THINK THE OTHER WAY TO UNDERSTAND WHY THERE'S PROGRESS ON PREMATURE MORTALITY BUT NOT DISABILITY IS THAT THE PRIMARY CAUSES OF DISABILITY ARE FUNDAMENTALLY DIFFERENT THAN THE PRIMARY CAUSES OF PREMATURE MORTALITY. THIS SHOWS THE DISTRIBUTION OF THE LEADING CAUSES OF THE ACTUAL NUMBER OF YLDs DPLOABL Ds GLOBALLY BY AGE. THE SORT OF PURPLE COLOR IS THE MUSCULOSKELETAL DISORDERS, THE DARKER PURPLE COLOR IS OTHER NON-COMMUNICABLE, WHICH INCLUDES VISION LOSS, HEARING LOSS, ANEMIAS AND A NUMBER OF OTHER CONDITIONS, AND YOU CAN ALSO SEE SOME DISABILITY COMING FROM INJURY, SOME COMING FROM DIABETES AND ENDOCRINE DISORDERS. BUT THE REALLY LARGE COMPONENTS OF CHRONIC DISABILITY ARE THINGS FOR WHICH WE HAVE NOT SEEN REAL PROGRESS IN EITHER NEW INTERVENTIONS OR IN REDUCING RATES AROUND THE WORLD. IF YOU LOOK AT THE MORE SPECIFIC LEVEL FOR LEADING CAUSE OF DISABILITY, AGAIN, THIS IS IN THE YLD PAPER, YOU FIND AN INTERESTING MIX OF THE LEADING CAUSES WITH RELATIVELY LITTLE CHANGE IN THE LEADING CAUSES FROM 1990 TO 2010. LOW BACK PAIN, MAJOR DEPRESSION, ANEMIA, IRON DEFICIENCY AND ANEMIA NUMBER THREE, NECK CANE, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, ANXIETY DISORDERS, MIGRAINE, DIABETES, SOME DISABILITY RELATED TO FALLS, OSTEOARTHRITIS ARE SOME OF THE LEADING CAUSES. IT'S A BLEND OF THE LEADING MENTAL DISORDERS, SUBSTANCE ABUSE, MUSCULOSKELETAL DISORDERS AND A FEW OTHER THINGS MIXED IN AS WELL. NOW, THE RISK TRANSITION IS THE FOURTH MAIN FACTOR THAT EXPLAINS WHAT WE'RE SEEING AROUND THE WORLD, AND THIS IS STRAIGHT FROM THE PAPER. YOU CAN ACTUALLY LOOK IN THE LANCET ISSUE, YOU'LL BE ABLE TO SEE IT A LITTLE MORE CLEARLY, BUT BASICALLY THIS SHOWS THE LEADING GLOBAL RISKS FOR MALES, FEMALES, MALES ON TOP LEFT, FEMALES ON THE RIGHT, BOTH SEXES ON THE BOTTOM LEFT, AND IT'S AN INTERESTING SET OF LEADING RISKS NOW. WITH HIGH BLOOD PRESSURE BEING THE NUMBER ONE RISK FOLLOWED BY TOBACCO, THEN ALCOHOL, HOUSEHOLD AIR POLLUTION FROM SOLID FUEL USE IS NUMBER FOUR, MUCH HIGHER THAN IN THE PAST, AND THEN WE HAVE A SERIES OF COMPONENTS OF DIET. COLLECTIVELY DIET ACCOUNTS FOR ABOUT 10% OF THE BURDEN OF DISEASE, AND WE'VE BROKEN THAT DOWN INTO 15 DIFFERENT COMPONENTS WITH SEPARATE METAANALYSES AND EXPOSURE ANALYSES FOR EACH. THEN NUMBER SIX, YOU SEE HIGH BODY MASS INDEX, CHILDHOOD UNDER WEIGHT NOW NUMBER EIGHT ON THIS LIST. ANOTHER WAY TO LOOK AT THAT IS JUST HOW MUCH CHANGE THERE HAS BEEN IN THE LEADING RISKS FROM 1990 TO 2010. IN 1990, ON THE LEFT PANEL, CHILDHOOD UNDERWEIGHT WAS THE NUMBER ONE RISK. IT'S NOW DROPPED TO THE NUMBER EIGHT RISK. THE NUMBER FIVE RISK IN 1990 WAS SUBOPTIMAL BREAST READING, THAT'S NOW THE NUMBER 14 RISK. UNAPPROVED SANITATION IS GONE FROM 15TH TO 26TH, THE MICRO NUTRIENTS HAVE ALSO DROPPED SUBSTANTIALLY. PART OF THIS IS BOTH IMPROVEMENTS IN EXPOSURE BUT ALSO THAT THERE'S A VERY BRISK DECLINE IN DIE REAL DEATHS IN CHILDREN, ABOUT 3% PER YEAR GLOBALLY, AND SLIGHTLY LOWER BUT STILL SUBSTANTIAL DECLINE IN PNEUMONIA DEATHS IN CHILDREN OVER THE LAST TWO DECADES. SO WHAT THAT MEANS, WHY THEY'VE DROPPED SO MUCH IS BOTH IMPROVEMENTS IN EXPOSURE TO THOSE RISKS AS WELL AS THE BACKGROUND RATES THAT THEY'RE APPLIED TO ARE DROPPING SUBSTANTIALLY. OP THE FLIP SIDE, WE SEE SUBSTANTIAL INCREASES BOTH IN ABSOLUTE TERMS AND RELATIVE TERMS FOR BLOOD PRESSURE, TOBACCO AND ALCOHOL USE AS WELL AS ALL THE DIFFERENT COMPONENTS OF DIET THAT INFLUENCE CARDIOVASCULAR DISEASE. MY LAST KEY METHOD AT THE GLOBAL LEVEL IS ABOUT AFRICA, WHICH AS WE SAW ON THE MAP FOR THE NCDs AND FOR THE DISABILITY COMPONENT THAT AFRICA STOOD OUT AS BEING QUITE A BIT DIFFERENT THAN THE REST OF THE WORLD AND HERE'S ANOTHER WAY OF LOOKING AT THAT, SHOWING THE FRACTION OF THE BURDEN OF DISEASE IN EACH OF THE REGIONS RELATED TO MGDs FOUR, FIVE AND SIX UNDER CHILDHOOD MORTALITY, MATERNAL MORTALITY, H.I.V., T.B AND MALARIA. IN GREEN IN 1990 AND IN RED IN 2010. AND THERE'S SUBSTANTIAL REDUCTIONS IN THE MGD -- IN ALL REGIONS EXCEPT IN SUB-SAHARAN AFRICA WHERE THERE'S SOME REDUCTION IN EAST AFRICA AND WEST AFRICA, BUT IN GENERAL, THE MDG AGENDA STILL PREDOMINATES IN SUB-SAHARAN AFRICA, WITH 60 TO 70% OF THE BURDEN ATTRIBUTABLE TO THOSE CONDITIONS IN 2010. SO LET ME ILLUSTRATE, IF YOU WILL, THESE FINDINGS ACROSS REGIONS USING SOME OF THESE LIVE TOOLS. THIS IS ONLINE, SO PLEASE USE IT, AND ON MARCH 5TH, WE'LL BE RELEASING THESE TOOLS AND OTHERS THAT I'LL BE SHOWING YOU AT THE COUNTRY LEVEL AS WELL. SO FOR NOW, IT'S AT THE GLOBAL AND THE RENALLAL LEVEL. HERE'S THE NUMBER OF DEATHS FOR ACROSS 21 BROAD -- GROUPS BY REGION. IF WE SWITCH TO LOOKING AT RATES, FOR EXAMPLE, YOU TAKE A WAY THE GIANT DIFFERENCES IN POPULATION ACROSS REGIONS AND YOU SEE IN TERMS OF CRUDE DEATH RATES, THIS IS THE DIFFERENCE AROUND CAUSES, IN THE CARIBBEAN, THIS DARK RED COMPONENT IS THE HAITI EARTHQUAKE, YOU CAN SEE HOW THAT STANDS OUT, AND YOU CAN SEE HOW, FOR EXAMPLE, H.I.V. AID AND T.B. IN DARK YELLOW HERE IS PREDOMINANT IN SUB-SAHARAN AFRICA, YOU HAVE AN IMPORTANT COMPONENT TO DIARRHEA AND PNEUMONIA STILL, OTHER INFECTIOUS DISEASES AND MALARIA, IN THIS LIGHTER YELLOW COLOR. AND AS YOU MOVE FROM THE DEMOGRAPHICALLY LEAST ADVANCED TO MOST ADVANCED REGIONS, THE CRUDE DEATH RATES RISE FOR CANCER AND HEART DISEASE. IF YOU STICK TO A VIEW OF YEARS OF LIFE LOST, YOU GET A DIFFERENT VIEW, YOU RECOGNIZE MUCH GREATER VARIATION IN RATES ACROSS REGIONS WITH PREMATURE MORTALITY BEING DRAMATICALLY HIGHER IN SUB-SAHARAN AFRICA THAN PREMATURE MORTALITY IN THE MORE ADVANCED REGIONS, AND IF YOU GO TO A CAUSE COMPOSITION VIEW, PREMATURE MORTALITY PUTS MORE EMPHASIS ON INJURIES AND MORE EMPHASIS ON SOME OF THE INFECTIOUS DISEASES OF CHILDREN. WHEN WE GO TO LOOK AT DISABILITY, ACROSS REGIONS, THE DISABILITY FROM MENTAL DISORDERS IN GREEN -- AND LET ME GO BACK TO LOOKING AT RATES HERE SO YOU CAN SEE RATES, NOT PERCENT. THE DISABILITY FOR MENTAL BEHAVIOR DISORDER IS QUITE SIMILAR, TH YOU SEE VARIATION IN VISION/HEARING LOSS ACROSS REGIONS AND IT IS TRUE THAT THE DISABILITY RELATED TO COMMUNICABLE MATERNAL AND NUTRITIONAL CAUSES IS MUCH HIGHER IN THE SUB-SAHARAN AFRICA THAN ELSEWHERE, BUT DESPITE THE DISAPPEARANCE OF THOSE, THE TOTAL RATES OF DISABILITY ACTUALLY AREN'T DECLINING IN CRUDE TERMS. WHEN WE PUT THIS TOGETHER IN TERMS OF DALYs, YOU GET THIS FINAL PICTURE ACROSS REGIONS. SO HUGE HETEROGENEITY ACROSS RENALES IN TERMS OF BOTH THE TOTAL LEVEL OF BURDEN, BUT IF WE DRILL DOWN BY CAUSE, THERE TURNS OUT, AS YOU WOULD GET, TO BE ENORMOUS VARIATION FOR SPECIFIC CAUSES. AND IT'S TRICKY FOR US TO CONVEY THAT DETAIL, BUT I'LL TRY TO GIVE YOU SOME SIMPLE SENSE OF THAT IN THESE PICTURES. SO IF YOU WANT A VERY SIMPLISTIC WAY TO LOOK AT COUNTRY VARIATION AND BURDEN, THIS MAP SHOWS THE LEADING CAUSE OF BURDEN IN EACH COUNTRY. SO IT'S JUST ONE CAUSE, BUT IT DOES GIVE YOU A FRAMEWORK FOR THINKING ABOUT EPIDEMIOLOGICAL HETEROGENEITY. THE DARK BLUES ARE ISCHEMIC HEART DISEASE. AND YOU CAN SEE THAT IN MANY DEVELOPING AS WELL AS MOST OF THE DEVELOPED WORLD, ISCHEMIC HEART DISEASE IS STILL THE NUMBER ONE CAUSE OF BURDEN. IN SOME COUNTRIES SHOWN IN PURPLE, DIABETES, LIKE IN MEXICO OR MOROCCO AND MANY OF THE ISLANDS IN THE CARIBBEAN AND THE PACIFIC IS NOW THE NUMBER ONE CAUSE OF BURDEN. THERE ARE PLACES, FOR EXAMPLE, WHERE ROAD TRAFFIC ACCIDENTS LIKE SAUDI ARABIA OR AHMAN OR EQUADOR ARE THE LEADING CAUSE OF BURDEN. THERE ARE PLACES WHERE HOMICIDE IS THE LEADING KAWSES OF BURDEN. IF I WERE TO SHOW YOU A MAP FOR MALES, HOMICIDE IS THE NUMBER ONE CAUSE OF THE BURDEN OF DISEASE ALL THE WAY FROM CENTRAL AMERICA THROUGH TO BRAZIL IN MALES IN THAT PART OF THE WORLD. IN SUB-SAHARAN AFRICA, YOU CAN SEE A SORT OF X, A RED LINE FOR THE H.I.V. CORRIDOR FROM KENYA DOWN TO SOUTH AFRICA, WHERE H.I.V. IS THE NUMBER ONE CAUSE, AND ANOTHER LINE IN YELLOW RUNNING FROM MAUI TO MADAGASCAR. IN OTHER PARTS OF THE WORLD, STROKE HAS BECOME THE NUMBER ONE CAUSE OF THE BURDEN OF DISEASE. SO A HINT AT THE RICHNESS OF THE UNDERLYING DATA AND THE INTERESTING PATTERNS THAT WE SEE, AND THE COUNTRIES IN LIGHT BROWN AND MEDIUM BROWN ARE WHERE DIARRHEA REMAINS THE NUMBER ONE CAUSE OF THE BURDEN OF DISEASE. WE CAN DO THE SAME THING FOR RISKS. INTERESTING STORY WHERE SMOKING IS STILL THE NUMBER ONE CAUSE IN NORTH AMERICA, MANY PARTS OF WESTERN EUROPE, PLACES LIKE THAILAND, VIETNAM. BUT YOU ALSO SEE WHERE SYSTOLIC BLOOD PRESSURE OR ELEVATED SYSTOLIC BLOOD PRESSURE IN DARK GREEN IS THE LEADING CAUSE IN MANY PARTS OF EAST AND SOUTHEAST ASIA, BUT AS WELL AS SOME PARTS OF LATIN AMERICA AND NORTH AMERICA AND THE MIDDLE EAST. THE LIGHT PURPLY COLOR IS WHERE OBESITY HAS BECOME THE NUMBER ONE RISK TO MEXICO TO AUSTRALIA TO MANY PARTS OF THE MIDDLE EAST. SHOWING A DIVERSITY OF RISK FACTORS, ALCOHOL IS THE LIGHT GREEN COLOR, WHERE ALCOHOL IS THE LEADING RISK RUNNING FROM MUCH OF CENTRAL AMERICA THROUGH TO BRAZIL, AS WELL AS MOST OF SOUTHERN AFRICA. INTERESTING BLEND OF RISKS IN A PLACE LIKE SOUTHERN AFRICA. AND THEN CHILDHOOD UNDERWEIGHT, ALTHOUGH DROPPING GLOBALLY FROM THE FIRST CAUSE TO THE EIGHTH CAUSE REMAINS THE LEADING CAUSE OF BURDEN IN MUCH OF WEST AFRICA AND CENTRAL AFRICA. SO THAT'S THE STORY AT THE REGIONAL GLOBAL LEVEL. I WANT TO ILLUSTRATE THE APPROACH FROM THE BURDEN OF DISEASE BECAUSE I THINK THERE'S A USE FOR THIS DATABASE THAT WE'RE JUST STARTING TO EXPLORE, WHICH IS THE CAPACITY TO BENCHMARK A COUNTRY'S PROGRESS IN THE LAST TWO DECADES VERSUS OTHERS. SO HERE'S THE US STORY BEHIND THE SCENES FROM THE RESULTS. THIS SHOWS THE SAME PICTURE I SHOWED YOU AT THE GLOBAL SCALE FOR CHANGES IN AGE-SPECIFIC MORTALITY FOR THE U.S. FROM 1990 TO 2010. PROGRESS. THE ONLY CASE WHERE THERE HAS NOT BEEN NATIONAL PROGRESS IN REDUCING DEATH RATES IS IN FEMALES AGE 40 TO 44, BUT YOU CAN SEE THAT THERE'S LOWER LEVELS OF PROGRESS THAN AT THE GLOBAL SCALE, AND CERTAINLY LOWER LEVELS OF PROGRESS COMPARED TO SOME OTHER HIGH INCOME COUNTRIES, AND HERE'S A WAY TO SEE THAT. FOR AN ANALYSIS ASKED BY THE U.K. GOVERNMENT, WE'VE LOOKED AT THE EU15, THE ORIGINAL 15 MEMBERS OF THE EUROPEAN UNION US FROM AUSTRALIA, CANADA, NORWAY AND THE U.S. A SORT OF GROUP OF HIGH INCOME COUNTRIES THAT HAVE QUITE ADVANCED HEALTHCARE SYSTEMS AND HAVE A SUBSTANTIAL SPENDING ON HEALTHCARE. THIS IS THE RANK OF THE U.S. FOR THE AIDS-SPECIFIC DEATH RATE FOR MALES BY AGE GROUP. IN 1990 IN BLUE, AND 2010 IN RED. ESSENTIALLILY WHAT IT SAYS, OUT OF 19 COUNTRIES, THE U.S. RANKED SOMEWHERE BETWEEN 15TH TO 19TH, UP THROUGH TO AGE 65, AND ABOVE 65, CERTAINLY IN 1990 IT WAS DOING MUCH BETTER AND THOSE RANKS HAVE NOW DROPPED FROM 1990 TO 2010, SO WE'RE BACK TO NOT DOING VERY WELL EXCEPT AGE GROUP 75 TO 79 AND 80-PLUS, AND LOTS OF HIGH POT CEASE, I'M SURE, YA THAT MIGHT BE. FOR WOMEN THE STORY IS SIMILAR EXCEPT WE'VE PRETTY CONSISTENTLY GONE TO THE BOTTOM OF THE EU15 PLUS, RANKING 19TH FOR WOMEN FOR MOST AGE GROUPS UNDER 70, AND EVEN IN THE OLD AGE GROUPS NOW ONLY RANKING 14TH, ALTHOUGH DOING MUCH BETTER IN 1990 IN THOSE OLDER AGE GROUPS. NOW, THE UNDER DP UNDERLYING BURDEN OF DISEASE ARE COMPLICATED TO COMMUNICATE BECAUSE WE HAVE MANY DIFFERENT NUMBERS AND YOU HAVE TO MULTIPLY THAT BY A THOUSAND BECAUSE WE DO A THOUSAND DRAWS FOR EACH AREA OF INTEREST SO WE HAVE SITTING IN OUR SYSTEM THE 650 MILLION DATABASE REPLICATED WITH A THOUSAND REPLY CATS TO BE ABLE TO LOOK AT DISTRIBUTIONS ACROSS VARIOUS OUTCOMES. SO WE'VE SPENT QUITE A BIT OF TIME TRYING TO BUILD TOOLS TO EXPLORE THESE RESULTS. AND WHAT I'M GOING TO SHOW YOU NOW IS -- THAT'S MY DAUGHTER. I'M GOING TO SHOW YOU AT THE GLOBAL LEVEL HOW WE BUILT ONE OF THESE INTERFACES. SO THIS IS A DI DYNAMIC TOOL THAT ALLOWS YOU TO LOOK AT TRENDS OVER TIME AND OTHER QUANTITIES WITHIN THE DATABASE AT DIFFERENT LEVELS OF DETAIL. SO THIS IS GLOBALLY DALYS IN 1990, THE NON-COMMUNICABLE CAUSES ARE IN BLUE, THE COMMUNICABLE MATERNAL CAUSES IN RED, INJURIES IN GREEN, AND YOU CAN SEE HOW THE EPITRANSITION, THE DEMOGRAPHIC TRANSITION, IS SHIFTING THE GLOBAL BURDEN TOWARDS THE NCDs, PRETTY SIMPLY, AT THAT LEVEL. NOW, IF WE BREAK IT DOWN TO A MORE DETAILED LEVEL, ONE CAUSE DOWN, YOU START TO SEE SOME OF OF THE PATTERNS, FOR EXAMPLE, WHERE THIS IS THE BREAKDOWN AROUND CANCERS, CARDIOVASCULAR DISEASE, THE MENTAL DISORDER, THE MUSCULOSKELETAL DISORDERS HERE, BREAKDOWN BY DIFFERENT NEUROLOGICAL CONDITIONS, BREAKDOWN FOR INJURIES. NOW, IF I SHOW YOU THE UNITED STATES, WE CAN ALSO SEE THIS STORY PLAYING OUT IN THE U.S. THIS IS FOR BOTH SEXES COMBINED. WE ALSO HAVE IT FOR EACH AGE GROUP IN HERE, AND WE CAN ALSO WATCH THIS STORY BACK TO 1990 FOR THE U.S. AS WELL. WHERE THERE'S BEEN SOME SHIFTS. YOU'LL NOTICE THE DECLINE IN CARDIOVASCULAR DISEASE IS PRETTY OBVIOUS AT THIS MACRO LEVEL FOR THE UNITED STATES AROUND THE BURDEN OF DISEASE. JUST AS A FLAG, THESE WILL BECOME AVAILABLE TO THE PUBLIC ON MARCH 5TH, ALL THESE TOOLS, SO THAT ANYBODY CAN EXPLORE THE DATABASE AND HOPEFULLY COME UP WITH BOTH HIG HYPOTHESES AND THINGS WE CAN DO IN THE FUTURE. U.S. RESULTS FOR BURDEN, THIS IS SHOWING U.S. LEADING CAUSES OF DEATH IN 1990, COMPARED TO 2010, LOOK AT THE RISE OF ALZHEIMER'S, FOR EXAMPLE, IN THE NUMBER OF DEATHS IN THE U.S. OTHER BIG RISERS, CHRONIC KIDNEY DISEASE, PANCREATIC CANCER SLIGHT INCREASE, FALLS WAY UP, AND THEN YOU CAN SEE THE RISE OF THINGS LIKE KIDNEY CANCER, PARKINSON'S, DECLINES IN VIOLENCE, LIVER CANCER GOING UP IN NUMBERS, DRUG USE DISORDERS. WE CAN THEN LOOK AT HOW A LENS ON PREMATURE MORTALITY SHIFTS THE VIEW, AND WHAT HAPPENS, OFTEN, IS THINGS THAT KILL YOU AT A YOUNGER AGE BECOME MUCH MORE IMPORTANT, SO YOU SEE ROAD INJURY GOING TO THE SIXTH CAUSE AND SUICIDE -- I MEAN THE FIFTH CAUSE AND SUICIDE THE SIXTH CAUSE, BUT STILL EVEN IN TERMS OF PREMATURE MORTALITY, ISCHEMIC HEART DISEASE, LUNG CANCER, STROKE AND COPD ARE AT THE TOP. SO WE'VE HAD BIG PROGRESS IN ABSOLUTE REDUCTION IN BURDEN BUT THEY STILL REMAIN THE LEADING CAUSES OF PREMATURE MORTALITY, BUT SEE THE BIG RISE OF DIABETES, SIR OW CIRRHOSIS, AND THEN IF YOU PUT THIS ALL TOGETHER IN TERMS OF THE BURDEN IN THE U.S., YOU GET THIS BLEND OF PREMATURE CAUSES AND CAUSES OF CHRONIC DISABILITY. WITH ISCHEMIC HEART DISEASE AND COPD AT THE TOP AND LOW BACK PAIN, THE THIRD LEADING CAUSE. LUNG CANCER FOUR, MAJOR DEPRESSION FIVE, STROKE, DIABETES, NECK PAIN, ROAD INJURY, DRUG USE DISORDERS AND ON DOWN THE LIST. SO THERE IS U.S. RESULTS. I RECOGNIZE THESE ARE SMALL TO SEE ON THE SCREEN, PU MOSTLY MOST -- BUT MOSTLY THIS IS TO FLAG THAT THE UNDERLYING ANALYSIS HERE IS BY COUNTRY, AND WILL BE AVAILABLE I IN THE NOT TOO DISTANT FUTURE. SO COMING BACK TO THE BENCHMARKING IDEA, HERE'S ANOTHER WAY OF LOOKING AT THOSE RESULTS, WHICH IS TAKING THOSE 19 COMPARATIVE COUNTRIES WITH REASONABLY HIGH EXPENDITURE HEALTH SYSTEMS IN ADVANCED DEM KRA GREE, THIS SHOWS FOR THE 30 LEADING CAUSES OF PREMATURE MORTALITY IN THE U.S., FOR EACH CAUSE, HOW THE U.S. RANKS ACROSS THOSE 19 COUNTRIES. WHAT YOU FIND, WE USED A HEAT MAP TO HELP YOU VISUALLY SEE WHERE THE U.S. DOES WELL IN GREEN AND WHERE IT DOES MODERATELY WELL IN YELLOW AND THEN BELOW AVERAGE IN THE ORANGE AND RED COLORS. WHAT LEAPS OUT, THAT AMONGST THE LEADING CAUSES IN THE U.S., WE DO RATHER WELL FOR STROKE. WE'RE FIFTH ACROSS THESE COUNTRIES FOR STROKE, WE DO RATHER WELL FOR COLORECTAL CANCER. WE'RE THIRD FOR COLORECTAL CANCER, DO WE VE VERY WELL IN BRAIN CANCER, PROSTATE CANCER AS WELL, NUMBER FIVE, INTERESTING FALL TO NUMBER SEVEN. EVERYTHING ELSE WE'RE BELOW AVERAGE AND ACTUALLY ARE THE WORST FOR A RANGE OF CONDITIONS, INCLUDING DIABETES AT NUMBER 19, ISCHEMIC HEART DISEASE DESPITE ALL THE PROGRESS AT EAB, COPD AT NUMBER 19. HERE'S ONE LAST WAY TO TAKE THAT SAME DATA AND JUST SHOW YOU THE SENSE OF TIME. SO THIS IS TAKING THE 20 LEADING CAUSES OF YLLs ON THE X AXIS ORDERED FROM BIGGEST ON THE LEFT TO SMALLEST ON THE RIGHT AMONGST THE TOP 20 AND SHOWING THE CHANGE IN THE U.S. RANK ACROSS THESE 19 COUNTRIES. RED, THE RANK IS GETTING WORSE, GREEN, THE RANK IS GETTING BETTER, AND YOU CAN SEE QUITE SUBSTANTIAL -- WELL, MODEST, I SHOULD SAY, IMPROVEMENT FOR LUNG CANCER FROM 18TH TO 16TH, FOE COLORECTAL CANCER ALREADY DOING WELL IN 1990, FOR BREAST CANCER, A ONE RANK IMPROVEMENT, AND THEN ALL THE OTHER RED DIAGRAMS IS WHERE THE U.S. HAS ACTUALLY DROPPED RELATIVE PERFORMANCE OR OUTCOME COMPARED TO THESE OTHER HIGH INCOME COUNTRIES. SO ANOTHER WAY TO HELP NAVIGATE PERHAPS WHERE THE U.S. HAS DONE AN EFFECTIVE JOB AT A POPULATION HEALTH LEVEL VERSUS A LESS EFFECTIVE JOB. SAME STORY CAN BE LOOKED AT FOR DALYs. I JUST NOTE THAT ALTHOUGH LOW BACK PAIN IS AN ISSUE, PREVALENCE SUPPORTS IT'S LOWER THAN THE REST OF THE HIGH INCOME WORLD. I HAVE NO EXPLANATION FOR WHY THAT IS. BUT IT DOES APPEAR IN THE AVAILABLE DATA. NOW ON THE RISK FACTOR FRONT FOR THE U.S., TOBACCO IN TERMS OF DEATHS, TOBACCO IS THE NUMBER ONE RISK, BUT VERY CLOSE BEHIND IT IS HIGH BLOOD PRESSURE, OBESITY, AND ALCOHOL USE. THEN WE DROP DOWN TO NUMBER FIVE BEING PHYSICAL ACTIVITY, THEN THESE COMPONENTS OF DIET, WHICH I THINK IS ONE OF THE LIMITATIONS I'LL COME TO ABOUT HOW MUCH WE BELIEVE THERE MAY BE RESIDUAL CONFOUNDING STILL IN THE PUBLISHED META ANALYSES AROUND DIE DIET. I THINK THAT'S A WORT WORTHWHILE DEBATE. THE STORY FOR DALY IS FAIRLY SIMILAR. TOBACCO AT THE TOP, AND OBESITY NUMBER TWO. ALCOHOL CLOSE BEHIND AT NUMBER THREE, FOLLOWED BY HIGH BLOOD PRESSURE. NOW, IN A STUDY THIS LARGE, THERE ARE LOTS OF ISSUES. AND LIMITATIONS. AND MANY OF THEM, I THINK, CAN BE ADDRESSED IN THE FUTURE. AND I'D LIKE TO THINK OF THE LIMITATIONS IN A TOPOLOGY OF THREE BROAD CATEGORIES: PRIMARY DATA, THERE'S HUGE GAPS IN THE PRIMARY DATA. THERE'S ALSO LOTS OF DATA OUT THERE THAT WE COULDN'T GET AHOLD OF BECAUSE OF THE TENDENCY FOR SOME DATA SOURCES TO NOT BE MADE AVAILABLE FOR A STUDY LIKE THIS OR NEVER AVAILABLE FOR OTHER USE. AND I THINK THAT'S AN ISSUE, DR. COLLINS REFERRED TO THAT AS WELL AT THE BEGINNING. THERE'S A WHOLE SERIES OF ISSUES ABOUT THE IMPORTANT ROLE OF POST DATA COLLECTION, CORRECTIONS OR ADJUSTMENTS TO ENHANCED COMPARABILITY. ALL THE THINGS WE HAVE TO DO TO ENHANCE CAUSE OF DEATH DATA FOR GARBAGE CODING OR CODING -- UNLIKELY CAUSES OF DEATH OR EVEN POPULATION BASED CANCER REGISTRIES, WHERE INCIDENTS OR DEATHS GET ASSIGNED TO BROAD CATEGORIES TA ARE NOT A SPECIFIC SITE. ANOTHER EXAMPLE IS IN THE PUBLISHED STUDIES, UNPUBLISHED STUDIES ON DIABETES, WE IDENTIFIED 18 DIFFERENT FUNCTIONAL DEFINITIONS OF DIABETES. SO TO BE ABLE TO USE THAT DATA, WE HAVE TO CROSSWALK BETWEEN 18 DIFFERENT DEFINITIONS. OTHERWISE YOU HAVE TO THROW OUT MOST OF THE DATA IF YOU JUST PICK OUT ONE DEFINITION AND USE IT. SO THERE'S A WHOLE AGENDA ABOUT ENHANCED STANDARDIZATION AS WELL AS IMPROVEMENT AROUND WAYS THAT WE DO THIS POST DATA COLLECTION COMPARABILITY ADJUSTMENTS. THIRD, THERE'S THE WHOLE AREA ABOUT STATISTICAL MODELING AND ESTIMATION TO FILL IN -- DEAL WITH THE TWO PARADOXICAL ISSUES, MISSING DATA OR THE ABSENCE OF DATA IN SOME CASES, AND INCONSISTENT MULTIPLE MEASUREMENTS FOR THE SAME QUANTITY OF INTEREST AT THE SAME PLACE AT THE SAME TIME. WE'VE LARGELY SHIFTED TO -- METHODS BUT THEY CAN CERTAINLY BE STRENGTHENED IN A WAY, AND I THINK THERE'S MANY IDEAS IN THE FUTURE ON HOW ONE WOULD DO THAT. SOME VERY SPECIFIC LIMITATIONS THAT I'D LIKE TO FLAG, BECAUSE I THINK THEY ARE -- THEY'VE COME OUT ALREADY IN THE DISCUSSION, THEY CAME OUT IN OUR PREPARATION OF THE WORK. THERE'S A REAL ISSUE AROUND ADULT MORTALITY MEASUREMENT IN PARTS OF SUB-SAHARAN AFER KA. THERE IS THE OUTSTANDING ISSUE OF VARIATION IN MEDICAL CERTIFICATION PRACTICE THAT ALTHOUGH WE TRY TO CORRECT SOME OF IT, IT'S STILL THERE, THAT IN SOME PLACES PEOPLE ARE MORE LIKELY TO TAKE THE SAME CASE AND CALL IT DIABETES, SOMEWHERE ELSE, THEY MAY CALL IT SOMETHING DIFFERENT. THERE IS THE VERY WEAK DATA ON PNEUMONIA PATHOGENS, PNEUMONIA BY PATHOGENS, AND LESS WEAK BUT STILL PROBLEMATIC DATA AROUND DIARRHEA. HAPPY TO TALK ABOUT THAT MORE. THERE IS THE ISSUE AROUND DISABILITY WEIGHT MEASUREMENT, ALTHOUGH WE SHIFTED TO POPULATION-BASED SURVEYS OF DISABILITY WEIGHTS WHICH IS A HUGE ADVANCE, I BELIEVE. THERE'S STILL THE ISSUE ABOUT WHO GETS TO CLAIM WHAT, SO THE FOLKS WORKING ON VISUAL IMPAIRMENT SAY IF YOU'RE VISUALLY IMPAIRED, YOU'RE MORE LIKELY TO BE DEPRESSED AND THEY WANT TO CLAIM FOR VISUAL IMPAIRMENT THAT COMPONENT OF DEPRESSION, RIGHT NOW WE'RE GIVING ALL THE KEY DEE PRETION DEPRESSION TO DEPRESSION. THERE IS A BIG ISSUE ON LIMITED DATA ON THE DISTRIBUTION OF SAIFORT FOR CONDITIONSEVERITY FOR CONDITIO NS THAT HAVE A BIG WIDE SPECTRUM. DEPRESSION, FOR EXAMPLE, FROM DYSTHYMIA TO SEVERE DEPRESSION, EPILEPSY, FROM ONE FIT A MONTH TO SEVERAL A DAY. THERE'S 20 TO 30 CONDITIONS WHERE THE DISTRIBUTION OF SEVERITY IS A VERY BIG ISSUE AND THERE'S VERY FEW DATA SETS THAT ALLOW YOU TO TACKLE THAT QUESTION, CONTROLLING FOR CO-MORBIDITY. TWO DATA SETS FROM THE U.S. ARE EXAMPLES WHERE ONE CAN TRY TO USE THOSE TO INVESTIGATE THOSE, BUT IT'S A BIG GAP IN THE WORLD'S KNOWLEDGE AROUND SEVERITY DISTRIBUTIONS. THERE ARE DISEASES THAT SHOULD BE ADDRESSED IN THE FUTURE THAT ARE ROLLED INTO OUR RESIDUAL CATEGORIES, AND I THINK THERE ARE MANY THAT YOU COULD ADD TO THAT LIST, AND THEN TWO OTHERS, BECAUSE THEY CERTAINLY HAVE COME UP ALREADY IN THE DISCUSSIONS IS THAT SOME RISK FACTORS GOT EXCLUDED BECAUSE OF INSUFFICIENT DATA, UNSAFE SEXUAL PRACTICES OR -- FOR EXAMPLE, THE EFFECT OF INTIMATE PARTNER -- ON H.I.V. THERE WAS ONLY ONE STUDY IN SOUTH AFRICA AND WE FELT YOU COULD NOT GENERALIZE THE WORLD FROM ONE STUDY, BUT CLEARLY, THAT'S A LIMITATION OF INTERPRETING THE RESULTS THAT WE SHOW AND I THINK THE DIET COMPONENT DESERVES SPECIAL MENTION. WE HAD A TREMENDOUS AMOUNT OF DISCUSSION IN OUR INTERNAL PEER REVIEW PROCESSES FOR THE STUDY AROUND THE RESULTS FOR DIET. WE ENDED UP BEING CONVINCED THAT THEY SHOULD BE AS PRESENTED BECAUSE OF THE COMBINATION OF RANDOMIZED FEEDING STUDIES, I DIET PATTERN STUDIES AS WELL AS THE METAANALYSES OF THE PUBLISHED COHORT STUDIES, BUT I THINK MANY HAVE CONCERNS ABOUT THE CONFOUNDING AROUND THINGS LIKE FRUIT, NUTS, GRAINS AND SOME OF THE OTHER SPECIFIC DIET ASPECTS. LET ME END WITH WHERE WE'RE GOING NEXT, AND A PLEA FOR COLLABORATION AND INTEREST FROM NIH IN THIS IN PARTICULAR. SO WITH THE PROMPTING OF TREVOR MONDELL FROM THE GATES FOUNDATION, PRESIDENT OF GLOBAL HEALTH THERE, WE ARE NOW POOLING UP FOR DBD2.0. RATHER THAN EVERY DECADE, THIS SHOULD BE A CONTINUOUS PROCESS. AND THAT ANYBODY FROM THEIR DESKTOP IN THE WORLD SHOULD HAVE ACCESS TO A REASONABLY UP TO DATE IF NOT EXACTLY UP TO DATE ASSESSMENT OF THE WORLD'S EVIDENCE ON DESCRIPTIVE EPIDEMIOLOGY. AND THAT'S OUR GOAL NOW, WHICH IS TO SHIFT TO CONTINUOUS UPDATES, AND I THINK WE'RE DEBATING WHETHER THOSE WILL BE QUARTERLY, YEARLY OR MONTHLY, VARIOUS VIEWS ON THAT, BUT AS A NEW STUDY GETS PUBLISHED, WE WOULD QUICKLY INCORPORATE IT -- ON DIARRHEA ETIOLOGY, THE $40 MILLION MULTISITE GEM STUDY WILL BE PUBLISHED SOON, AND THAT'S GOING TO GIVE US A WHOLE BUNCH OF NEW INSIGHTS INTO DIARRHEA ETIOLOGY THAT WE WOULD WANT TO RAPIDLY INCORPORATE INTO THE GBD RESULTS. AS WELL AS INCORPORATING IN A SORT OF PARALLEL STREAM NEW METHODS INNOVATION AND RESEARCH THAT MAY COME ALONG. SO WE'D LIKE A WAY TO MORE FORMALLY ENGAGE NIH AND YOUR VARIOUS INSTITUTES THAT HAVE AB INTEREST IN THIS IN DOING THIS WORK GOING FORWARD, AND WE'RE VERY OPEN AND INTERESTED IN SEEING -- IN TRYING TO PURSUE THAT WITH YOU BECAUSE WE HAD 500 PEOPLE WORKING ON THIS STUDY, WE IMAGINE THAT IN ADDITION, WE'RE GOING TO BUILD OUT COLLABORATOR WE WOULD LIKE IN EVERY COUNTRY SO THEY WOULD LOOK AT THEIR RESULTS FROM A COUNTRY VIEW AS WELL AS A DISEASE RISK AND INJURY VIEW, AND WE'RE IN THE PROCESS OF TRYING TO IMAGINE HOW WE BOTH GOVERN THE STUDY AS WELL AS MAKE THIS WORK TO PRODUCE REGULAR UPDATES. WE'RE ALSO GOING TO EXPAND SCOPE. WE ARE BEING ASKED TO ADD MUCH MORE DETAIL ON ADVERSE EVENTS PARTICULARLY DUE TO VACCINES BUT ALSO TO DRUGS, AND WE'RE ALSO GOING TO ADD A FORECASTING COMPONENT AND PERHAPS THE MOST INTERESTING ONE IS THAT WE WILL BE ADDING A COMPONENT OF TRACKING DOLLARS BY THE SAME DISEASE AND INJURY CATEGORY. THE IDEA BEING THAT IF YOU CAN JUXTAPOSED THE BURDEN OF DISEASE AGAINST WHERE MONEY GOES, THAT WOULD BE A POWERFUL WAY FOR RAISING HYPOTHESIS ABOUT DIFFERENT SYSTEMS. ULTIMATELY WE'D LIKE TO LINK THIS BACK, I THINK IT'S PART OF THE BIGGER VISION, TO THE WORK ON COS COST-EFFECTIVENESS THAT GOES ON IN VARIOUS EFFORTS SUCH AS THE DISEASE CONTROL PRIORITIES NETWORK PROJECT. NAMELY, IF YOU KNOW THE BURDEN OF DISEASE, YOU KNOW WHERE MONEY GOES, WHAT ABOUT THE OPPORTUNITIES FOR UNDERSTANDING BOTH WHAT'S BEING ACHIEVED WITH PAST EXPENDITURE AND WHERE YOU COULD BETTER SPEND THE MONEY IN THE FUTURE. FOR EXAMPLE IN THE U.S., IF YOU LOOK AT THE DATA, THERE'S 12.7 MILLION OUTPATIENT VISITS FOR CELLULITIS. WHAT DO WE GET FOR THOSE RESOURCES AND IS THERE A BETTER WAY TO USE THOSE RESOURCES GOING FORWARD? SO I THINK IN THE LONG TERM, WE HOPE THAT THE GBD AND ITS EXPANDED SCOPE AND EXPANDED COLLABORATION BECOMES A VEHICLE FOR PROVIDING A COHERENT FRAMEWORK FOR THINKING ABOUT WHAT'S ACHIEVED BY PUBLIC HEALTH AND MEDICAL CARE AND WHERE THERE ARE OPPORTUNITIES FOR BETTER USE OF THOSE RESOURCES IN THE FUTURE. I'LL STOP THERE AND OPEN UP FOR QUESTIONS. [APPLAUSE] >> HELLO. RI CHEAL FROM NCI. THIS IS FASCINATING WORK. ONE OF THE OTHER AREAS OF RECENT FOCUS HAS BEEN LOOKING AT ISSUES SUCH AS URBANIZATION, BUILT ENVIRONMENT, THINGS OF THAT SORT IN TERMS OF HOW THEY INFLUENCE A NUMBER OF THE RISK FACTORS THAT YOU DESCRIBED. DO YOU HAVE ANY PLANS OR ARE THERE WAYS TO TRY TO INCORPORATE SOME OF THAT DATA IN THIS WORK? >> SO YOU KNOW, WE'VE GONE THROUGH SEVERAL CYCLES OF THINKING ABOUT HOW WE CAPTURE MORE DISTAL DETERMINANTS, BECAUSE IN A SENSE, OUR LIST OF RISK FACTORS ARE EITHER PHYSIOLOGICAL RISKS OR PATHOPHYSIOLOGICAL RISK OR BEHAVIORAL RISKS AT THE INDIVIDUAL LEVEL AND WE DON'T REALLY HAVE MUCH ON THE COMMUNITY LEVEL RISK. WE DON'T HAVE POVERTY, WE DON'T HAVE URBANIZATION AS AN EXAMPLE. AND THE CHALLENGE THERE IS IF YOU TAKE THE SORT OF CRITERIA THAT WE'VE USED FROM THE -- LITERATURE, THE DEFINITION OF COMPELLING OR PROBABLE EVIDENCE, USUALLY THE STUDIES AVAILABLE ON DISTAL DETERMINANTS DON'T MEET THOSE CRITERIA. SO THEY START OUT SAYING WE'LL TRY TO INCLUDE THESE, THEY NEVER INCLUDE THEM, AND I THIC BECAUSE IT'S SUCH AN OBVIOUS THING THAT ONE WOULD WANT TO INVESTIGATE, WE MAY NEED TO THINK OF SOME OTHER SET OF CRITERIA OR ANOTHER TYPE OF ANALYSIS AROUND THE DISTAL DETERMINANTS SO THAT ONE DOESN'T IGNORE THOSE. ALTHOUGH THEY DEFINITELY DON'T MEET THE SAME BAR OF EVIDENCE AS SOME OF THE COMPONENTS THAT ARE HERE, DOESN'T MAKE THEM NOT TRUE OR IMPORTANT, THOUGH. SO I THINK WE'VE ALWAYS BEEN SORT OF TRYING TO NAVIGATE THAT. >> GOOD MORNING. THANK YOU, DR. MURRAY, THAT WAS VERY ELEGANT. THIS IS BEL FROM THE NIH RECORD. WHAT SURPRISED YOU MOST ABOUT THIS STUDY? >> I GUESS ON A PERSONAL LEVEL, THE THING I FOUND THE MOST SURPRISING IS JUST THE PACE OF CHANGE IN TWO DECADES. WE'VE NEVER HAD, IN TERMS OF SPECIFIC GLOBAL -- WORK A TIME PERIOD ASSESSMENT USING CONSISTENT METHODS, AND WHAT IS SHOWS IS JUST HOW FAST BOTH THE DEMOGRAPHIC TRANSITION IS, SHIFT TO MDGs AND SHIFT TO -- IN MANY REGIONS OUTSIDE OF SUB-SAHARAN AFRICA. LATIN AMERICA, MIDDLE EAST, SOUTHEAST ASIA, REALLY DRAMATIC SHIFTS, AND THOSE SHIFTS, I THINK ARE SO FAST THAT WHEN YOU TALK TO PEOPLE IN MINISTRIES, THEY'RE ALSO STILL THINKING ABOUT AN AGENDA THAT WAS DOMINANT WHEN THEY WERE TRAINED OR WHEN THEIR PROGRAMS WERE SET UP. >> THANK YOU. >> CONGRATULATIONS FOR A COMPREHENSIVE REVIEW OF OUR -- COMPLICATIONS. SO WHAT IS THE EFFECT OF -- ON POPULATION GROWTH, HOW IS IT AFFECTING THIS MORTALITY? >> SO IN THE ISSUE, IN THE CAUSE OF DEATH PAPER IN THE YEARS OF THE DISABILITY PAPER AND THE DALY PAPER, WE PRESENT A SERIES OF ASSESSMENTS TO TRY TO TEASE APART THE CHANGE IN DALYS BY LARGE CAUSE GROUP OR DEATHS INTO POPULATION GROWTH, INTO POPULATION AGING, AND INTO CHANGE IN AGE SPECIFIC RACE. SO IF YOU LOOK IN THE PAPERS, YOU'LL SEE THAT ANALYSIS. IN GENERAL, POPULATION GROWTH IS GREATER IN SUB-SAHARAN AFRICA, AND IT WAS THE ONLY FACTOR, WE WOULD ACTUALLY BEING A SHIFT TOWARDS COMMUNICABLE MATERNAL AND NEONATAL CAUSES. WHAT WE ACTUALLY SEE IS TOP OF POPULATION GROWTH, POPULATION AGING IS A KEY DRIVER OUTSIDE OF AFRICA TOWARDS NCDs AND MOST IMPORTANTLY OF ALL IS SHIFT IN AGE SPECIFIC RATES FOR MORTALITY, WHERE DESPITE H.I.V., OVERALL AGE SPECIFIC RATES OR CHANGES HAVE LED TO A 50% DECLINE IN THE COMMUNICABLE MATERNAL AND PERINATAL CAUSES AND THERE'S ALSO A DECLINE DUE TO THE RATES OF NCDs BUT IT'S MUCH SMALLER. ALL THOSE FORCES COME TOGETHER TO DRIVE THE CHANGES THAT WE SEE. IT'S SOMEWHAT COMPLICATED, THAT'S WHY WE'VE INCLUDED THESE DECOMPOSITION TABLES IN THE PAPERS. WE PLAN TO DO OR PUBLISH THOSE DECOMPOSITION ANALYSES BY SPECIFIC CAUSE IN THE FUTURE. IT'S ONLY PROVIDED FOR THE LARGE CAUSE GROUPS AT THIS POINT. >> THANK YOU. >> JOEL FROM THE FOGARTY CENTER. THIS STUDY IS ABSOLUTELY MARVELOUS FOR HAVING LEADERS, AND EVEN COUNTRIES, THINK ABOUT PLANNING FOR ADDRESSING THESE PROBLEMS THAT YOU'VE MENTIONED. LET ME COMMENT ON THE FACT THAT ALL THESE DATA ARE SECONDARY, DERIVATIVE, COMING FROM MANY COUNTRIES WHERE THERE ARE NO VITAL STATISTICS COLLECTED. WHAT ARE YOUR VIEWS ON ENCOURAGING COUNTRIES THEMSELVES TO START ASSESSMENTS USING PROSPECTIVE POPULATION BASE STUDIES WITH PRIMARY DATA FOR THEIR OWN LOCALITIES SO THEY CAN DO THEIR OWN PLANNING FOR THE FUTURE, OF THE TYPE THAT FRAMING FRAMINGHAM OR WASHINGTON STATE AND OTHERS HAVE DONE SO SUCCESSFULLY? >> I THINK THE AGENDA THERE IS VERY IMPORTANT ABOUT STRENGTHENING HEALTH INFORMATION SYSTEMS NOT JUST IN LOW INCOME COUNTRIES, BUT ACTUALLY IN MANY COUNTRIES, WHERE THERE'S REAL GAPS. AND I THINK THE WAY -- THE STRATEGY THAT MAKES SENSE IS A LITTLE BIT OF A FUNCTION OF WHERE. SO IN SOME PLACES OUTSIDE OF EASTERN, WESTERN, CENTRAL SUB-SAHARAN AFRICA, I WOULD PUT VERY HIGH ON THE LIST PROMOTING THE IMPROVEMENT IN VITAL REGISTRATION THROUGH FORMAL SYSTEMS, RATHER THAN THE CREATION OF STUDY SITES. IN SUB-SAHARAN AFRICA, AND I THINK ALSO, YOU KNOW, SOUTH AFRICA HAS NOW GOT PRETTY COMPLETE REGISTRATION, I THINK IN EASTERN CENTRAL AND WESTERN CENTRAL AFRICA THERE'S STILL PROBABLY A ROLE FOR SURVEILLANCE SITES. THERE'S A LOT OF DEMOGRAPHIC SURVEILLANCE SITES, AS YOU KNOW, COLLECTING DATA. THE PROBLEM HAS BEEN THAT DESPITE THE WEALTH OF THOSE SITES, THE DATA FROM THOSE HAVE NOT BEEN AS USED AS MUCH EITHER BY GOVERNMENT OR IN THIS STUDY AS ONE WOULD HAVE THOUGHT BECAUSE VERY OFTEN IT'S NEVER PUBLISHED OR RELEASED. THAT THERE ARE ACTUAL ONGOING SURVEILLANCE STUDIES. SO I THINK THERE'S AN ISSUE THERE ABOUT NOT JUST WHAT MODEL DO YOU USE, COHORT MODEL, COMMUNITY SURVEILLANCE MODEL OR STRENGTHENING ROUTINE SYSTEMS BUT ALSO JUST HOW DO YOU MAKE SURE IT GIVES GOVERNMENT AND OTHERS IN THE COUNTRY TIMELY INFORMATION SO THAT IT ACTUALLY FEEDS INTO THAT. WE'VE GOT WITH OTHERS A NUMBER OF INITIATIVES IN SOME COUNTRIES TO TRY TO WORK ON THIS TOPIC. FOR EXAMPLE, IN ZAMBIA, WE'VE BEEN TRYING TO WORK ON HOW WOULD YOU GET THIS TYPE OF INFORMATION AT THE DISTRICT LEVEL AND INCORPORATE MANAGEMENT INFORMATION AS WELL AS SURVEY DATA, AND I THINK THERE'S SOME INTERESTING EXPERIMENTS OUT THERE. WE'RE HOPEFULLY GOING TO BE STARTING TO DO MORE OF THOSE EXPERIMENTS JOINTLY WITH UNICEF IN A NUMBER OF COUNTRIES AROUND THAT SORT OF STRENGTHENING HEALTH SYSTEM. THE COHORT IDEA, I DON'T KNOW. BECAUSE OF THE TRANSACTION COST OF FINDING PEOPLE IN PLACES WITH HIGH MOBILITY. SO THIS IS ALWAYS THE USUAL ISSUE ABOUT WHAT'S THE RIGHT STRATEGY FOR THE RIGHT PLACE. BUT THE GENERAL NOTION THAT WE NEED BETTER DATA IS CLEARLY THE CASE. >> THANKS VERY MUCH FOR THAT. IT'S REALLY INTERESTING. I WANTED TO ASK YOU ABOUT YOUR THOUGHTS ON THESE LAST THINGS YOU WERE DESCRIBING ABOUT THE USE OF THE DATA BY POLICY MAKERS. ONE OF THE CONCERNS THAT TENDS TO ARISE WITH SPECIFIC MEASURES LIKE DALYS, WHEN YOU PRESENT THE BURDEN OF DISEASE IN TERMS OF DALYS IS THAT POLICY MAKERS WILL THINK WHAT OUT, THEREFORE, TO BE DONE IS TO MAXIMIZE THE NUMBER OF DALYS THAT YOU DIVERT. YOU FIND WHATEVER IS THE GREATEST BURDEN OF DISEASE AND YOU PUT THE GREATEST AMOUNT OF YOUR RESOURCES TO THAT BURDEN OF DISEASE. SO WE SPEND A LOT OF MONEY ON LOWER BACK PAIN, SAY, ALL RIGHT? BUT OF COURSE A LOT OF PEOPLE ON REFLECTION WOULD THINK THAT'S NOT THE RIGHT WAY TO MAKE THESE SORTS OF DECISIONS, THERE ARE A LOT MORE COMPLICATED FACTORS. FOR EXAMPLE, WE WOULD THINK THAT AVERTING ONE DALY FOR SOMEONE WHO HAS ALREADY LIVED A HEALTHY LIFE AND IS NOW OLD IS NOT AS IMPORTANT AS AVERTING A DALY FOR SOMEONE WHO IS, SAY, A YOUNG ADULT. SO I WANTED YOU TO SAY SOMETHING ABOUT HOW THE TOOLS THAT YOU HAVE HERE, THE DIFFERENT WAYS YOU HAVE TO PRESENT YOUR DATA, COULD BE USED TO HELP POLICY MAKERS AND HELP THEM AVOID THOSE SORTS OF PITFALLS. >> SO YOU KNOW, I THINK THAT THE WAY RESOURCES GET ALLOCATED IN ALL SOCIETIES IS NEVER BY FORMULA. IT IS THROUGH SOME SORT OF EITHER DEMOCRATIC OR NOT SO DEMOCRATIC PROCESS OF BALANCING A WHOLE SET OF CONCERNS, AND, IN FACT, THAT'S WHAT POLICY MAKERS -- THAT'S THEIR JOB N A SENSE, TO TAKE A BUNCH OF COMPETING CONCERNS AND FIND A WAY TO BALANCE THEM. WE ALWAYS LIKE TO HOPE THAT THERE WILL BE ONE PARTICULAR TYPE OF ANALYSIS THAT WILL SUBSTITUTE FOR THAT PROCESS. I DON'T THINK ANYBODY WOULD ACTUALLY WANT TO LIVE IN THAT SOCIETY. YOU REALLY DO WANT THAT SORT OF BALANCING OF DIFFERENT CONCERNS. AND I THINK THERE'S A REASONABLE CONSENSUS AROUND THE WORLD IN MOST PLACES THAT THE LIST OF THINGS THAT YOU WANT TO TAKE INTO ACCOUNT ARE THE LEVEL OF HEALTH AS REPRESENTED BY SOMETHING LIKE THE BURDEN OF DISEASE, SPECIAL SOCIAL PRIORITIES TO CERTAIN GROUPS THAT MAY BE BECAUSE OF A SOCIAL EQUITY CONCERN OR NEFARIOUS CONCERNS, WHAT'S FEASIBLE, GIVEN THE CURRENT HEALTH SYSTEM AND THE MANPOWER THAT'S AVAILABLE, AND THEN MAYBE LESS APPROPRIATELY, A WHOLE SERIES OF POLITICAL ECONOMICS TYPE CONCERNS THAT FACTOR INTO THE DECISION-MAKING. SO I'M NOT TERRIBLY WORRIED ABOUT THE SORT OF ACADEMIC CONCERNS THAT THERE WILL BE A FLOOD OF POLICY MAKERS THAT SUDDENLY FORGET ABOUT WHY THEY'RE POLICY MAKERS. IT'S ACTUALLY PROBABLY A LITTLE BIT MORE TRYING TO GET THESE VARIOUS TYPES OF ISSUES THAT PEOPLE SHOULD TAKE INTO ACCOUNT IN RESOURCE ALLOCATION TO PLAY -- INFORM A RICHER DIALOGUE IN COUNTRIES AND HOPEFULLY LESS OF THE POLITICAL ECONOMIC CONCERNS DOMINATING DECISION-MAKING AND OF THESE OTHER TYPES OF CATEGORIES. SO I SEE THIS TYPE OF DESCRIPTIVE EPIWORK AS ONE REALLY IMPORTANT INPUT, BUT ONE OF MANY INPUTS INTO A HOPEFULLY DEMOCRATIC DECISION-MAKING PROCESS ABOUT HOW RESOURCES GET ALLOCATED. >> HI, PAMELA COLLINS FROM NIMH. THANKS FOR A GREAT PRESENTATION. YOU MENTIONED IN THE LIMITATIONS THAT ONE OF THEM HAS TO DO WITH THE SOURCES OF DATA AND SIMPLY ACCESS TO DATA, AND I JUST WANTED TO ASK YOU ABOUT THE MENTAL HEALTH DATA SPECIFICALLY, AND COULD YOU COMMENT ON THE REPRESENTATIVE -- OF THAT DATA ACROSS LOW INCOME, MIDDLE INCOME AND HIGH INCOME SETTINGS? >> SO ALTHOUGH, FOR EXAMPLE, THE NIMH FUNDED WORLD MENTAL HEALTH SURVEY DATASETS, YOU KNOW, WE WERE -- THE MENTAL HEALTH GROUP WERE ABLE TO GET CERTAIN TABULATIONS FROM THE PEOPLE WHO SEEM TO HOLD THAT DATA, IT WAS NOT USED PERHAPS AS EXTENSIVELY AS ONE MIGHT HAVE THOUGHT JUST BECAUSE IT'S NOT WIDELY AVAILABLE AS AN EXAMPLE. BUT ON THE OTHER HAND THERE'S A LOT OF LOCAL PUBLISHED STUDIES, SO IN SOME WAYS, BASED ON THE SYSTEMATIC REVIEWS, I THINK IT'S A SURPRISE TO ME JUST HOW MUCH DATA COLLECTION THERE HAD BEEN IN THE LAST 20 YEARS. YOU HAVE ALL THE ISSUES THAT PLAY INTO THE MENTAL HEALTH EPI IEPIAREA ABOUT SOME HAVE 12 MONTH PREVALENCE, ONE MONTH PREVALENCE, SOME HAVE DIFFERENT DYING NIS INSTRUMENTS, SO THERE'S A LOT OF THESE SORT OF CROSSWALK ISSUES THAT CREEP IN, AND THEN I'D SAY THE BIGGEST PROBLEM ON THE DATA FOR MENTAL HEALTH HAS BEEN THE LACK OF GOOD COMPARABLE DATA ON THE DISTRIBUTION OF SEVERITY, WHERE YOU CAN TAKE INTO ACCOUNT CO-MORBIDITY. BECAUSE WHAT WE SAW IN DATA SETS, FOR EXAMPLE, LIKE NETZARK IN THIS COUNTRY IS THAT THERE'S SO MUCH CO-MORBIDITY BETWEEN ALCOHOL, DRUGS AND MULTIPLE PSYCHIATRIC DIAGNOSES, THAT TEASING THAT APART REQUIRES DATA THAT CAPTURES MULTIPLE DIAGNOSES AND GIVES YOU SOME, YOU KNOW, REASONABLE MEASURE OF FUNCTIONAL LIMITATION, UP WIT ONE OF THOSE TYPES OF MEASURES SO THAT YOU IN SORT OF A MULTI-REGRESSION ENVIRONMENT COULD TEASE OUT WHAT'S REALLY DEPRESSION VERSUS THEIR CO-MORBID ANXIETY VERSUS THEIR DRUG DEPENDENCE. THE DISTRIBUTION OF DATA BY LOW, MIDDLE AND HIGH, SURPRISINGLY I WOULD SAY THAT'S NOT A BIG AXIS OF THE DIFFERENCE. SUB-SAHARAN AFER CAR, THAT IS TRUE, BUT ELSEWHERE, I WAS PLEASED HOW MUCH DATA THERE WAS AVAILABLE. BUT I THINK BIG SCOPE PARTICULARLY ON THE SEVERITY SIDE TO DO A BETTER JOB. >> THANKS. >> PETER SAWYER FROM THE CENTER ON CRISIS REPORTING. I WAS CURIOUS TO KNOW AS PART OF YOUR BROADER STRATEGY, YOU SPOKE IN THIS TH JE'S QUESTION BEFORE ME ABOUT THE DEMOCRATIC PROCESS ALLOCATING RESOURCES, PARTICULARLY AS NEEDS ARE CHANGING RAPIDLY. HAVE YOU THOUGHT ABOUT TRYING TO GET KIND AFTER DISTILLED RESULT OF YOUR STUDY INTO MORE POPULAR MEDIA? I WAS CURIOUS ABOUT STRATEGY ON THAT FRONT. >> WE HAVE A PRETTY BROAD DISSEMINATION STRATEGY, SO PART OF IT WAS THE MEDIA WORK FOR THE LAUNCH IN DECEMBER, AND I THINK THERE WAS SOME GOOD MEDIA UP TAKE, AND I THINK WHAT WE FOUND IS THAT THE ONLINE VISUAL TOOLS GENERATED MILLION HITS, ACTUALLY, BECAUSE THE PUBLIC DOES SEEM TO LIKE DYNAMIC VISUALIZATION. ON THE POLICY FRONT, WE ARE ALSO PURSUING DUSH KNOW, WE CAN'T DO IT IN 187 COUNTRY, BUT WE'RE PURSUING A SERIES OF SORT OF MORE HIGH LEVEL POLICY DISCUSSIONS THAT ARE COMING. WE'RE HOPING FOR ONE HERE IN D.C. THAT THE ILH WILL HOST AND HOPEFULLY THAT WILL HAPPEN. WE'RE DOING ONE POLICY MAKER EVENT IN CHINA, AUSTRALIA, WE HAD ONE IN THE U.K. ALREADY, AND THERE'S A LONGER LIST OF COUNTRIES THAT WE'RE TRYING TO MAKE THOSE ARRANGEMENTS AROUND. SO THAT'S ANOTHER PART OF THE STRATEGY. WE'RE ALSO GOING TO MAKE A SORT OF MORE POPULIST SUMMARY DOCUMENT OF SOME OF THE KEY MESSAGES THAT ARE NOT TECHNICAL NIN NATURE, AND THEN WE'RE HOPING WITH THE LAWN P OF MARCH 5TH GENERATE ENOUGH BROAD MEDIA ATTENTION TO GET A LOT OF PUBLIC TRAFFIC TO THESE TOOLS, AND HOPEFULLY ENGAGE PEOPLE IN THE RESULTS FOR THAT MECHANISM. >> THANK YOU. >> BEAUTIFUL AND ELEGANT WORK. THE WORLD IS FLAT, SO HOW DO YOU ACCOUNT FOR T CELLS EFFECT OF IMMIGRATION AND POPULATION MIGRATION ON YOUR ANALYSIS AND DATA? >> WELL, OUR DEFINITION OF HEALTH IS A DE FACTO DEFINITION, SO WE'RE TRYING TO MEASURE THE POPULATION, THE HEALTH OF THE PEOPLE IN A PARTICULAR GEOGRAPHY. WHETHER THEY'RE RECENT MIGRANTS OR NOT. I THINK THAT WORKS WELL IN PLACES WHERE DATA IS COLLECTED ON THE DE FACTO POPULATION. THERE ARE PLACES WHERE WE HAVE FUNDAMENTAL ISSUES WHERE CERTAIN MIGRANT GROUPS DON'T SHOW UP IN DATA SOURCES, AND THAT SOMETIMES IS NATIONAL POLICY, AND I THINK THOSE -- ALTHOUGH WE'VE TRIED TO DEAL WITH SOME OF THAT, THERE ARE STILL CERTAIN COUNTRIES WHERE THAT'S FUNDAMENTAL ISSUE. THE EXISTING DATA SETS, WHETHER THEY'RE SURVEYS, OR THEIR REGISTRATION SYSTEMS DON'T CAPTURE CERTAIN GROUPS, THEY'RE JUST EXCLUDED. SO THAT REMAINS A CHALLENGE. I THINK WE WOULD LIKE TO BE ABLE IN A STATISTICAL ESTIMATION SENSE TO HAVE BETTER DATA ON MIGRATION TO INCLUDE ITS COVARIANT FOR SOME OF THESE CAUSES, AND IT'S SURPRISING HOW POOR THESE SORT OF DATA OF THE MATRIX, YOU THINK OF 187 COUNTRY, THAT MATRIX OF WHO MOVES FROM WHERE TO WHERE IS NOT -- WE'VE STRUGGLED A LITTLE BIT WITH THAT. >> THANK YOU. >> CHRIS, ABSOLUTELY LOVELY PRESENTATION. I WANTED TO FOCUS ON THAT ONE GRAPH WHERE YOU SHOWED THE UNITED STATES AT THE BOTTOM WITH BEING THE WORST OF MANY AREA, WITH SWEDEN ON THE TOP. SWEDEN, A VERY HOMOGENEOUS POPULATION. ARE THOSE DIFFERENCES ISSUES OF HEALTH EQUITY, IS IT POPULATION HOME JE NATE OR DIFFERENCES, ARE THEY LIFESTYLES, CAN YOU BREAK THAT DOWN MORE GRANULARLY TO GIVE US AN INSIGHT INTO ITS TRUE MEANING? >> WELL, YES AND NO. >> THERE YOU GO. >> THIS IS I THINK WHAT YOU'RE TALKING ABOUT. >> YES. >> HOW TO LOOK AT A PLACE LIKE DENMARK, YOU KNOW, DENMARK IS DOING JUST ABOUT AS BADLY AS THE U.S. IT'S A VERY HOMOGENEOUS PLACE. SO I'M NOT SURE HETEROGENEITY IS -- IF WE -- I DON'T KNOW HOW I'D DO IT, BUT IF YOU RANSOM INDEX OF HETEROGENEITY ACROSS THESE RESULTS, I'M NOT SURE IT WOULD EVEN STICK OUT BECAUSE AUSTRALIA IS AT THE TOP, VERY HOMOGENEOUS NOW, MIGRANT POPULATION. YOU HAVE SOME PRETTY BAD PERFORMANCE AROUND BELGIUM AND DENMARK AND THEY'RE PRETTY HOMOGENEOUS. THE U.K. IS NOW VERY HETEROGENEOUS IN THE LAST TWO DECADES. AND THEY'RE ONLY SOMEWHAT BETTER THAN THE U.S., ALTHOUGH THEY DO MUCH BETTER ON ROAD INJURY, DIABETES, EVERYTHING ELSE IS PRETTY SIMILAR. SO WHAT IS IT? AND I MUST SAY, I ALWAYS STRUGGLE TO UNDERSTAND WHY WE DO SO BADLY. IT IS SOMETHING THAT I FIND DIFFICULT TO FATHOM. PART OF THE LEGACY -- THE U.S. AND THE U.K. PROBABLY HAS THE BIGGEST PER CAPITA CIGARETTE CONSUMPTION IN THE 50s AND 60s, SO THERE'S A LITTLE BIT OF THAT IN THE BACKGROUND, BUT I THINK AS TIME GOES ON, THAT'S INCREASINGLY HARD TO EXPLAIN. PART OF IT IS WE HAVE A WORSE OBESITY EPIDEMIC, AND WE'VE DONE MUCH WORSE MAYBE RELATED TO THAT ON MANAGING BLOOD PRESSURE. BUT I GUESS THE TYPE OF ANALYSIS TO ANSWER WHAT YOU'RE DESCRIBING WHICH IS NOW SLOWLY BECOMING FEASIBLE WOULD BE TO STRIP OFF ALL THE COUNTRIES, THESE 19 COUNTRIES, LET'S SAY, THE EFFECTS OF THE TOP RISK. TAKE AWAY TOBACCO, TAKE AWAY ALCOHOL, TAKE AWAY BLOOD PRESSURE, AND THEN PROGRESSIVELY SEE IF THE U.S. AND THESE CON KUN TRIES CONVERGE OR HOW MUCH IS UNEXPLAINED BY THAT. BUT CERTAINLY SOMETHING THAT SHOULD BE DONE. >> FOGARTY INTERNATIONAL CENTER, THANK YOU VERY MUCH, CHRIS. YOU SAID YOU COULD SAY A LITTLE BIT MORE ABOUT ETIOLOGY SPECIFIC ON PNEUMONIA AND LIMITATIONS, ESPECIALLY WITH A LARGE BURDEN OF DISEASE IN DEVELOPING COUNTRIES, SO I WOULD LIKE TO ASK YOU TO SAY THAT. >> IN THE PAPER, WE HAVE THE LONGEST PARAGRAPH ABOUT OUR CONCERNS ABOUT THE NATURE OF THE DATA IN THE ANALYSIS. SO FOR PNEUMONIA, I THINK THERE'S AN ISSUE AROUND WHAT A CHILD -- IN OTHER RESEARCH NOT RELATED TO GBD, I THINK IT'S BECOMING INCREASINGLY CLEAR THAT VERBAL AUTOPSY AS A DATA COLLECTION MECHANISM TENDS TO OVERASSIGN DEATHS TO PNEUMONIA. AS FAR AS WE CAN TELL IN CHILDREN. AND THAT MAY EXPLAIN WHY DIFFERENT ESTIMATES LIKE -- ESTIMATES FOR PNEUMONIA DEATHS ARE SOMEWHAT HIGHER. MAYBE 30% HIGHER THAN WHAT WE HAVE FOR THE TOTAL VOLUME. FOR ETIOLOGY, MUCH TRICKIER. THE CHOICE YOU HAVE TO MAKE TO ANALYZE ETIOLOGY IS YOU DO WHAT WE DO FOR EVERYTHING ELSE, WHICH IS TAKE ALL THE PUBLISHED STUDIES, THEN SIFT THEM INTO A METAREPRESSION OR DO YOU ONLY USE THE -- TRIAL, FOR EXAMPLE, TO GET US -- AND THE ANSWER OF DOING THOSE GIVES YOU QUITE A DIFFERENT ANSWER. SO ONE OF THE BIG ISSUES THAT I'M SURE ANYBODY THAT FOLLOWS THIS KNOWS ABOUT IS HOW MUCH PNEUMONIA -- BIG FRACTION OF PNEUMONIA DEATHS IN KIDS AND THE OBSERVATIONAL DATA THAT'S AVAILABLE SUGGESTS IT'S MUCH LOWER THAN IN AFRICA, THERE'S BEEN TRIAL DATA FROM INDIA, AND PERCH IS NOT PUBLISHED YET, AND HOPEFULLY WILL GIVE US SOME INSIGHT BECAUSE THERE'S AN ENGLISH SITE, BANGLADESH SITE, BUT I THINK THAT'S THE NATURE PARTICULARLY AROUND PNEUMONIA PNEUMONIACOCUS. THE PUBLISHED STUDIES SHOW CONSIDERABLE HIB, NOT AS MUCH AS BUT CONSIDERABLE OVER AGE 2, AND SERVELY RSCERTAINLY RSV, AND THAT RUNS COUNCIL FER TO, I THINK, THE EXPERT JUDGMENT OF MANY IN THE FIELD. SO AGAIN, YOU HAVE THIS SORT OF VERY DIFFICULT CHOICE, WHICH IS DO YOU REJECT THE DATABASED ON EXPERT VIEW OR DO YOU JUST DO THE SAME METHOD THAT WE APPLY TO EVERYTHING ELSE. I THINK THOSE ARE SOME OF OUR CONCERNS. ON DIARRHEA, WE'VE HAD A PEAK AT THE GEM RESULTS, WE'VE BEEN GIVEN THEM UNDER A NON-DISCLOSURE AGREEMENT, AND WHAT THAT SUGGESTS TO US IS THAT OUR RESULTS WILL NEED TO BE SUBSTANTIALLY REVISED FOR ETAC AND EPAC, AND MAYBE SHIDELLA BUT NOT SO MUCH FOR RODA. THEY'LL PROBABLY COME UP THE SAME, ONCE THE GEM IS PUBLISHED. SO I THINK DIARRHEA IS A LITTLE BIT BETTER CIRCUMSTANCE, YOU'VE GOT THE WHOLE ISSUE ABOUT CULTURING OUT PATHOGENS IN KIDS WITHOUT DIARRHEA, AND SO THAT'S AN INTERESTING TWIST THERE AND I THINK WHAT GEM IS ADVANCING IS A METHOD THAT'S SORT OF MORE OF A RELATIVE RISK APPROACH, AND I THINK IT'S REALLY AN ATTRACTIVE IDEA. SO WE'LL SEE IN THE COURSE OF THE NEXT YEAR OR SO AS THESE GET PUBLISHED OF HOW THAT MODIFIES THE RESULTS. >> THANKS. >> HEART, LUNG AND BLOOD INSTITUTE. THANKS FOR A VERY NICE AND EXCELLENT PRESENTATION. YOU MENTIONED THAT DATA WILL BE -- DATABASE WILL BE AVAILABLE ON MARCH 5. WILL THAT BE ON UNIVERSITY OF WASHINGTON'S WEBSITE? >> IT WILL BE AT OUR WEBSITE, THE INSTITUTE FOR HEALTH METRICS AND EVALUATION. >> ALSO, IS THERE ANY PLAN TO LOOK AT REGIONAL DIFFERENCES WITHIN COUNTRIES? FOR EXAMPLE, RURAL, URBAN AND? >> SO WE'RE VERY INTERESTED AND HAVE STARTED DISCUSSION WITH A FEW PLACES ABOUT SUBNATIONAL BURDEN OF DISEASE WORK, BUT THOSE ARE THEIR OWN STUDIES, IN A SENSE, BECAUSE ALTHOUGH THE TOOLS CAN BE USED FROM THE GLOBAL STUDY, THAT REQUIRE AS WHOLE SERIES OF INCORPORATION OF LOCAL DATA. SO WHAT WE'D LIKE TO DO IN PLACES WHERE THAT WILL HAPPEN IS WE WOULD LIKE TO, YOU KNOW, HAVE A SERIES OF COLLABORATORS IN THOSE COUNTRIES DOING MOST OF THAT ANALYSIS, AND HOPEFULLY PROVIDING ACCESS AND USE OF THESE TOOLS. ONE STUDY IS ALREADY LAUNCHED ON THAT, SAUDI ARABIA, OVER A FIVE YEAR PERIOD, WE'RE WORKING WITH THE MINISTRY, AND WE'RE HAVING THESE DISCUSSIONS FOR SOME OTHER PLACES AS WELL. WHAT I'D LOVE TO SEE IS THIS DONE IN THE U.S. AT THE STATE OR COUNTY LEVEL. BECAUSE I THINK IT WOULD BE INCREDIBLY USEFUL INPUT TO A BROADER PUBLIC AND DECISION-MAKER DISCUSSION ABOUT PRIORITIES FOR HEALTH. SO THAT'S SOMETHING THAT WE WOULD LIKE TO PURSUE AND SOME -- SOME STATES HAVE COME TO US, SO WE'RE TALKING ABOUT A COLLABORATIVE, MAYBE PURSUE THAT HERE. >> MY LAST QUESTION, IF I MAY, THE DATA FROM AFRICA IS VERY DEPRESSING. ESPECIALLY WHEN YOU LOOK AT THE LIFE EXPECTANCY, IT RANGES BETWEEN 25 TO 40, AND I'M WONDERING WHETHER THERE IS A PROBLEM WITH COLLECTING OR GETTING THAT DATA. IS THERE A SCARCITY OF DATA OR IS IT REALLY TRUE THAT YOU HAVE, YOU KNOW, LIFE EXPECTANCY -- AND WHEN YOU ANALYZE, YOU ADD THE LIFE EXPECTANCY OF CHILDREN, RIGHT, TO THE ANALYSES, SO IT MAKES IT -- BECAUSE YOU HAVE HIGHER PREVALENCE OF -- NUTRITION, IT GETS A LITTLE SKEWED. >> SO I THINK THE RESULTS FROM SUB-SAHARAN AFRICA ARE PERHAPS NOT AS DEPRESSING AS THEY CAME ACROSS, BECAUSE IF YOU LOOK, FOR EXAMPLE, AT LIFE EXPECTANCY OUTSIDE OF SOUTHERN AFRICA, THERE'S BEEN SUBSTANTIAL IMPROVEMENTS DESPITE H.I.V. IN EAST AFRICA, BIG DECLINE IN CHILD MORTALITY, AND THERE'S CERTAINLY BEEN IMPROVEMENTS IN WEST AFRICA, MAYBE CENTRAL AFER A LITTLE BIT LESS IMPRESSIVE, BUT REAL PROGRESS IN MANY PARTS IN REDUCING CHILD MORTALITY, AND WITH ARB SCALEUP IN THE H.I.V. AFFECTED BELT FROM KENYA DOWN TO SOUTH AFRICA, AT LEAST IN HALF THOSE COUNTRIES, MARKED DROPS, WE THINK, IN ADULT MORTALITY. THE BIG PART IS WE'RE WAITING FOR CONFIRMATION IN MANY OF THOSE COUNTRIES FROM ACTUAL DEMOGRAPHIC DATA SOURCES FOR MORTALITY DROP, BUT IT'S VERY -- I THINK WHAT THE MESSAGE THAT CAME OUT TO US IN THE STUDY IS NOT THAT THERE ISN'T PROGRESS IN H.I.V., IN CHILD MORTALITY, IN SUB-SAHARAN AFRICA, BUT THAT DESPITE THAT PROGRESS, THE AGENDA IS STILL FOCUSED, WE BELIEVE, AROUND MDGs 4, 5 AND 6. SO THE STORY OF REAL TANGIBLE PROGRESS, FOR MALARIA, H.I.V., CHILD MORTALITY IN THE LAST FIVE OR SIX YEARS, ONE IN WHICH THE FOCUS PROBABLY SHOULD REMAIN THE MDG AGENDA, AT LEAST FOR A WHILE, ALTHOUGH I THINK THERE'S REASONABLE PREDICTION TO SAY AS LONG AS RESOURCES KEEP FLOWING FOR PROGRAMS LIKE MALARIA AND H.I.V., THAT AFRICA WILL SOON BE JOINING THE REST OF THE DEVELOPING WORLD IN HAVING TO DEAL WITH THE CHALLENGES OF NCDs AND DISABILITY. >> THANK YOU. >> CONGRATULATIONS AND THANKS ESPECIALLY FOR YOUR WORK TO MAKE THE DATA COME TO LIFE WITH COMPELLING VISUAL REPRESENTATION. THAT'S REALLY IMPORTANT. WONDER IF YOU WOULD ELABORATE A LITTLE BIT ON THE METHODOLOGICAL DEVELOPMENTS AROUND CO-MORBIDITIES AND AROUND CONNECTING OUTCOMES TO CAUSAL RELATIONSHIPS TO RISK FACTORS. >> SURE. THE CO-MORBIDITY FRONT, I THINK WE ARE HOPING TO PUBLISH MORE FROM WHAT'S BEEN DONE BECAUSE IT'S PRETTY LIKELY -- IT'S IN THE BACKGROUND, IT DOESN'T COME OUT IN THE SUMMARY PAPERS VERY MUCH. THE GOOD NEWS IS THAT WE'VE SET UP A FRAMEWORK AND WE'VE CREATED CREATED -- FOR EVERY COUNTRY, AGE, SEX GROUP AND YEAR IN THE BACKGROUND, SO WE TAKE ALL THE PREVALENCE DATA FOR ALL THE CONDITIONS AND WE RUN A MICRO SIMULATION TO TRY TO FIGURE OUT WHAT IS LIKELY CO-MORBID COMBINATION THAT OCCURRED IN A GIVEN AGE-SEX GROUP. SO THAT'S THE GOOD NEWS. THERE'S LOTS OF USES FOR THAT. TO EXPLORE. THE BAD NEWS IS THAT WE'VE ONLY SO FAR CAPTURED INDEPENDENT CO-MORBIDITY. CO-MORBIDITY THAT COMES ABOUT BY CHANCES NOT BECAUSE MY PROBABILITY OF HAVING ISCHEMIC HEART DISEASE IS HIGHER BECAUSE I'M A DIABETIC. WHICH WOULD BE DEPENDENT CO-MORBIDITY. ALTHOUGH WE COULD IN THEORY CAPTURE THAT, WE HAVE NOT BEEN ABLE TO FIND LARGE ENOUGH DATA SETS TO REALLY GET THE FULL MATRIX ACROSS A THOUSAND-PLUS CONDITIONS WITH EACH OTHER BY AGE AND BY SEX, SO THAT'S, I THINK, A BIG AGENDA FOR THE FUTURE. AND THE INTERESTING THING THERE ON THE CO-MORBIDITY FRONT IS WHEN WE RAN TESTS FOR EXAMPLE ON THE MEPS DATA HERE IN THE U.S., OUR INDEPENDENT CO-MORBIDITY BY AGE AND SEX DOES A REALLY GOOD JOB OF FREE DICTIONARYING THE OBSERVED DISTRIBUTION, FOR EXAMPLE, OF SF12 IN MEPS EVEN WITHOUT TAKING FOO ACCOUN INTO ACCOUNT THE INTERDPENT DEPEND DEN SEES. SO OUR INTERPRETATION IS YES, CLEARLY THERE ARE CASES WHERE IT'S IMPORTANT, THE DIABETES CASE, BUT FOR MOST CO-MORBIDITY THAT WE'VE OBSERVED, PROBABLY IT'S THE RELATIONSHIP WITH -- AND AGE THAT'S THE KEY DRIVER WITH COMORE IDITY. SOCIOECONOMIC STATUS, THAT WE'VE NOT INCORPORATED, THE POOR HAVE MORE OF EVERYTHING, FOR MOST THINGS. SO THAT'S -- I THENG IT'S A REALLY INTERESTING AREA FOR FURTHER WORK. BOTH USING WHAT'S BEEN DONE ALREADY AND STRENGTHENING THE CO-MORBIDITY PART. ON THE CAUSAL LINKAGES FOR THE RISK FACTORS, WE TRIED BY CALCULATING THE JOINT EFFECTS OF SOME COMBINATIONS LIKE DIET TO DO THAT. THERE'S STILL WORK UNDERWAY WHERE THEY'RE ALSO TRYING TO LOOK AT MEDIATION, SO IF YOU WANT TO LOOK AT THE JOINT EFFECTS AROUND SOME OF THE THINGS LIKE BLOOD PRESSURE, CHOLESTEROL, OBESITY, YOU REALLY HAVE TO FIGURE OUT PATHWAYS WHERE THEY WORK THROUGH EACH OTHER TO GET THAT JOINT DISTRIBUTION, SO THEY'RE WORKING ON THAT IN RELATED RESEARCH. >> CAN WE MAKE THIS QUICK? >> I'LL DO MY BEST. I CAN IMAGINE FOR A DISEASE LIKE DIABETES OR MENTAL HEALTH, ONE COUNTRY MIGHT HAVE A HIGH PREVALENCE BUT MANAGE THE DISEASE WELL SO THE DISABILITY IS LOW, OTHER COUNTRIES MIGHT HAVE A LOWER PREVALENCE BUT THEY DON'T MANAGE IT AS WELL SO THE DISABILITY MIGHT BE THE SAME. THE WAY A SOCIETY OR POLICY MAKERS WOULD ADDRESS THOSE TWO PROBLEMS IS WILDLY DIFFERENT. DOES YOUR ANALYSIS, DOES YOUR DATA TEASE APART THOSE TWO, DOES IT MAKE A DISTINCTION BETWEEN THE TWO CASES? >> SURE, BECAUSE THE BACKGROUND COMPLICATION AND PREVALENCE TIMES DISABILITY WEIGHT IS EASY ENOUGH OR WILL BE EASY ENOUGH TO LOOK AT BOTH PREVALENCE VERSUS THE YLD NUMBERS, SO THAT IS SORT OF SAYING, FOR EXAMPLE, THIS BENCHMARKING DIAGRAM -- FOR YLDs, YOU COULD LOOK AT PREVALENCE FOR DIFFERENT CONDITIONS AS WELL. SO I THINK YOU CAN TEASE THAT APART. WE HAVEN'T COME UP WITH A CLEVER VISUAL TOOL YET TO DO THAT, BUT I THINK THAT'S PART OF WHERE WE'RE VERY INTERESTED IN CONTINUING TO BUILD OUT THE SET OF VISUAL INTERFACES TO TRY TO HELP PEOPLE EASILY TEASE OUT SOME OF THE INSIGHTS THAT WOULD BE USEFUL FOR THEM TO HAVE. >> DR. COLLINS HAD TO STEP OUT BUT HE WANTED ME TO THANK YOU SPECIFICALLY FOR YOUR WONDERFUL PRESENTATION. IT'S REALLY BEEN A LANDMARK PRESENTATION. WE LOOK FORWARD TO SEEING HOW THIS DEVELOPS, HOW IT'S LAUNCHED, AND I THINK TO SEE HOW THE NIH COMMUNITY MIGHT PARTICIPATE IN SOME OF THE RESEARCH THAT WILL BE NEEDED TO ADVANCE IN OUR UNDERSTANDING OF WHAT THIS MEANS FOR ALL OF US. SO ON THAT, ON BEHALF OF ALL NIH AND THE AUDIENCE HERE, LET ME THANK YOU AND WELCOME YOUR CONTINUATION OF THIS VISIT THIS AFTERNOON. THANK YOU. [APPLAUSE]