Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
Homicide/fatal violence in the Global Burden of Disease 2010
Rafael Lozano MD6th Milestones of a Global Campaign for
Violence PreventionMexico City November 13th 2013
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
• The Global Burden of Interpersonal Violence
What are we measuring ?
What is the global burden of disease, injuries and risk factors?
• A systematic scientific effort to quantify the comparative magnitude of health loss due to diseases, injuries and risk factors by age, sex, geographies for specific points in time
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
Health loss is the key GBD concept: how do we measure it?
• Usually we count deaths and events (cases) as health loss, but we cannot add them.
• Thus, to combine them in a summary measure, we calculate the time loss due to premature mortality and the time lived with disability
3
DALYs = YLL + YLD
Health loss Health loss due to premature mortality
Time lived with disability
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud 4
GBD terminology
1) DALYs = Years of life lost due to premature mortality (YLLs) and years lived with disability (YLDs).
2) Years of life lost due to premature mortality due to a death at age x is the standard life expectancy at age x. A death at age 5 years counts as 81.4 YLLs, while a death at age 50 counts as 27.8 YLLs.
3) Years lived with disability for a cause in an age-sex group equals the prevalence of the condition times the disability weight for that condition.
4) Disability weights quantify the impact from any short-term or long-term health loss.
5) In the GBD 2010, DALYs are not discounted or age-weighted.
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
Background
– In 1991 the World Bank commissioned the first study to C. Murray (Harvard U.) and A. Lopez (WHO). In 1993, results were published in the World Report "Investing in Health“
– In 1996, final results were disseminated in 2 books and subsequently published in The Lancet
– Under the leadership of Dr. Gro Brundtland, WHO issued annual updates of the GBD from 1998-2002
– This activity continued in 2004 and 2008
5
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
GBD 2010: new methods, wider scope
• “GBD 2010 study” initiated in 2007 and was funded by Bill & Melinda Gates Foundation.
• IHME head institution: shaped by University of Queensland, WHO, Harvard University, Johns Hopkins University, Imperial College London, University of Tokyo.
• Final study with 486 authors from 50 countries.
• Seven summary papers and an overview were published in a dedicated triple issue of the Lancet on December, 2012; and more than hundred detailed publications in submission or preparation.
• Systematic attempt to quantify health loss from all major diseases, injuries and risk factors for 187 countries overtime from 1990 to 2010.
• By the numbers: 291 diseases and injuries; 1,160 sequelae of these diseases and injuries; and 67 risk factors or clusters of risk factors.
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
GBD Causes of Injury Categories
Unintentional
Transport Injury Road Injury PedestrianBicyclistMotorcyclistCar occupantOther
Other transportNon-transport Injury Falls
DrowningFirePoisoningsExposure to mechanical forces Firearm
OtherAdverse effects of medical RxAnimal contact venomous
non venomous‐Exposure to forces of natureOther unintentional injuries
Intentional
Self-harm and interpersonal violence
Self-harmInterpersonal violence Assault firearm
Assault sharp objectAssault other means
Forces of nature, war & legal intervention
Collective violence and legal intervention
Forces of nature
LEVEL II LEVEL IVLEVEL III LEVEL V
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
Sources and Methods for Interpersonal violence
SourcesDeaths: • Country Years• Vital Registration 2,705• Verbal Autopsy 71 • Surveillance Systems 17• Survey/Census 49• Police Reports 1,070
Non fatal outcomes:• Surveys for 61 countries• tabulations of hospital admissions from 27
different countries disaggregated by age, sex, external cause and sequela.
E/N code Matrrx• Brazil SIHSUS (2006-2009), Canada DAD data
(2004-2009), Mexico SINAIS data (2003-2009), and US NHDS data (1980-2008)
MethodsDeaths: Similar strategy to other GBD causes • Cause of death ensemble model (CODEM)
for Interpersonal violence, assault due to firearms, sharp objects and other means.
Non fatal outcomes:Same strategy to other injuries • Incidence by external cause and
incidence by nature of the injury (23 conditions)
• N/E code matrix• Probability of permanent disability• DW from the household survey and
adjusted from cohort studies in order to capture severity
Sources: Lozano R, et al 2012; Vos T. et al 2012; Murray CJL et al 2012
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
For 2010, we have estimated 456.3 (359-611) thousand homicides in the world• 86% in developing countries• 43% related with firearms • 28% related with sharp
objects• 81% in males• 70% occurred before 40
years old
The Global Burden of Intentional Violence
Source: Lozano R, et al 2012
Mortality (age-adj) due to homicides, both sexes
1990 1995 2000 2005 20100.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
Rate
x 1
00,0
00 p
op
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 800.0
5.0
10.0
15.0
20.0
25.0
Mortality by age and sex, 2010
Male Female
Rate
s x 1
00,0
00 p
op
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
The Global Burden of Intentional Violence
• In 2010, estimates displayed 25.5 (20-33) million of DALYs due to interpersonal violence in the world, meaning 1% of the total burden
• Globally 94% were YLL and 6% YLD. In developed countries, health loss due to non fatal outcomes was 10%
• GBD estimated 31.3 million population with some sequelae of interpersonal violence. 78% male and 22% female.
• 55% were related with lacerations, multiple wounds, eye injuries; 26% fractures and 7% long term sequelae
Percent of DALYs due to interpersonal violence, 2010
< 10y 10-19y 20-49y 50-69 70+0.0
2.0
4.0
6.0
8.0
10.0
12.0
male female
Global Prevalence rate of interpersonal violence by age and sex, 2010
Rate
per
1,0
00 p
op
Source: IHME, 2012
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
What is the leading cause of premature death in men in 2010?
Source: IHME, 2012
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
The place of homicide within the leading causes of premature mortality in men, 2010
Source: IHME, 2012
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
Mortality rate(age-adj) due to Homicides by sex and mechanisms, GBD Regions 2010
Asia Pacific High IncomeEurope Western
AustralasiaAsia East
Europe CentralNorth Africa-Middle East
Asia SouthNorth America High Income
SubSaharan Africa-WestOceania
Asia SoutheastAsia Central
Latin America SouthernSub Saharan Africa East
LatinAmericaAndeanEurope Eastern
Sub S Africa CentralCaribbean
Sub S Africa SouthernLatin America TropicalLatin America Central
0.0 10.0 20.0 30.0 40.0 50.0 60.0
Firearm Sharp Other
Male
Europe Western
Asia Pacific High Income
Europe Central
Asia South
Asia Central
Asia Southeast
SubSaharan Africa-West
Sub Saharan Africa Central
Latin America Tropical
Latin America Central
Sub Saharan Africa Southern
0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0
Firearm Sharp Other
Female
Rate per 100,000 male Rate per 100,000 female
Source: IHME, 2012
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
The burden of Interpersonal Violence by Sex and Mechanism in Latin American Countries, 2010
Rate per 1,000 male Rate per 100,000 female
UruguayCubaPeruChile
BoliviaArgentina
C RicaNicaragua
R DomPanama
BeliceParaguay
EcuadorMexico
JamaicaBrasil
HondurasColombia
VenezuelaGuatemalaEl Salvador
0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0
Firearm
Sharp
Other
ChileUruguay
C RicaArgentina
PeruCuba
NicaraguaBolivia
ParaguayMexico
EcuadorPanama
BrasilR Dom
VenezuelaColombia
BeliceJamaica
GuatemalaEl Salvador
Honduras
0.0 2.0 4.0 6.0 8.0 10.0 12.0
Firearm
Sharp
Other
Source: IHME, 2012
MALE FEMALE
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
To understand where you are, you have to know where you come from
1990 1995 2000 2005 20100
10
20
30
40
50
60
70
80
90
El SalvadorGuatemalaVenezuelaColombiaSouth AfricaBrazilMexicoRussia
YLL
per 1
000
pop
Rate of YLL (age-adj) due to Interpersonal Violence in Male, 1990- 2010
Source: IHME, 2012
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
Homicide mortality in Male, Mexico 1955-2011
19551959
19611964
19671970
19731976
19791982
19851988
19911994
19972000
20032006
20090.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
f(x) = − 1.14885565385417 x + 77.7290150265946R² = 0.948037624185136
2005-2011 1955-2004 Linear (1955-2004)
Rate
per
100
,000
men
*Rate per 100,000 males (age adj)Sources: WHO, 1955-1978; SSA/INEGI, 1979-2011. CONAPO, Population Estimates 1955-2011
What happens after 2004?
What did you do to decrease homicides in the second half of the last century?
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
Rate per 100,000 pop
Source: INEGI, Boletín de Prensa 288/13
Yucatán
Baja California Sur
Querétaro
Chiapas
Tabasco
Quintana Roo
Guanajuato
San Luis Potosí
México
Oaxaca
Jalisco
Nayarit
Morelos
Colima
Tamaulipas
Sinaloa
Guerrero
0 10 20 30 40 50 60 70 80
Brazil 31 x 100,000
Guatemala 62 x 100,000Colombia 46 x 100,000
USA 6 x 100,000
Central Europe 2.2 x 100,000
Homicide mortality both sexes, Mexico 2012
National Averages hide disparities
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
Male Female
As all the world, homicides in Mexico are a matter of young males
1980 2011 1980 20110
80
30-40% of all deaths are due to homicides
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
Interpersonal Violence is the lead cause of DALYS in Mexico in males, 2010
http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-arrow-diagram
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
Leading causes of DALYs for both sexes in Latin American and Caribbean countries, 2010
http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-arrow-diagram
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
Final remarks
• For purposes of violence prevention, it would be convenient to incorporate the GBD framework. – Using an holistic approach, interpersonal violence is located at the top of the
health losses in several countries– We have to measure the burden by type of violence and not only by mechanism
• Premature mortality and young population are key for measurable targets• Violence related with firearms is spreading significantly in LAC countries.
The burden of this mechanism is over 70% in Venezuela, Colombia and El Salvador.
• An update of the “GBD 2010 study” is coming soon (GBD2013), but it demands more collaboration
• To analyze health disparities it is imperative to do subnational studies (Mexico, UK and China are on track)
Instituto Nacional de Salud Pública
Centro de Investigaciones en Sistemas de Salud
Crime and violence statistics portrait reality crudely, but we must not ignore
that behind each number there is a person, a family, and therefore, a tragedy that we must respect ....
when we prevent and avoid violencewe show respect