South Africa has one of the greatest misalignments in the world between development and health progress. It is one of only a handful of countries where healthy life expectancy decreased since 1990, although this has reversed in the past decade. In contrast, the top five countries that have improved since the year 2000 are Botswana, Zimbabwe, Rwanda, Malawi, and Zambia.
'Communicable diseases, car accidents, and waves of violence are taking the lives of far too many South Africans, especially young people. This is one of the few countries in the world where the number of healthy years that men and women can expect to live has fallen over the past 25 years. We have a lot of work to do,' said Professor Charles Shey Wiysonge, director of Cochrane South Africa and a co-author of the study.
“Life expectancy in South Africa is rapidly increasing, but that doesn’t mean we’re enjoying healthier lives,” said ProfessorWiysonge.
The latest Annual Global Burden of Disease study shows that it is one of five countries where actual health burden rates far exceed what one would expect based on its income and education levels, plus fertility rates.
The study’s main findings for South Africa include: A South African man born in 2016 can expect to live 59.2 years, an increase in life expectancy of 9.5 years over the past decade. A woman has a life expectancy of 65.5 years, up 13.2 years from 2006. But illness and injuries take away years of healthy life. A South African man born in 2016 will live approximately 51.5 years in good health; a woman only 56.1 years. South Africa is one of only a handful of countries where healthy life expectancy decreased from 1990, when it was 53 years for men and 58.6 for women.
In contrast among the emplary countries that have improved the gap between observed and expected life expectancy the most since the year 2000, the top five include Botswana, Zimbabwe, Rwanda, Malawi, and Zambia; in four of these countries, the scale-up of ART played a crucial role in the recent progress.
The top five causes of premature death in South Africa are HIV, lower respiratory infection, road injuries, interpersonal violence, and tuberculosis. The ailments that cause illness can be very different. While HIV is also the number one cause of disability in South Africa, other top causes of non-fatal illness are back pain, hearing loss, and depression.
Deaths of children younger than five are a persistent health challenge. For every 1,000 live births, 43.4 South Africa children under the age of five die. That exceeds the global figure of 38.4, but is lower than in other southern African countries like Zimbabwe and Lesotho.
The report says this year’s version study comprises five peer-reviewed papers, and was published in the The Lancet. The five papers provide in-depth analyses of life expectancy and mortality, causes of death, overall disease burden, years lived with disability, and risk factors that lead to health loss.
Summary
Background: Detailed assessments of mortality patterns, particularly age-specific mortality, represent a crucial input that enables health systems to target interventions to specific populations. Understanding how all-cause mortality has changed with respect to development status can identify exemplars for best practice. To accomplish this, the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) estimated age-specific and sex-specific all-cause mortality between 1970 and 2016 for 195 countries and territories and at the subnational level for the five countries with a population greater than 200 million in 2016.
Methods: We have evaluated how well civil registration systems captured deaths using a set of demographic methods called death distribution methods for adults and from consideration of survey and census data for children younger than 5 years. We generated an overall assessment of completeness of registration of deaths by dividing registered deaths in each location-year by our estimate of all-age deaths generated from our overall estimation process. For 163 locations, including subnational units in countries with a population greater than 200 million with complete vital registration (VR) systems, our estimates were largely driven by the observed data, with corrections for small fluctuations in numbers and estimation for recent years where there were lags in data reporting (lags were variable by location, generally between 1 year and 6 years). For other locations, we took advantage of different data sources available to measure under-5 mortality rates (U5MR) using complete birth histories, summary birth histories, and incomplete VR with adjustments; we measured adult mortality rate (the probability of death in individuals aged 15–60 years) using adjusted incomplete VR, sibling histories, and household death recall. We used the U5MR and adult mortality rate, together with crude death rate due to HIV in the GBD model life table system, to estimate age-specific and sex-specific death rates for each location-year. Using various international databases, we identified fatal discontinuities, which we defined as increases in the death rate of more than one death per million, resulting from conflict and terrorism, natural disasters, major transport or technological accidents, and a subset of epidemic infectious diseases; these were added to estimates in the relevant years. In 47 countries with an identified peak adult prevalence for HIV/AIDS of more than 0·5% and where VR systems were less than 65% complete, we informed our estimates of age-sex-specific mortality using the Estimation and Projection Package (EPP)-Spectrum model fitted to national HIV/AIDS prevalence surveys and antenatal clinic serosurveillance systems. We estimated stillbirths, early neonatal, late neonatal, and childhood mortality using both survey and VR data in spatiotemporal Gaussian process regression models. We estimated abridged life tables for all location-years using age-specific death rates. We grouped locations into development quintiles based on the Socio-demographic Index (SDI) and analysed mortality trends by quintile. Using spline regression, we estimated the expected mortality rate for each age-sex group as a function of SDI. We identified countries with higher life expectancy than expected by comparing observed life expectancy to anticipated life expectancy on the basis of development status alone.
Findings: Completeness in the registration of deaths increased from 28% in 1970 to a peak of 45% in 2013; completeness was lower after 2013 because of lags in reporting. Total deaths in children younger than 5 years decreased from 1970 to 2016, and slower decreases occurred at ages 5–24 years. By contrast, numbers of adult deaths increased in each 5-year age bracket above the age of 25 years. The distribution of annualised rates of change in age-specific mortality rate differed over the period 2000 to 2016 compared with earlier decades: increasing annualised rates of change were less frequent, although rising annualised rates of change still occurred in some locations, particularly for adolescent and younger adult age groups. Rates of stillbirths and under-5 mortality both decreased globally from 1970. Evidence for global convergence of death rates was mixed; although the absolute difference between age-standardised death rates narrowed between countries at the lowest and highest levels of SDI, the ratio of these death rates—a measure of relative inequality—increased slightly. There was a strong shift between 1970 and 2016 toward higher life expectancy, most noticeably at higher levels of SDI. Among countries with populations greater than 1 million in 2016, life expectancy at birth was highest for women in Japan, at 86·9 years (95% UI 86·7–87·2), and for men in Singapore, at 81·3 years (78·8–83·7) in 2016. Male life expectancy was generally lower than female life expectancy between 1970 and 2016, and the gap between male and female life expectancy increased with progression to higher levels of SDI. Some countries with exceptional health performance in 1990 in terms of the difference in observed to expected life expectancy at birth had slower progress on the same measure in 2016.
Interpretation: Globally, mortality rates have decreased across all age groups over the past five decades, with the largest improvements occurring among children younger than 5 years. However, at the national level, considerable heterogeneity remains in terms of both level and rate of changes in age-specific mortality; increases in mortality for certain age groups occurred in some locations. We found evidence that the absolute gap between countries in age-specific death rates has declined, although the relative gap for some age-sex groups increased. Countries that now lead in terms of having higher observed life expectancy than that expected on the basis of development alone, or locations that have either increased this advantage or rapidly decreased the deficit from expected levels, could provide insight into the means to accelerate progress in nations where progress has stalled.
Authors
GBD 2016 Mortality Collaborators
The review found, no country is currently positioned to meet more than 13 of the 37 UN Sustainable Development Goal (SDG) health-related targets, and 11 health-related targets will be met by only 5% of the 188 countries. No country is projected to reach the goal of eliminating new tuberculosis cases by 2030. Hopes of controlling HIV without improved, increased, and more efficient use of resources are only slightly more hopeful with just 7% of countries projected to reduce HIV incidence to the level necessary to eliminate the virus as a global health threat.
While more than 60% of the countries reviewed were projected to reduce child and newborn deaths, increase childhood vaccination coverage, and drop rates of malaria incidence sufficiently to meet 2030 goals for those indicators, at least half of the countries had already met those goals by the end of 2016.
The authors of the report note that while the SDGs were based on an overarching goal of “leaving no one behind” disparate progress and resources ensure that is what will happen under current projections, which show wealthy countries faring better across many indicators, including HIV than many low-income countries, and countries that receive limited donor support. Fortunately, they note, both policy and funding decisions surrounding the SDGs have just begun, giving leaders worldwide a chance to assess current challenges and projections, as well as the likelihood of new challenges, as they craft their responses.
Poor diet is a factor in one in five deaths around the world. The Guardian reports that according to the GBD study, millions of people are eating the wrong sorts of food for good health. Eating a diet that is low in whole grains, fruit, nuts and seeds and fish oils and high in salt raises the risk of an early death.
The study, based at the Institute of Health Metrics and Evaluation at the University of Washington, compiles data from every country in the world and makes informed estimates where there are gaps.
It finds that people are living longer. Life expectancy in 2016 worldwide was 75.3 years for women and 69.8 for men. Japan has the highest life expectancy at 84 years and the Central African Republic has the lowest at just over 50. In the UK, life expectancy for a man born in 2016 is 79, and for a woman 82.9.
Diet is the second highest risk factor for early death after smoking. Other high risks are high blood glucose which can lead to diabetes, high blood pressure, high body mass index (BMI) which is a measure of obesity, and high total cholesterol. All of these can be related to eating the wrong foods, although there are also other causes.
“This is really large,” Dr Christopher Murray, IHME’s director, is quoted in the report as saying. “It is amongst the really big problems in the world. It is a cluster that is getting worse.” While obesity gets attention, he was not sure policymakers were as focused on the area of diet and health as they needed to be. “That constellation is a really, really big challenge for health and health systems,” he said.
The problem is often seen as the spread of western diets, taking over from traditional foods in the developing world. But it is not that simple, says Murray. “Take fruit. It has lots of health benefits but only very wealthy people eat a lot of fruit, with some exceptions.” Sugary drinks are harmful to health but eating a lot of red meat, the study finds, is not as big a risk to health as failing to eat whole grains. “We need to look really carefully at what are the healthy compounds in diets that provide protection,” he said in the report.
Professor John Newton, director of health improvement at Public Health England, said the studies show how quickly diet and obesity-related disease is spreading around the world. “I don’t think people realise how quickly the focus is shifting towards non-communicable disease (such as cancer, heart disease and stroke) and diseases that come with development, in particular related to poor diet. The numbers are quite shocking in my view,” he said. The UK tracks childhood obesity through the school measurement programme and has brought in measures to try to tackle it. “But no country in the world has been able to solve the problem and it is a concern that we really need to think about tackling globally,” he said.
Today, 72% of deaths are from non-communicable diseases for which obesity and diet are among the risk factors, with ischaemic heart disease as the leading cause worldwide of early deaths, including in the UK. Lung cancer, stroke, lung disease (chronic obstructive pulmonary disorder) and Alzheimer’s are the other main causes in the UK.
The report says the success story is children under five. In 2016, for the first time in modern history, fewer than 5m children under five died in one year – a significant fall compared with 1990, when 11m died. Increased education for women, less poverty, having fewer children, vaccinations, anti-malaria bed-nets, improved water and sanitation are among the changes in low-income countries that have brought the death rate down, thanks to development aid.
People are living longer but spending more years in ill health. Obesity is one of the major reasons. More than a billion people worldwide are living with mental health and substance misuse disorders. Depression features in the top 10 causes of ill health in all but four countries.
“Our findings indicate people are living longer and, over the past decade, we identified substantial progress in driving down death rates from some of the world’s most pernicious diseases and conditions, such as under age-five mortality and malaria,” said Murray “Yet, despite this progress, we are facing a triad of trouble holding back many nations and communities – obesity, conflict, and mental illness, including substance use disorders.”
In the UK, the concern is particularly about the increase in ill-health that prevents people from working or having a fulfilling life, said Newton. A man in the UK born in 2016 can expect only 69 years in good health and a woman, 71 years.
“This is yet another reminder that while we’re living longer, much of that extra time is spent in ill-health. It underlines the importance of preventing the conditions that keep people out of work and put their long-term health in jeopardy, like musculoskeletal problems, poor hearing and mental ill health. Our priority is to help people, including during the crucial early years of life and in middle age, to give them the best chance of a long and healthy later life,” he said.
Tobacco was responsible for more than 7.1m deaths, reports The Journal. The authors note that the relatively poor track record for global risk reduction might in part reflect low investment, as compared to curative health care, as well as the continuing challenges of improving many risky behaviours.
Over 1bn people around the world are living with mental health and addiction problems, the study showed. Furthermore, major depressive disorders rank in the top 10 causes of ill health in almost every country in the world, reports Irish Health.
"Our findings indicate people are living longer and, over the past decade, we identified substantial progress in driving down death rates from some of the world's most pernicious diseases and conditions, such as under age-5 mortality and malaria.
"Yet, despite this progress, we are facing a triad of trouble holding back many nations and communities – obesity, conflict, and mental illness, including substance use disorders," commented Murray.
James J Sejvar at the National Centre for Emerging and Zoonotic Infectious Diseases, US Centres for Disease Control and Prevention writes in a comment in The Lancet, that we are living in a rapidly changing landscape in terms of global public health. On one hand, the immense increase in and ageing of the world's population, mass migration of people from rural to urban areas, and unhealthy lifestyles – either by choice or by circumstance – are negatively affecting the overall health of the planet.
On the other hand, medical advances such as vaccines, antibiotics, and new medications, and renewed emphasis on workplace safety, have benefitted global health.
These balancing influences perhaps have the most effect on neurological diseases, which affect many different daily functions and therefore have a disproportionately large effect on global health.
The US had a life expectancy of 78.9 years on average in 2016, good for the 58th highest life expectancy in the world. MedPageToday reports that that's the country's lowest rank since the study began in 1970. And while the life expectancy did increase slightly from 2010 to 2016, the change was an anaemic 0.1% – falling far short of the average 1% increase that had been recorded every five years previously.
The report says the US’ fall is perhaps indicative of a broader trend, as the gaps between the world's haves and the have-nots are generally shrinking. Absolute differences in death rates between countries have converged, meeting one of the aims of The Lancet's Commission on Investing in Health.
The report says some countries in particular stand out: Ethiopia, the Maldives, Nepal, Niger, Portugal and Peru have seen large increases in life expectancy beyond what would be expected based on the country's level of development, the study's authors wrote.
Of course, the report says, higher life expectancies have their downsides. People are living more of their years with ill health, especially in poor countries without access to quality medical care. Lower back pain, migraines, hearing loss, anaemia, and depressive disorders were the biggest contributors to years lived with disability. Some of those conditions were geographically inescapable: Major depressive episodes were one of the top causes of ill health in all but four countries worldwide.
The initial publication of study numbers in 1997 was a major step in the establishment of a revolutionary new concept: the global burden of disease, says a Discover Magazine report. Former World Health Organisation epidemiologists, Chris Murray, now at the University of Washington, and Alan Lopez, now at the University of Melbourne, compared not just the death toll of various illnesses and conditions, but also the burdens the illnesses and conditions cause while people are still alive.
Initially, they were concerned about whether their way of quantifying the toll of disability – assigning different degrees of burdens to different conditions such as deafness or schizophrenia – would be accepted. Today, says Lopez, the stress comes from the magnitude of the ongoing project. There are now 2,500 collaborators, and the work has gotten much more complex.
The report says Murray and Lopez started with just over 100 diseases and injuries, and that’s grown to more than 300. In the early years, they considered 10 risk factors for ill health, such as tobacco and alcohol. Today there are 80 risk factors, including such new ones as sodium intake, hand-washing, and exposure to second-hand smoke. It has been called “the most comprehensive worldwide observational epidemiological study to date.”
The report says over the years, new infections such as Ebola and Zika have come into play. The availability of antiretroviral therapy for HIV/Aids has dropped the death and disability rate from that infection. And the new study shows a rise in non-infectious diseases. Diabetes was the 24th leading contributor to the global burden of disease in 1990. In 2005, it was 16 th. And now it’s 11th “and still rising,” Lopez says.
[link url="http://www.bizcommunity.com/Article/196/148/167477.html"]Bizcommunity report[/link]
[link url="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31833-0/fulltext"]The Lancet article summary[/link]
[link url="http://www.thelancet.com/gbd"]The Lancet GDB reports[/link]
[link url="http://sciencespeaksblog.org/2017/09/13/global-health-data-review-finds-no-country-on-track-to-end-tb-incidence-by-2030-vast-majority-of-countries-falling-short-of-goals-to-control-hiv/"]Sciencespeaks blog[/link]
[link url="https://www.theguardian.com/society/2017/sep/14/poor-diet-is-a-factor-in-one-in-five-deaths-global-disease-study-reveals"]The Guardian report[/link]
[link url="http://www.thejournal.ie/tobacco-use-caused-7-million-deaths-3597257-Sep2017/"]The Journal report[/link]
[link url="http://www.irishhealth.com/article.html?id=25919"]Irish Health report[/link]
[link url="http://www.thelancet.com/journals/laneur/article/PIIS1474-4422(17)30333-2/abstract"]The Lancet comment[/link]
[link url="https://www.medpagetoday.com/publichealthpolicy/publichealth/67946"]MedPageToday report[/link]
[link url="http://blogs.discovermagazine.com/d-brief/2017/09/14/global-disease-burdern/#.Wb5qvtGxXIU"]Discover Magazine[/link]