Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: Quantifying the epidemiological transition

Background The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age–sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development. Methods We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time. Findings Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6–6·6), from 65·3 years (65·0–65·6) in 1990 to 71·5 years (71·0–71·9) in 2013, HALE at birth rose by 5·4 years (4·9–5·8), from 56·9 years (54·5–59·1) to 62·3 years (59·7–64·8), total DALYs fell by 3·6% (0·3–7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6–29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non–communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries. Interpretation Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition—in which increasing sociodemographic status brings structured change in disease burden—is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions.

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk–outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990–2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8–58·5) of deaths and 41·6% (40·1–43·0) of DALYs. Risks quantified account for 87·9% (86·5–89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

Empire, Tourism, Nostalgia: Joseph Brodsky and Travel Writing

Joseph Brodsky, one of the most influential Russian intellectuals of the late Soviet period, was born in Leningrad in 1940, emigrated to the United States in 1972, received the Nobel Prize for Literature in 1987, and died in New York City in 1996. Brodsky was one of the leading public figures of Soviet emigration in the Cold War period, and his role as a model for the constructing of Russian cultural identities in the last years of the Soviet Union was, and still is, extremely important. One of Joseph Brodsky’s great contributions to Russian culture of the latter half of the twentieth century is the wide geographical scope of his poetic and prose works. Brodsky was not a travel writer, but he was a traveling writer who wrote a considerable number of poems and essays which relate to his trips and travels in the Soviet empire and outside it. Travel writing offered for Brodsky a discursive space for negotiating his own transculturation, while it also offered him a discursive space for making powerful statements about displacement, culture, history and geography, time and space—all major themes of his poetry. In this study of Joseph Brodsky’s travel writing I focus on his travel texts in poetry and prose, which relate to his post-1972 trips to Mexico, Brazil, Turkey, and Venice. Questions of empire, tourism, and nostalgia are foregrounded in one way or another in Brodsky’s travel writing performed in emigration. I explore these concepts through the study of tropes, strategies of identity construction, and the politics of representation. The theoretical premises of my work draw on the literary and cultural criticism which has evolved around the study of travel and travel writing in recent years. These approaches have gained much from the scholarly experience provided by postcolonial critique. Shifting the focus away from the concept of exile, the traditional framework for scholarly discussions of Brodsky’s works, I propose to review Brodsky’s travel poetry and prose as a response not only to his exilic condition but to the postmodern and postcolonial landscape, which initially shaped the writing of these texts. Discussing Brodsky’s travel writing in this context offers previously unexplored perspectives for analyzing the geopolitical, philosophical, and linguistic premises of his poetic imagination. By situating Brodsky’s travel writing in the geopolitical landscape of postcolonial postmodernity, I attempt to show how Brodsky’s engagement with his contemporary cultural practices in the West was incorporated into his Russian-language travel poetry and prose and how this engagement thus contributed to these texts’ status as exceptional and unique literary events within late Soviet Russian cultural practices.

"Four Ways of Writing the City" : St. Petersburg-Leningrad as a Metaphor in the Poetry of Joseph Brodsky

The present study discusses the theme of St. Petersburg-Leningrad in Joseph Brodsky's verse works. The chosen approach to the evolving im-age of the city in Brodsky's poetry is through four metaphors: St. Petersburg as "the common place" of the Petersburg Text, St. Petersburg as "Paradise and/or Hell", St. Petersburg as "a Utopian City" and St. Petersburg as "a Void". This examination of the city-image focusses on the aspects of space and time as basic categories underlying the poet's poetic world view. The method used is close reading, with an emphasis on semantical interpretation. The material consists of eighteen poems dating from 1958 to 1994. Apart from investigating the spatio-temporal features, the study focusses on exposing and analysing the allusions in the scrutinised works to other texts from Russian and Western belles lettres. Terminology (introduced by Bakhtin and Yury Lotman, among others) concerning the poetics of space in literature is employed in the present study. Conceptions originating from the paradigm of possible worlds are also used in elucidating the position of fictional and actual chronotopes and heroes in Brodsky's poetry. Brodsky's image of his native city is imbued with intertextual linkings. Through reminiscences of the "Divine Comedy" and Russian modernists, the city is paralleled with Dante's "lost and accursed" Florence, as well as with the lost St. Petersburg of Mandel'shtam and Akhmatova. His city-image is related to the Petersburg myth in Russian literature through their common themes of death and separation as well as through the merging of actual realia with the fictional worlds of the Petersburg Text. In his later poems, when his view of the city is that of an exiled poet, the city begins to lose its actual world referents, turning into a mental realm which is no longer connected to any particular geographical location or historical time. It is placed outside time. The native city as the homeland in its entirety is replaced by another existence created in language.

Ajan sisäkkäiset tilat. Arkkitehtuuri, valokuva ja menneisyyden esittäminen W. G. Sebaldin romaanissa Austerlitz

In her thesis, Kaisa Kaakinen analyzes how the German emigrant author W. G. Sebald (1944-2001) uses architecture and photography in his last novel "Austerlitz" to represent time, history and remembering. Sebald describes time in spatial terms: it is like a building, the rooms and chambers of which are connected to each other. The poetics of spatial time manifests itself on multiple levels of the text. Kaakinen traces it in architectural representations, photographic images, intertextuality, as well as in the form of the text, using the concept of spatial form by Joseph Frank. Architectural and photographic representations serve as meeting points for different aspects and angles of the novel and illustrate the idea of a layered present that has multiple connections to the past. The novel tells a story of Jacques Austerlitz, who as a small child was sent from Prague to Britain in one of the so-called Kindertransports that saved children from Central Europe occupied by the National Socialists. Only gradually he remembers his Jewish parents, who have most likely perished in Nazi concentration camps. The novel brings the problematic of writing about another person's past to the fore by the fact that Austerlitz's story is told by an anonymous narrator, Austerlitz's interlocutor, who listens to and writes down Austerlitz's story. Kaakinen devotes the final part of her thesis to study the demands of representing a historical trauma, drawing on authors such as Dominick LaCapra and Michael Rothberg. Through the analysis of architectural and photographic representations in the novel, she demonstrates how Austerlitz highlights the sense of singularity and inaccessibility of memories of an individual, while also stressing the necessity - and therefore a certain kind of possibility - of passing these memories to another person. The coexistence of traumatic narrowness and of the infinity of history is reflected in ambivalent buildings. Some buildings in the novel resemble reversible figures: they can be perceived simultaneously as ruins and as construction sites. Buildings are also shown to be able to both cover and preserve memories - an idea that also is repeated in the use of photography, which tends to both replace memories and cause an experience of the presence of an absent thing. Commenting and critisizing some recent studies on Sebald, the author develops a reading which stresses the ambivalence inherent in Sebald's view on history and historiography. Austerlitz shows the need to recognize the inevitable absence of the past as well as the distance from the experiences of others. Equally important, however, is the refusal to give up narrating the past: Sebald's novel stresses the necessity to preserve the sites of the past, which carry silent traces of vanished life. The poetics of Austerlitz reflects the paradox of the simultaneous impossibility and indispensability of writing history.

Joseph Molling with wife Margarete "Gretchen" nee Benjamin and son Peter on a walk.

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Portrait of Hedwig and Ludwig Heinemann and Margarete nee Benjamin and Joseph Molling.

Elderly couple Hedwig and Ludwig Heinemann envolved with Adolph Molling Business. Younger couple is Margarete "Gretchen" Molling geb. Benjamin and Joseph Molling.

Portrait of Joseph and his sister Elly Schoenbeck; Cologne, Germany. Portraits family

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Portrait of Joseph Rothschild and his wife Rosalie nee Stern; Bad Ems, Germany. Portraits Couples

Handwritten on verso of original photograph: Joseph u Rosalie Rothschild

Hal Godshaw (Gottschalk) with his wife Anne nee Pick Portraits Couples

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Members of the Godshaw (Gottschalk) family, Anne, Donald, Molly, Freddy, Jan and Hal; Hannover, Germany. Portraits Family

The family was in Hannover, Germany, for the dedication of the memorial to the Holocaust, the Mahnmal am Opernplatz; from left to right: Anne Godshaw nee Pick, Donald Godshaw, Molly Godshaw nee Peck, Freddy Godshaw, Jan Godshaw nee McKay, and Hal (Hans Ludwig Gottschalk) Godshaw.

Tombstone of Joseph Benjamin; Strangriede Cemetery, R83.8; Hannover Cemeteries Tombs

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Tombstones of Joseph Benjamin and Marianne Benjamin nee Sussmann; Strangriede Cemetery (R 83.8 and R 83.9); Hannover Cemeteries Tombs

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Portrait of Dr. Joseph Wallerstein holding his infant grandson Hans Stern.

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