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.

Rintamamiesten muonitus Suomessa sotavuosina 1939-1945

This study analyzes the war-time rations the Finnish soldiers received on the front from 1939 until 1945. The main objective was to determine the contents of the rations and how they affected the soldiers' nutrition and morale. The information concerning food and feeding is mainly based on the official documents found in the Military Archives. Some additional material was from the historical literature, some from memoirs, or from the veterans who personally experienced the front. The documents in the Archives of Military Medicine provided information on the soldiers' deficiencies. During the Winter War, which took place from 30 November 1939 until 13 March 1940, ample food was available. The cold climate caused problems and the fresh food got frozen. However, no severe deficiency cases were reported and the morale was high. By contrast, during the Continuation War, which began in June, 1941 and ended in September, 1944, difficulties were experienced. At the time farming in the country faced serious problems due to the shortage of labour, fuel, etc. Furthermore, importing food was generally not possible. However, importing food mainly from Germany saved the Finns from hunger. In addition, the self activity of the soldiers on the front added somewhat to the food production. But the rations had to be reduced. Their energy values were consequently low, especially for the young men. Food was monotonous and occasionally caused complaints. The main sources of protein, vitamins and minerals were the whole cereal foods. Butter was fortified with vitamin A and vitamin C tablets were also distributed, to compensate for the scant food sources. Only approximately 300 serious deficiency cases required hospital care during the three years time, out of a total of 400 000 soldiers. Feeding the young soldiers during the war (1944 - 1945) in Lapland, which had been destroyed, was problematic but the increased rations also saved them from deficiencies. In spite of the severe difficulties experienced occasionally in feeding the soldiers during the wars, the system worked all the time. The soldiers were fed, the cases of nutritional deficiency and epidemics caused by food were kept very limited and the morale of soldiers remained high.

The great errand 1939-1955

The novel was written in 2001. Description of post-war Germany from the viewpoint of a German, Fritz Meyer, who was a member of a local Nazi Youth organization in Sonneborn. He fought as a soldier and fell into the hands of the English in Northern France. He was taken to Canada as a prisoner of war. He escaped the camp and found refuge at a German family. Description of erotic encounters. Reflection on Nazi ideology. At the request of the family he returns to Germany for something subscribed as "the great errand", taking up the identity of a former American G.I. Desolation of post-war Germany. Confrontation with British emigre soldiers. Identifying with the anger of his German countrymen. Reflection on the Bible and the denial of the Jewish roots of Christianity. Creating an underground network of conspiracy with former Nazi leaders and high members of the Catholic church in order to continue the ideals of National Socialism. Donations from secret supporters abroad. Connections with the political leaders in the newly established German Republic. Revisionist history.

Escape to Shanghai, China, 1939-1949.

This memoir was written for educational purposes, particularly for its use in schools (7th and 8th grade), which is reflected in the style it was written. It also includes a map showing his emigration route from Vienna to Shanghai, a photograph, and many resources for teachers. It was originally published in the State of New Jersey Holocaust/Genocide Curriculum in 2002. The memoir starts with the family’s departure from Vienna, on January 23, 1939. It later on describes daily life in Shanghai and the later Jewish ghetto. The memoir ends with the Seiden family’s departure to Israel on January 1, 1949.

Die letzten Lebensjahre meines Vaters Prof. Ernst Neisser 1939-1942

Description of Prof. Neisser's last years in form of a letter written by his daughter to a relative in the USA; concentrates mainly on suicide of Ernst Neisser and his cousin in 1942 to escape deportation.

Miraculous Survival 1939-1982

Description of war years in France and Spain, including experiences in internment camps, life in hiding, etc.; emigration to USA.

The File Marked "Rita". Selections from the Letters of Herbert Mueller and Rita Klein (1939-1945) 1939-1946

Exchange of letters between Herbert Mueller and Rita Klein after Mueller's emigration to England in 1939; Rita Klein's attempt to obtain divorce; suicide attempt by her husband Leo Klein; correspondence through intermediaries after outbreak of World War II; notice of Rita Klein's deportation to Auschwitz; (translation from original German)

My First 6701 Days : July 31 1921 to December 1939 /

The memoirs contain photocopies of documents and photos as well as extracts from letters and were written in October 1989 in the United States. Description of life in Baden, a famous health resort near Vienna. The family lived in Vienna in the second district (Leopoldstadt). Recollections of schoolteachers and childhood friends. Occasional Friday night services in the Leopoldstadt temple. Theater and opera visits and cultural life in Vienna. Private piano and music lessons. Description of the family apartment and Jewish life in the Leopoldstadt. The family celebrated Christmas and observed the high Jewish holidays. Recollections of the author's bar mitzvah celebration. His mother Charlotte, nee Schwadron, was an artistic woman, who studied painting at the Frauenakademie with Tina Blau. Walter's father Leo Schaffir was born in Byalistock, Russia and studied in Berlin. He was a travelling businessmen. His family lived in Lemberg, Galicia. Leo and Charlotte Schaffir got married in 1919 in Vienna by rabbi Dr. Grunwald. Recollections of a family trip to Poland and to the World Fair in Posen in 1930. Suicide of the author's father due to business failure in 1930. Schaffir and Schwadron family history. Both families originated in Galicia, Poland. Family and social life. Summer vacation at the Semmering. Austrian politics in the 1930's and rising National Socialism. Life in Vienna after the "Anschluss" in 1938. Walter had to leave school and took lessons in graphic arts with the artist Heinrich Koerner. Preparations to emigrate. Walter was picked up in the streets in the days after Kristallnacht and released due to his mother's intervention. He was sent with his brother Kurt on a "Kindertransport" to Holland. They were sent to a quarantine camp at Heyplaat. Reunition with their mother in the United States in December 1939. Reflections on life as an emigre.

Before the Holocaust: Letters to Alice (and Edith) 1939-1941.

Collection of transcribed 32 letters with accompanying notes, photographs and family trees. The letters were written by Flora Mattersheim Kleinmann to her daughter Alice Kleinmann Loewenstein and her granddaughter Edith from Vienna between July 1939 and October 1941. Introduced and edited by Ruth Leeds Love (Inge Ruth Loewenstein), Alice Kleinmann Loewenstein's granddaughter; transcripts by Herbert Weber.

Nachman Zonabend 1939-1944

The records reflect the organizational structure of the Jewish ghetto administration and consist of the following: Correspondence with German government agencies, 1939-1941, including the Police and Gestapo, the *Oberburgermeister* of Litzmannstadt (German name for Lodz), the *Gettoverwaltung* (German administration of the ghetto). The correspondence pertains to the establishment of the ghetto, expropriation of Jewish property, resettlement of Lodz Jews into the ghetto, sanitary conditions, ghetto industry, anti-Jewish ordinances. Announcements issued by Rumkowski, 1940-1944. A complete set of daily communications to the ghetto population on all subjects pertinent to ghetto life such as: confiscations of Jewish property, food rationing, availability of work, relief distribution, deportations, liquidation of the ghetto. Files of various departments of the Jewish ghetto administration including labor divisions and workshops, the Jewish police (*Ordnungsdienst*), Statistics Department, Ghetto Court, Archives, Resettlement Department, Deportation Commission. Of special interest are the Archives files which contain essays and reports written by the Archives staff expressly for the purpose of historical record on subjects related to ghetto life. Outstanding in this group are reports and literary sketches by Joseph Zelkowicz, including his extensive account about the *Gesperre* (Yid. Shpere) - the deportation of the children, the old and the infirm in September, 1942. In addition, the Archives files contain bulletins of the *Daily Chronicle* of the Lodz Ghetto, transcripts of speeches by Rumkowski, and issues of the *Geto-tsaytung*, a short-lived official publication of the Eldest of the Jews. Iconographic materials, including photographs and albums. The photographs taken by Mendel Grossman, Henryk Ross, Maliniak, Zonabend and others, provide an extensive visual record of ghetto life.