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The burden of disease and injury in the United States 1996

  • Catherine M Michaud1Email author,
  • Matthew T McKenna2,
  • Stephen Begg3,
  • Niels Tomijima4,
  • Meghna Majmudar5,
  • Maria T Bulzacchelli6,
  • Shahul Ebrahim2,
  • Majid Ezzati1,
  • Joshua A Salomon1,
  • Jessica Gaber Kreiser,
  • Mollie Hogan3 and
  • Christopher JL Murray1
Population Health MetricsAdvancing innovation in health measurement20064:11

DOI: 10.1186/1478-7954-4-11

Received: 14 November 2005

Accepted: 18 October 2006

Published: 18 October 2006

Abstract

Background

Burden of disease studies have been implemented in many countries using the Disability-Adjusted Life Year (DALY) to assess major health problems. Important objectives of the study were to quantify intra-country differentials in health outcomes and to place the United States situation in the international context.

Methods

We applied methods developed for the Global Burden of Disease (GBD) to data specific to the United States to compute Disability-Adjusted Life Years. Estimates are provided by age and gender for the general population of the United States and for each of the four official race groups: White; Black; American Indian or Alaskan Native; and Asian or Pacific Islander. Several adjustments of GBD methods were made: the inclusion of race; a revised list of causes; and a revised algorithm to allocate cardiovascular disease garbage codes to ischaemic heart disease. We compared the results of this analysis to international estimates published by the World Health Organization for developed and developing regions of the world.

Results

In the mid-1990s the leading sources of premature death and disability in the United States, as measured by DALYs, were: cardiovascular conditions, breast and lung cancers, depression, osteoarthritis, diabetes mellitus, and alcohol use and abuse. In addition, motor vehicle-related injuries and the HIV epidemic exacted a substantial toll on the health status of the US population, particularly among racial minorities. The major sources of death and disability in these latter populations were more similar to patterns of burden in developing rather than developed countries.

Conclusion

Estimating DALYs specifically for the United States provides a comprehensive assessment of health problems for this country compared to what is available using mortality data alone.

Background

This paper presents the results of a study conducted cooperatively by scientists from the Centers for Disease Control and Prevention (CDC) and the Harvard School of Public Health. The study essentially applied the methods used in the Global Burden of Disease analysis to data specific to the United States in order to calculate Disability-Adjusted Life Year (DALY) values for major health conditions and risk factors [1].

The genesis of the US Burden of Disease and Injury study (USBODI) was the release of the 1993 World Development Report: Investing in Health published by the World Bank. This landmark report in international health policy introduced a new summary measure of population health – the Disability-Adjusted Life Year (DALY) [2]. In contrast to the traditional reliance on death counts and rates to assess the burden of health events, the DALY attempted to combine the impact of non-fatal health outcomes with mortality. Though originally developed for comparative analyses of disease burden in different regions of the world, this perspective seemed particularly appropriate to inform policy in a country such as the United States. In industrialized country settings, where death rates are low relative to developing countries, the majority of deaths occur after the age of 75 years. Yet too many deaths still occur at younger ages and many could be prevented. Therefore, information for health policy deliberations needs to emphasize the burden of premature mortality as well as disability. As stated in a recent Institute of Medicine report on summary health measures, "Mortality measures, although important, provide decision makers incomplete and insensitive information about overall population health." [3].

From the outset, this study had three major goals. The first goal was to incorporate non-fatal conditions into assessments of health status in the United States. So far most discussions about the relative importance of various health conditions centered on the number of deaths attributed to specific diseases, injuries or risk factors [4]. The focus on deaths has important implications for policy and great influence on resource allocation. As the average life expectancy continues to rise in economically developed countries, more and more deaths are attributed to chronic conditions that are recalcitrant to treatment and may have limited preventability [5]. Prioritization of research and health care expenditures based on such data tends to result in a focus on rescue-oriented, life-saving, and technologically advanced approaches rather than adequate consideration of interventions that promote healthy life-styles and improve overall physical and emotional function [6]. The DALY offers a rational methodology for weighing the relative importance of fatal and non-fatal health events. Hence, a much broader range of health conditions that are rarely identified as causes of death, such as mental health disorders and musculoskeletal diseases, can be introduced into data-based deliberations on health policy.

The second major goal was to develop a comprehensive set of internally consistent and scientifically credible epidemiological estimates for the major health conditions in the United States. This is greatly facilitated by a plethora of population-based surveys, registries and administrative data systems that attempt to capture information on a wide range of health events [7]. The major challenge is to impose a consistent and conceptually rigorous analytic approach so that the estimates are internally consistent. Reviews of cost-effectiveness ratios that depend on epidemiologic data and statistical modeling have demonstrated that it is very difficult to compare results from one study to the next because of major variations in methods, underlying assumptions, data sources and conceptual frameworks [8]. A major source of these inconsistencies is that most such models are developed on a case by case, disease by disease basis, with little attention to conceptual consistency and integration of data from multiple sources [9]. Estimates developed with an adherence to conceptual consistency for the United States can serve not only as a useful source of epidemiologic information, but can also stimulate further analyses and refinements by other investigators.

The third and final goal of the US Burden of Disease and Injury study was to provide a set of internationally comparable health statistics that place the United States public health situation in a global context. World population growth and technological developments over the last few decades in telecommunications, industrial pollution and transportation have effectively made the earth a much smaller planet [10]. This dynamic has major implications for the importation and exportation of health related vectors that include infectious diseases, manufactured products (e.g. energy rich foods, tobacco), and health system organization and practices [1113]. Given the emergence of this global public health "village," and the growing importance of the DALY as a metric for assessing population health, it seems critical to provide an analysis of the public health situation in the United States that uses methods being adopted by international organizations and health ministries throughout the world.

The Global Burden of Disease (GBD) study developed health statistics for 8 large regions of the world. It includes the United States, which possesses substantial intra- national racial, ethnic and cultural variability. Generating a set of estimates specific to the United States not only provides an opportunity to frame the major health problems in this country in a global context, but also facilitates explication of intra- national disparities. For example, a previously published monograph that resulted from this project identified differences between race, sex and county-specific life expectancies that rivaled differences seen between the nations with the highest (Japan) and lowest (Sierra Leone) life expectancy values in the world [14].

The overall purpose of this study is to expand the understanding of the major determinants of ill and good health in the United States. The ultimate goal of such understanding should be policies and programs that decrease the overall impact and disparities in disease, disability and premature death.

Methods

The study was patterned after the GBD and applied methods used in the GBD analysis to compute years of life lost due to premature mortality (YLL), years of life lost due to disability (YLD), and disability-adjusted life years (DALYs). The conceptual and computational details of how these parameters were estimated for individual conditions have been presented in the GBD. A summary overview of GBD methods is provided [see Additional file 1].

The detailed mortality data file for 1996 provided deaths by age, sex and race to compute YLL [15]. The National Health Interview Survey (NHIS), National Health and Nutrition Examination Survey (NHANES), National Longitudinal Alcohol Epidemiologic Survey (NLAES), the National Hospital Discharge Database, disease registers, and epidemiological studies provided the epidemiological parameters needed to compute YLD for 72 conditions that account for at least 90 per cent of the DALY total in the United States. If data on race and gender specific subgroups were too sparse to derive reasonable epidemiological parameters for particular conditions, YLD were estimated for these subgroups using YLD to YLL ratios for the overall population. For the remaining 26 conditions, YLD were calculated using YLD to YLL ratios from Established Market Economies (EME) countries in the GBD, applied to US specific estimates of YLL. A detailed presentation of analytic methods, data sources, and data sets used to develop estimates for major causes of diseases and injuries is provided [see Additional file 2].

Below we describe adjustments that were made to GBD methods in the context of the United States. These were 1) the inclusion of race; 2) a revised list of causes; and 3) a revised algorithm to allocate cardiovascular disease garbage codes to ischaemic heart disease (IHD).

Selection of population groups

Estimates of the burden of disease and injury were done by gender and seven age groups (0–4; 5–14; 15–24; 25–44; 45–64; 65–74 and 75+) for the total US population, as well as for each of the four official race groups specified by the Office of Management and Budget (OMB): White; Black; American Indian or Alaskan Native; and Asian or Pacific Islander. Whites were the largest population group (82.8 per cent, or 219.7 million). Blacks represented 12.6 per cent of the population (33.5 million); American Indians – 0.9 per cent (2.3 million), and Asians – 3.7 per cent (9.7 million). Estimates by ethnicity were not included in this report because reliable estimates were only available for a subset of the Hispanic population.

The inclusion of race in the analysis posed particular challenges for minority populations because of race misclassification. Two independent data sets were combined to calculate death rates: the number of deaths in the numerator comes from the detailed mortality file, and population numbers in the denominator are from the census. There was no discrepancy in reporting of race in both data sets for Whites and Blacks, but race misclassification was found to be problematic for Asians and American Indians. Self-reporting of race in the census tended to be higher, particularly for American Indians, than was the attribution of race (by a third party) on death certificates – which will yield an underestimate of death rates [16]. However, we did not correct for race misclassification in American Indians and Asians because evaluations showed that discrepancies in race reporting varied from year to year and thus provided supportive evidence that there may be no systematic bias. Therefore race differentials expressed as rates may have been slightly overestimated. Death and DALY rates were age-standardized to the general population.

There were also important gaps in the available epidemiological data for Asians and American Indians. In order to fill information gaps, we assumed that ratios of YLL to YLD by cause, gender and age were similar to that of the total population. Such assumptions introduce a certain level of uncertainty in the estimates, and call for caution in the interpretation of rankings for causes that have small differences in the number of DALYs. For simplicity, American Indians or Alaskan Natives are referred to as "American Indians," and Asians or Pacific Islanders as "Asians" in the text, tables and figures below.

USBODI cause list

Even though essentially all deaths in the United States are registered and medically certified, a detailed assessment of mortality data was conducted as part of the USBODI. This was done to further explore and refine the utility of the adjustment procedures for misclassification that were used in the GBD, and to provide a contrast to the overall results using the DALY.

The International Statistical Classification of Disease and Related Health Problems, Version 9, (ICD-9) [17] code listed as the underlying cause for each death recorded in the United States in 1996 was attributed to corresponding disease categories listed in the GBD. The GBD classification scheme was developed as a tool to better inform the health policy debate (Table 1). The list of causes selected for the USBODI was amended based on the distribution of causes of deaths in the United States. All ICD-9 reported codes accounting for more than 0.1 per cent of total deaths were examined. This process identified modifications that were needed from the GBD cause list. Several causes of little relevance to the United States were dropped, i.e. malaria and other tropical diseases. Other causes were added, i.e. Sudden Infant Death Syndrome (SIDS), and septicemia. For those codes accounting for more than 0.1 per cent of deaths that were not included in the GBD list the choice was made in consultation with CDC based on two major criteria. If the code represented a true cause of death with significance for health policy, it was added to the cause list. If the code more likely represented a "garbage category," then after consultation with experts in that disease and a review of published autopsy studies on this subject, a redistribution algorithm was proposed and applied. For example, careful consideration was given to the nearly 10.9 per cent of cancer deaths assigned to "unknown primary." There were another 4% of cancers that did not have a code that corresponded to the GBD classification system. The race and sex specific age distribution of cancers attributed to an ill-defined primary source were compared to all other cancer deaths. These distributions were generally similar. Therefore, cancers attributed to an ill-defined primary source were redistributed proportionally to all defined primary sources based on age, race and sex specific distributions. The detailed list of causes selected for the USBODI is provided [see Additional file 3].
Table 1

Global burden of disease classification system – main categories

Communicable, maternal, perinatal and nutritional conditions (Group I)

   A. Infectious and parasitic diseases

   B. Respiratory infections

   C. Maternal conditions

   D. Conditions arising during the perinatal period

   E. Nutritional deficiencies

Noncommunicable diseases (Group II)

   A. Malignant neoplasms

   B. Other neoplasms

   C. Diabetes mellitus

   D. Endocrine disorders

   E. Neuro-psychiatric conditions

   F. Sense organ diseases

   G. Cardiovascular diseases

   H. Respiratory diseases

   I. Digestive diseases

   J. Genito-urinary diseases

   K. Skin diseases

   L. Musculo-skeletal diseases

   M. Congenital anomalies

   N. Oral conditions

Injuries (Group III)

   A. Unintentional injuries

   B. Intentional injuries

Source: Global Burden of Disease and Injury 1990

Redistribution algorithm for cardiovascular garbage codes

The most problematic aspect of cause of death coding pertains to coding of ischaemic heart disease (IHD) (ICD-9 codes 410–414), which is one of the leading causes of premature mortality. The wide cross-national variations that exist in IHD reported mortality rates were explored in the context of the GBD and were convincingly attributed to variations across countries in coding practices. Physicians may use several ICD-9 codes that are actually due to IHD when they assign the cause of death. These include heart failure (428), ventricular dysrhythmias (427.1, 427.4, 427.5), general atherosclerosis (440.9), and ill-defined descriptions and complications of heart disease (429.0, 429.1, 429.2 and 429.9). IHD deaths may be assigned to these ill-defined cardiovascular codes, or "garbage codes" because of insufficient clinical information at the time of death, local medical diagnostic practices or simply by error. The statistical approach developed to correct for likely undercoding resulting from different coding practices in the GBD included a two-step procedure comprising an ordinary least squares (OLS) regression equation predicting the proportion of cardiovascular death for each age group assigned to ill-defined codes as a function of the proportion of deaths assigned to IHD, and the correction of proportions for each country within set constraints, based on the assumption that the cluster of countries where ill-defined coding was low defined the standard coding practices.

An exploration of cardiovascular death coding in the United States showed important differences in coding practices between states. Indeed, the proportion of all cardiovascular deaths (minus stroke) coded to cardiovascular "garbage" codes ranged from 14% in New Mexico to 37% in Alabama and New Jersey (Table 2). Figure 1 illustrates the enormous variation across US states in coding practices with respect to these ill-defined cardiovascular codes. For each state, the fraction of cardiovascular deaths (excluding stroke) that are assigned to ICD-9 codes 410–414 is shown on the y-axis. On the x-axis the fraction of cardiovascular deaths (excluding stroke) that are assigned to the ill-defined cardiovascular codes is measured. The strong negative relation between IHD mortality and that from ill-defined cardiovascular codes supports the suggestion that the quality of IHD death certification varies substantially across states, as it does across countries in the world.
Table 2

Proportion of all cardiovascular deaths (except stroke) coded to cardiovascular "garbage codes" by state – United States 1996

State name

% CV garbage

State name

% CV garbage

State name

% CV garbage

Alabama

37

Kentucky

25

North Dakota

19

Alaska

22

Louisiana

23

Ohio

25

Arizona

22

Maine

24

Oklahoma

18

Arkansas

21

Maryland

24

Oregon

23

California

18

Massachusetts

22

Pennsylvania

15

Colorado

26

Michigan

19

Rhode Island

20

Connecticut

29

Minnesota

35

South Carolina

21

Delaware

29

Mississippi

17

South Dakota

19

DC

28

Missouri

29

Tennessee

21

Florida

16

Montana

31

Texas

24

Georgia

30

Nebraska

34

Utah

24

Hawaii

28

Nevada

20

Vermont

26

Idaho

17

New Hampshire

17

Virginia

24

Illinois

19

New Jersey

37

Washington

26

Indiana

18

New Mexico

14

West Virginia

17

Iowa

20

New York

19

Wisconsin

21

Kansas

24

North Carolina

21

Wyoming

19

Figure 1

Proportion of cardiovascular disease deaths (excluding stroke) assigned to selected codes for ill-defined causes and directly assigned to ischemic heart disease in the United States.

This preliminary analysis confirmed the need to correct for under-registration of IHD in the US. To estimate the fraction of IHD deaths assigned to ill-defined cardiovasular codes, the regression equation applied in the GBD was revised. Age and sex specific lung cancer death rates were added to the model. Lung cancer mortality rates measure the cumulative effects of tobacco exposure as a risk factor for IHD [18].

The regression model for the US included age and sex specific lung cancer death rates, and ill-defined cardiovascular disease (CVD) rates for Blacks and Whites. These regression equations predicted the proportion of ill-defined CVD deaths by age and sex for Whites and Blacks. We applied results of regression equations for Whites to American Indians and Asians, which were not included in the regressions due their small population size.

The finding that the extent of miscoding increased in older age groups is consistent with GBD regression results: R-square increases with increasing age, which provides further evidence that ill-defined codes are indeed being used for IHD which is more common in older ages. Differences in coding practices observed by race as well as gender are not fully explained (Table 3). A recent study concluded that "the greater presence of medical knowledge at the time of death, reflected by place of death and cardiologist per capita, reduces the use of ill-defined cardiovascular clusters. Racial and gender effects on coronary heart disease (CHD) assignment may reflect disparities in access to care and quality of care." [19]
Table 3

R-squared values applied to the redistribution of cardiovascular garbage codes

WHITES

Male

Lung Cancer

CVGarbageCodes

R-squared

 

Coefficient

Pvalue

Coefficient

Pvalue

 

15

-0.499

0.273

0.557

.000

26.17%

30

2.396

.000

-0.193

0.424

52.10%

45

1.495

.000

-0.741

.000

77.77%

65

1.235

.000

-0.833

.000

69.02%

75

2.73

.000

-1.122

.000

47.64%

Female

     

15

0.348

0.0324

0.097

0.395

3.53%

30

0.727

.000

0.539

0.008

37.82%

45

0.869

.000

-0.315

0.283

31.41%

65

-0.459

0.206

0.752

0.018

11.47%

75

2.011

0.123

-0.679

0.021

12.25%

BLACKS

Male

Lung Cancer

CV GarbageCodes

R-squared

 

Coefficient

Pvalue

Coefficient

Pvalue

 

15

0.592

0.314

-0.0393

0.792

4.13%

30

1.575

0.013

0.0735

0.785

23.40%

45

1.211

.000

-0.403

0.025

47.27%

65

0.435

0.082

-0.551

.000

40.73%

75

0.183

0.769

-0.7207

0.005

26.34%

Female

     

15

-0.829

0.042

0.256

0.047

16.06%

30

-0.846

0.0127

0.532

0.03

12.85%

45

0.02

0.942

-0.11

0.634

8.30%

65

0.695

0.42

-1.369

0.059

13.60%

75

1.015

0.524

-0.772

0.013

16.67%

International comparisons

Ten countries with comparable levels of development and a population greater than 10 million: Australia, Canada, France, Germany, Greece, Italy, Japan, Netherlands, Spain and the United Kingdom, were selected for international comparisons. YLL by cause were obtained directly from the World Health Organization (WHO). YLD and DALY estimates were only available at the regional level, with the exception of Australia, where a national burden of disease study applying the GBD methodology had been conducted [21].

International comparisons may address two sets of issues – the difference in the magnitude of YLL (expressed as YLL rates), or differences in the distribution of major causes of YLL. We examined differences in rankings of major causes of YLL and YLL rates between the United States and other comparable countries.

Rankings for the twenty leading causes of mortality burden in the United States were compared to rankings for these conditions in the ten selected countries. We made one change in the list of conditions adopted for the United States to ensure comparability among countries, which was to combine mortality burden due to lymphomas and multiple myelomas. These two conditions are different forms of reticuloendothelial malignancies. Estimates were not available for these conditions separately in several of the selected countries. This change slightly altered rankings in the United States for several conditions, as the two conditions combined had a higher mortality burden than lymphomas alone. Lymphomas and multiple myelomas ranked 14th for males and 13th for females, and the mortality burden for lymphomas ranked 19th and 17th respectively. We plotted the rankings for each of the twenty leading causes of mortality burden in the United States (horizontal bars) against the range of rankings observed for each of these conditions in the selected countries (vertical bars), for each sex. The lowest and highest rankings observed in the countries other than the US define the bounds of vertical bars for each condition. Rankings, from one to twenty, are inversely related to the magnitude of mortality burden. Thus, IHD, which caused the largest number of YLL in the United States, ranked 1st. We also compared YLL rankings for the twenty leading causes of YLL for each race and sex against the ranges observed in the ten selected countries.

Results

Detailed tabulations of deaths, YLL, YLD and DALYs for the 73 causes included in the USBODI by age, gender and race are provided [see Additional file 4]. Epidemiological parameters (incidence, prevalence, age at onset, duration, remission rates) and disability weights for each condition are provided [see Additional file 5].

Below we report key findings for the burden of disease and injury (DALYs); the mortality burden due to premature deaths (YLL); and the disability burden due to non-fatal health outcomes (YLD).

Burden of disease and injury

Leading causes of DALYs

The burden of disease and injury resulting from premature deaths and disability was an estimated 33 million DALYs in 1996. Premature mortality contributed 55 per cent of the total (18 million YLL), and disability – 45 per cent (15 million YLD). Noncommunicable diseases (Group II) caused 80 per cent of total DALYs, the balance being almost equally divided between communicable diseases, maternal, perinatal and nutritional causes (Group I) and injuries (Group III). Cardiovascular diseases, neuropsychiatric conditions, cancers and injuries caused approximately two thirds of the total DALYs (Figure 2). Ischaemic heart disease (IHD) was the leading and single largest cause of deaths and DALYs causing almost 10 per cent of DALYs. The three other causes ranking in the top five-cerebrovascular diseases, motor vehicle accidents, unipolar major depression – contributed almost equally to the total burden, with shares ranging between 4.1 and 4.6 per cent (Table 6).
Figure 2

Burden of Disease (DALYs) by sex and major disease groups, US, 1996.

Table 6

Twenty leading causes of DALYs and deaths, US 1996

 

DALY

% of total

 

Deaths

% of total

Total DALYs

33,090,212

 

Total Deaths

2,314,689

 

Ischemic heart disease

3,134,732

9.5

Ischemic heart disease

536,314

23.17

Cerebrovascular Disease

1,510,287

4.6

Lung trachea or bronchial cancer

168,206

7.27

Motor vehicle accidents

1,393,278

4.2

Cerebrovascular Disease

161,678

6.98

Unipolar major depression

1,370,285

4.1

COPD

99,982

4.32

Lung trachea or bronchial cancer

1,362,712

4.1

Lower respiratory infections

84,319

3.64

COPD

1,253,491

3.8

Diabetes mellitus

62,452

2.70

Alcohol use

1,141,193

3.4

Cancer colon or rectum

61,189

2.64

HIV

956,418

2.9

Breast cancer

46,649

2.02

Diabetes mellitus

946,291

2.9

Motor vehicle accidents

43,735

1.89

Osteoarthritis

942,682

2.8

Dementia and other degenerative and hereditary CNS disorders

43,190

1.87

Dementia and other degenerative and hereditary CNS disorders

889,242

2.7

Hypertension and hypertensive heart disease

39,589

1.71

Congenital Abnomalities

761,951

2.3

Prostate cancer

36,667

1.58

Homicide and Violence

714,621

2.2

Self-inflicted

31,725

1.37

Self-inflicted

674,443

2.0

HIV

31,188

1.35

Asthma

665,103

2.0

Cancer pancreas

29,494

1.27

Drug use

543,841

1.6

Inflammatory Cardiac

29,066

1.26

Breast cancer

514,786

1.6

Lymphomas

26,443

1.14

Conditions arising during the perinatal period

493,958

1.5

Cirrhosis of the liver

25,488

1.10

Cancer colon or rectum

483,931

1.5

Nephritis or nephrosis

24,569

1.06

Cirrhosis of the liver

411,539

1.2

Homicide and Violence

22,351

0.01

Sex and age patterns

The total disease burden for males (17.9 million DALYs) exceeded that for females (15 million DALYs). The excess disease burden for males was mostly due to the much larger number of premature deaths in young adult males. IHD resulted in twice the number of DALYs for males as it did for females, and was equal to the combined disease burden due to the three major causes of injuries that took a high toll in young adult males – motor vehicle accidents, homicide and violence, and self-inflicted injuries. Unipolar major depression caused almost the same disease burden for females that did motor vehicle accidents for males (Table 7).
Table 7

Twenty leading causes of DALYs, by sex, US 1996

 

Males

 

Cause list

DALY

% total

 

Total DALY

17,860,393

 

1

Ischaemic heart disease

1,958,184

11.0%

2

Motor vehicle accidents

933,798

5.2%

3

Lung trachea or bronchial cancer

812,804

4.6%

4

HIV

763,816

4.3%

5

Alcohol use

731,890

4.1%

6

Cerebrovascular Disease

673,928

3.8%

7

COPD

641,701

3.6%

8

Homicide and Violence

567,717

3.2%

9

Self-inflicted

541,399

3.0%

10

Unipolar major depression

469,929

2.6%

11

Diabetes mellitus

442,051

2.5%

12

Osteoarthritis

434,856

2.4%

13

Drug use

411,780

2.3%

14

Congenital Abnomalities

410,388

2.3%

15

Dementia and other degenerative and hereditary CNS disorders

382,392

2.1%

16

Asthma

303,088

1.7%

17

Cirrhosis of the liver

280,632

1.6%

18

Conditions arising during the perinatal period

273,577

1.5%

19

Cancer colon or rectum

249,462

1.4%

20

Prostate cancer

238,889

1.3%

 

sub-total

11,522,281

64.5%

 

Females

 

Cause list

DALY

% total

 

Total DALY

15,229,819

 

1

Ischaemic heart disease

1,176,548

7.7%

2

Unipolar major depression

900,356

5.9%

3

Cerebrovascular Disease

836,359

5.5%

4

COPD

611,790

4.0%

5

Lung trachea or bronchial cancer

549,908

3.6%

6

Breast cancer

514,786

3.4%

7

Osteoarthritis

507,826

3.3%

8

Dementia and other degenerative and hereditary CNS disorders

506,849

3.3%

9

Diabetes mellitus

504,240

3.3%

10

Motor vehicle accidents

459,480

3.0%

11

Alcohol use

409,303

2.7%

12

Asthma

362,015

2.4%

13

Congenital Abnomalities

351,563

2.3%

14

Cancer colon or rectum

234,469

1.5%

15

Conditions arising during the perinatal period

220,382

1.4%

16

Lower respiratory infections

195,448

1.3%

17

PTSD

193,533

1.3%

18

HIV

192,602

1.3%

19

Panic disorder

182,218

1.2%

20

Bipolar disorder

165,236

1.1%

Half of the total disease burden in the United States occurred in adults between the ages of 25 and 64 years, the other half being almost evenly split between younger and older age groups: 23 per cent under the age of 25 years, and 27 per cent for ages 65 years and above. In sharp contrast, the number of deaths gradually increased with age. More than half of all deaths occurred in adults aged 75 years and older (Table 8).
Table 8

Ten leading causes of DALYs by age, US 1996

Rank

All ages

DALYs

% of total

0–4

DALYs

% of total

 

Total

33,090,212

 

Total

2,123,767

 

1

Ischaemic heart disease

3,134,732

9.5

Congenital abnomalities

679,542

32.0

2

Cerebrovascular disease

1,510,287

4.6

Perinatal conditions

492,486

23.2

3

Motor vehicle accidents

1,393,278

4.2

Sudden infant death syndrome

102,255

4.8

4

Unipolar major depression

1,370,285

4.1

Asthma

77,323

3.6

5

Lung, trachea or bronchial cancer

1,362,712

4.1

Diarrhoeal diseases

60,438

2.8

6

COPD

1,253,491

3.8

Motor vehicle accidents

48,630

2.3

7

Alcohol use

1,141,193

3.4

Falls

41,289

1.9

8

HIV

956,418

2.9

Homicide and violence

35,055

1.7

9

Diabetes mellitus

946,291

2.9

Lower respiratory infections

30,640

1.4

10

Osteoarthritis

942,682

2.8

Fires

22,090

1.0

Rank

5–14

DALYs

% of total

15–24

DALYs

% of total

 

Total

1,136,989

 

Total

3,884,235

 

1

Asthma

236,494

20.8

Motor vehicle accidents

499,505

12.9

2

Motor vehicle accidents

128,357

11.3

Alcohol use

433,515

11.2

3

Unipolar major depression

61,622

5.4

Drug use

291,844

7.5

4

Epilepsy

42,461

3.7

Homicide and violence

282,746

7.3

5

Schizophrenia

41,254

3.6

Schizophrenia

237,967

6.1

6

Falls

39,886

3.5

Bipolar disorder

221,134

5.7

7

Homicide and violence

28,242

2.5

Unipolar major depression

197,309

5.1

8

Fires

19,514

1.7

Panic disorder

158,379

4.1

9

Congenital abnomalities

17,860

1.6

Asthma

157,997

4.1

10

Drowning

16,472

1.4

Self-inflicted

157,281

4.0

Rank

25–44

DALYs

% of total

45–64

DALYs

% of total

 

Total

8,364,608

 

Total

8,478,954

 

1

Unipolar major depression

823,548

9.8

Ischaemic heart disease

1,154,002

13.6

2

HIV

751,598

9.0

Lung, trachea or bronchial cancer

630,224

7.4

3

Alcohol use

549,949

6.6

COPD

504,418

5.9

4

Motor vehicle accidents

523,203

6.3

Cerebrovascular Disease

492,918

5.8

5

Self-inflicted

352,241

4.2

Diabetes mellitus

395,612

4.7

6

Homicide and violence

308,550

3.7

Osteoarthritis

361,774

4.3

7

Ischaemic heart disease

274,704

3.3

Breast cancer

250,963

3.0

8

Diabetes mellitus

238,472

2.9

Unipolar major depression

237,590

2.8

9

COPD

234,552

2.8

Cirrhosis of the liver

208,861

2.5

10

Drug use

222,535

2.7

Cancer colon or rectum

190,453

2.2

Rank

65–74

DALYs

% of total

75+

DALYs

% of total

 

Total

4,710,335

 

Total

4,391,323

 

1

Ischaemic heart disease

820,583

17.4

Ischaemic heart disease

876,239

20.0

2

Lung, trachea or bronchial cancer

448,452

9.5

Dementias

469,035

10.7

3

Cerebrovascular disease

373,629

7.9

Cerebrovascular disease

420,278

48.0

4

COPD

282,397

6.0

Lung, trachea or bronchial cancer

200,620

4.6

5

Osteoarthritis

266,685

5.7

COPD

186,379

4.2

6

Dementias

224,484

4.8

Osteoarthritis

161,077

3.7

7

Diabetes mellitus

168,605

3.6

Lower respiratory infections

146,631

3.3

8

Cancer colon or rectum

138,630

2.9

Cancer colon or rectum

106,111

2.4

9

Prostate cancer

97,033

2.1

Diabetes mellitus

106,061

2.4

10

Breast cancer

94,919

2.0

Prostate cancer

81,456

1.9

The share of total DALYs was very similar for both sexes up to the age of 14 years, but increased in adult males between 15 and 64 years. In older adults, the share of total DALYs for females exceeded that for males (Table 9). Differentials in DALY rates between males and females were greatest between 25 and 44 years, when motor vehicle accidents, alcohol use and abuse, HIV/AIDS and major unipolar depression took the highest toll.
Table 9

Distribution of burden of disease (DALYs) by age group and sex, US, 1996

Total

Males

Females

Age Group

DALYs

% of total

DALYs

% of total

DALYs

% of total

0–4 years

2,123,767

6.4%

1,164,600

6.5%

959,167

6.3%

5–14 years

1,136,989

3.4%

623,416

3.5%

513,573

3.4%

15–24 years

3,884,235

11.7%

2,279,895

12.8%

1,604,340

10.5%

25–44 years

8,364,608

25.3%

4,800,710

26.9%

3,563,898

23.4%

45–64 years

8,478,954

25.6%

4,754,166

26.6%

3,724,788

24.5%

65–74 years

4,710,335

14.2%

2,455,407

13.7%

2,254,928

14.8%

75 years and over

4,391,323

13.3%

1,782,198

10.0%

2,609,125

17.1%

Total

33,090,212

 

17,860,393

 

15,229,819

 

Patterns by race

Blacks and American Indians suffered disproportionate shares of total burden relative to their population size: DALY rates per thousand were 165.7 for Blacks; 128.7 for American Indians; 120.6 for Whites, and 75.3 for Asians. The proportional distribution of Groups I, II, and III varied between races, pointing to important differences in prevailing patterns of burden of disease. Group I and III combined caused one fifth of total DALYs for Whites and Asians, and one third of total DALYs for Blacks and American Indians. The excess was due to Group I (17 per cent of total DALYs) for Blacks and Group III for American Indians (19 per cent of total DALYs) (Figure 3).
Figure 3

Groups I, II, and III as a percentage of total burden of disease (DALY) by race, US, 1996.

IHD was among the three leading causes of DALYs for all races. The two other causes were cerebrovascular diseases and lung cancer for Whites; HIV/AIDS and homicide and violence for Blacks; alcohol use and motor vehicle accidents for American Indians; and unipolar major depression and cerebrovascular diseases for Asians (Table 10).
Table 10

Ten leading causes of DALYs by race, US 1996

 

Whites

DALYs

% total

 

American Indians

DALYs

% total

Rank

Total

26,510,011

 

Rank

Total

294,474

 

1

Ischaemic heart disease

2,710,918

10.2%

1

Alcohol use

46,419

15.8%

2

Cerebrovascular Disease

1,201,246

4.5%

2

Motor vehicle accidents

23,112

7.8%

3

Lung trachea or bronchial cancer

1,170,492

4.4%

3

Ischaemic heart disease

14,598

5.0%

4

Motor vehicle accidents

1,148,293

4.3%

4

Unipolar major depression

11,815

4.0%

5

Unipolar major depression

1,127,045

4.3%

5

Cirrhosis of the liver

9,293

3.2%

6

COPD

1,111,489

4.2%

6

Diabetes mellitus

9,070

3.1%

7

Alcohol use

857,509

3.2%

7

Self-inflicted

8,336

2.8%

8

Osteoarthritis

820,284

3.1%

8

Cerebrovascular Disease

8,241

2.8%

9

Dementia and other degenerative and hereditary CNS disorders

791,780

3.0%

9

Homicide and Violence

7,754

2.6%

10

Diabetes mellitus

727,575

2.7%

10

Congenital Abnormalities

7,489

2.5%

 

Sub-total

11,666,630

44.0%

 

sub-total

146,128

49.6%

 

Blacks

DALYs

% total

 

Asians

DALYs

% total

Rank

Total

5,552,448

 

Rank

Total

733,279

 

1

HIV/AIDS

429,383

7.7%

1

Unipolar major depression

54,264

7.4%

2

Ischaemic heart disease

370,170

6.7%

2

Ischaemic heart disease

39,046

5.3%

3

Homicide and Violence

336,215

6.1%

3

Cerebrovascular Disease

33,883

4.6%

4

Cerebrovascular Disease

266,918

4.8%

4

COPD

29,040

4.0%

5

Alcohol use

230,780

4.2%

5

Osteoarthritis

29,027

4.0%

6

Motor vehicle accidents

193,159

3.5%

6

Motor vehicle accidents

28,714

3.9%

7

Diabetes mellitus

189,656

3.4%

7

Congenital Abnormalities

28,238

3.9%

8

Unipolar major depression

177,162

3.2%

8

Asthma

26,137

3.6%

9

Conditions arising during the perinatal period

174,558

3.1%

9

Diabetes mellitus

19,989

2.7%

10

Lung trachea or bronchial cancer

172,425

3.1%

10

Dementia and other degenerative and hereditary CNS disorders

17,831

2.4%

 

sub-total

2,540,426

45.8%

 

sub-total

306,170

41.8%

Sex differentials in total burden by race increased with higher DALY rates. Male to female DALY ratios were 1.23 for Blacks, 1.21 for American Indians, 1.10 for Whites, 1.05 for Asians, and 1.17 overall. Although patterns of disease burden differed between races, leading causes were common to both sexes. Premature deaths contributed the largest share of total burden for males in all races, with the exception of Asian males. Non-fatal health outcomes contributed the largest share for females in all races, with the exception of Black females (Figure 4).
Figure 4

Distribution of YLL and YLD by sex and race, US, 1996.

DALY rates by age, sex, and race for HIV/AIDS, IHD and cerebrovascular diseases; hypertension and hypertensive heart disease, inflammatory cardiac diseases; and major causes of injuries capture changes in DALY rates over the lifespan as well as differences by race and sex in these important causes of disease burden (Figures 5, 6, 7, 8). DALY rates peaked in young adults for HIV/AIDS and injuries, and increased with age for cardiovascular diseases. DALY rates for Black males and females exceeded rates for the other race groups for HIV/AIDS, hypertension, cerebrovascular diseases, inflammatory cardiac diseases, motor vehicle accidents, homicide and violence, and self-inflicted injuries. Differentials between Blacks and the other races were always greater for males than for females, and were greatest in young adult males for HIV/AIDS, homicide and violence, hypertension and inflammatory cardiac diseases. Asian males and females had the lowest DALY rates for all major causes of burden. Differentials between races were least pronounced for IHD for both sexes.
Figure 5

HIV/AIDS: distribution of DALY rates/100,000 by age, race and sex, US 1996.

Figure 6

IHD and cerebrovascular diseases: distribution of DALY rates/100,000 by age, race and sex, US 1996.

Figure 7

Hypertension and inflammatory cardiac diseases: distribution of DALY rates/100,000 by age, race and sex, US 1996.

Figure 8

Major causes of injuries: distribution of DALY rates/100,000 by age, race and sex, US 1996.

Mortality burden

Leading causes of YLL

In 1996, 2.3 million people died in the United States, causing the loss of 18.1 million YLL (55 per cent of total DALYs). Age patterns of deaths and YLL differ: the number of deaths increased with age, the resulting number of YLL was greater for children and young adults than it was for older ages (Figure 9). The number of deaths and resulting number of YLL from any cause are not equivalent (Figure 10).
Figure 9

Distribution of deaths and YLL by age, US 1996.

Figure 10

Ten leading causes of mortality burden and death, as per cent of total, both sexes, US 1996.

IHD was the unequivocal lead cause of death and YLL, causing almost one of every four deaths and 16 per cent of total YLL. The mortality burden due to IHD was more than double the mortality burden due to lung cancer, and almost three times that due to motor vehicle accidents (Table 11). The share of YLL exceeded that of YLD for cardiovascular diseases, cancers, injuries, respiratory infections, and conditions arising during the perinatal period.
Table 11

Leading causes of death and YLL, both sexes, all races combined

  

Deaths

%total

  

2,314,689

 

1

Ischaemic heart disease

536,314

23.2%

2

Lung trachea or bronchial cancer

168,206

7.3%

3

Cerebrovascular Disease

161,678

7.0%

4

COPD

99,982

4.3%

5

Lower respiratory infections

84,319

3.6%

6

Diabetes mellitus

62,452

2.7%

7

Cancer colon or rectum

61,189

2.6%

8

Breast cancer

46,649

2.0%

9

Motor vehicle accidents

43,735

1.9%

10

Dementia and other degenerative and hereditary CNS disorders

43,190

1.9%

11

Hypertension and hypertensive heart disease

39,589

1.7%

12

Prostate cancer

36,667

1.6%

13

Self-inflicted

31,725

1.4%

14

HIV

31,188

1.3%

15

Cancer pancreas

29,494

1.3%

16

Inflammatory Cardiac

29,066

1.3%

17

Lymphomas

26,443

1.1%

18

Cirrhosis of the liver

25,488

1.1%

19

Nephritis or nephrosis

24,569

1.1%

20

Homicide and Violence

22,351

1.0%

 

Sub-total

1,604,297

69.3%

  

YLL

% total

 

Total YLL

18,066,099

 

1

Ischaemic heart disease

2,858,744

15.8%

2

Lung trachea or bronchial cancer

1,301,182

7.2%

3

Motor vehicle accidents

1,027,005

5.7%

4

Cerebrovascular Disease

784,443

4.3%

5

HIV

718,975

4.0%

6

Self-inflicted

660,917

3.7%

7

Homicide and Violence

615,332

3.4%

8

COPD

526,219

2.9%

9

Conditions arising during the perinatal period

464,131

2.6%

10

Diabetes mellitus

450,913

2.5%

11

Breast cancer

450,327

2.5%

12

Cancer colon or rectum

409,534

2.3%

13

Lower respiratory infections

388,441

2.2%

14

Cirrhosis of the liver

321,588

1.8%

15

Congenital Abnomalities

318,948

1.8%

16

Inflammatory Cardiac

258,328

1.4%

17

Hypertension and hypertensive heart disease

241,073

1.3%

18

Lymphomas

233,048

1.3%

19

Poisoning

221,906

1.2%

20

Cancer pancreas

205,972

1.1%

 

Sub-total

12,457,024

69.0%

Sex and age patterns

The number of deaths and the age at death is driving differentials in mortality burden observed by age, sex and race. The mortality burden for males (10.5 million YLL) was 40 per cent greater than that for females (7.5 million YLL) (Table 12). The excess male mortality burden was largely due to the higher mortality burden resulting from IHD, injuries (motor vehicle accidents, homicide and violence, self-inflicted injuries), and HIV/AIDS. These causes combined resulted in 40 per cent of total YLL (4.1 million YLL) for males, but only in 24 per cent of total YLL for females (1.8 million YLL), and accounted for 80 per cent of the total sex differential. The female mortality burden exceeded that of males only for cerebrovascular diseases. Also noteworthy was the toll due to breast cancer (450 thousand YLL), which was almost equal to that of lung cancer (523 thousand YLL). YLL rates were higher for all leading causes for males than they were for females, with the exception of cerebrovascular diseases (Figure 11). The pattern of mortality burden shifted from a predominance of injuries between ages 5 and 44 years, to a gradual increase in chronic diseases (cancers and cardiovascular diseases) among older adults (Tables 13, 14, 15, 16, 17, 18).
Table 12

Leading causes of YLL, by sex, all races combined

 

Cause list

YLL

% total

 

All males

10,529,540

 

1

Ischaemic heart disease

1,806,420

17.2%

2

Lung trachea or bronchial cancer

777,726

7.4%

3

Motor vehicle accidents

701,111

6.7%

4

HIV

575,297

5.5%

5

Self-inflicted

533,874

5.1%

6

Homicide and Violence

486,129

4.6%

7

Cerebrovascular Disease

356,563

3.4%

8

COPD

268,774

2.6%

9

Conditions arising during the perinatal period

259,581

2.5%

10

Diabetes mellitus

220,494

2.1%

11

Cirrhosis of the liver

219,876

2.1%

12

Cancer colon or rectum

212,958

2.0%

13

Lower respiratory infections

202,668

1.9%

14

Congenital Abnomalities

172,399

1.6%

15

Poisoning

168,131

1.6%

16

Inflammatory Cardiac

167,316

1.6%

17

Prostate cancer

160,019

1.5%

18

Lymphomas

134,145

1.3%

19

Hypertension and hypertensive heart disease

127,968

1.2%

20

Leukemias

114,710

1.1%

 

Sub-total

7,666,158

72.8%

 

Cause list

YLL

% total

 

All females

7,536,559

 

1

Ischaemic heart disease

1,052,325

14.0%

2

Lung trachea or bronchial cancer

523,456

6.9%

3

Breast cancer

450,327

6.0%

4

Cerebrovascular Disease

427,881

5.7%

5

Motor vehicle accidents

325,894

4.3%

6

COPD

257,445

3.4%

7

Diabetes mellitus

230,419

3.1%

8

Conditions arising during the perinatal period

204,550

2.7%

9

Cancer colon or rectum

196,575

2.6%

10

Lower respiratory infections

185,774

2.5%

11

Congenital Abnomalities

146,548

1.9%

12

HIV

143,678

1.9%

13

Homicide and Violence

129,202

1.7%

14

Self-inflicted

127,043

1.7%

15

Ovarian cancer

122,350

1.6%

16

Hypertension and hypertensive heart disease

113,105

1.5%

17

Cirrhosis of the liver

101,712

1.3%

18

Cancer pancreas

99,766

1.3%

19

Lymphomas

98,902

1.3%

20

Inflammatory Cardiac

91,012

1.2%

 

Sub-total

5,027,963

66.7%

Figure 11

Leading causes of mortality burden (YLL) by sex, US, 1996.

Table 13

Five leading causes of mortality burden (YLL) by sex and age, US, 1996

 

Males

Rank

All ages

YLL

% of total

0–4

YLL

% of total

 

Total

10,529,540

 

Total

652,949

 

1

Ischaemic heart disease

1,806,420

17.16%

Perinatal conditions

258,750

39.63%

2

Lung/Trachea/Bronchial cancer

777,726

7.39%

Congenital abnormalities

127,080

19.46%

3

Motor vehicle accidents

701,111

6.66%

Sudden infant death syndrome

61,101

9.36%

4

HIV/AIDS

575,297

5.46%

Motor vehicle accidents

17,505

2.68%

5

Suicide

1,028,947

9.77%

Lower respiratory infections

17,259

2.64%

Rank

5–14

YLL

% of total

15–24

YLL

% of total

 

Total

185,702

 

Total

845,157

 

1

Motor vehicle accidents

42,534

22.90%

Motor vehicle accidents

263,631

31.19%

2

Homicide and violence

15,729

8.47%

Homicide and violence

210,534

24.91%

3

Drowning

12,290

6.62%

Suicide

131,075

15.51%

4

Congenital abnormalities

10,634

5.73%

Drowning

20,807

2.46%

5

Suicide

8,483

4.57%

Poisoning

18,087

2.14%

Rank

25–44

YLL

% of total

45–64

YLL

% of total

 

Total

2,548,913

 

Total

3,150,157

 

1

HIV/AIDS

444,123

17.42%

Ischaemic heart disease

763,334

24.23%

2

Motor vehicle accidents

279,389

10.96%

Lung/Trachea/Bronchial cancer

372,984

11.84%

3

Suicide

277,467

10.89%

Cerebrovascular disease

115,851

3.68%

4

Homicide and violence

207,217

8.13%

Cirrhosis of the liver

113,739

3.61%

5

Ischaemic heart disease

171,437

6.73%

HIV/AIDS

111,874

3.55%

Rank

65–74

YLL

% of total

75+

YLL

% of total

 

Total

1,786,501

 

Total

1,360,161

 

1

Ischaemic heart disease

484,267

27.11%

Ischaemic heart disease

382,495

28.12%

2

Lung/Trachea/Bronchial cancer

253,281

14.18%

Lung/Trachea/Bronchial cancer

104,020

7.65%

3

Chronic obstructive pulmonary disease

103,012

5.77%

Cerebrovascular disease

99,208

7.29%

4

Cerebrovascular disease

84,904

4.75%

Chronic obstructive pulmonary disease

85,031

6.25%

5

Colon/Rectum cancer

62,395

3.49%

Prostate cancer

64,236

4.72%

Table 14

Five leading causes of mortality burden (YLL) by sex and age, US, 1996

 

Females

Rank

All ages

YLL

% of total

0–4

YLL

% of total

 

Total

7,536,559

 

Total

512,861

 

1

Ischaemic heart disease

1,052,325

13.96%

Perinatal conditions

203,909

39.76%

2

Lung/Trachea/Bronchial cancer

523,456

6.95%

Congenital abnormalities

109,458

21.34%

3

Breast cancer

450,327

5.98%

Sudden infant death syndrome

41,154

8.02%

4

Cerebrovascular disease

427,881

5.68%

Motor vehicle accidents

14,795

2.88%

5

Motor vehicle accidents

325,894

4.32%

Homicide and violence

13,612

2.65%

Rank

5–14

YLL

% of total

15–24

YLL

% of total

 

Total

123,888

 

Total

285,089

 

1

Motor vehicle accidents

28,952

23.37%

Motor vehicle accidents

117,878

41.35%

2

Homicide and violence

8,134

6.57%

Homicide and violence

32,799

11.50%

3

Congenital abnormalities

7,226

5.83%

Suicide

22,517

7.90%

4

Leukemias

6,120

4.94%

Leukemias

6,726

2.36%

5

Brain cancer

5,611

4.53%

HIV/AIDS

5,830

2.05%

Rank

25–44

YLL

% of total

45–64

YLL

% of total

 

Total

1,192,947

 

Total

2,053,395

 

1

Motor vehicle accidents

117,878

9.88%

Ischaemic heart disease

524,172

25.53%

2

HIV/AIDS

109,310

9.16%

Lung/Trachea/Bronchial cancer

234,241

11.41%

3

Breast cancer

95,818

8.03%

Breast cancer

220,350

10.73%

4

Suicide

67,035

5.62%

Cerebrovascular disease

99,565

4.85%

5

Homicide and violence

60,074

5.04%

Diabetes mellitus

81,366

3.96%

Rank

65–74

YLL

% of total

75+

YLL

% of total

 

Total

1,503,549

 

Total

1,864,830

 

1

Ischaemic heart disease

277,053

18.43%

Ischaemic heart disease

459,396

24.63%

2

Lung/Trachea/Bronchial cancer

172,116

11.45%

Cerebrovascular disease

186,468

10.00%

3

Chronic obstructive pulmonary disease

97,759

6.50%

Chronic obstructive pulmonary disease

88,838

4.76%

4

Cerebrovascular disease

90,698

6.03%

Lung/Trachea/Bronchial cancer

84,492

4.53%

5

Breast cancer

82,227

5.47%

Lower respiratory infections

83,467

4.48%

Table 15

Leading causes of YLL by sex and race – Whites

 

Cause list

YLL

% total

 

Total White males

8,293,920

 

1

Ischaemic heart disease

1,584,087

19.1%

2

Lung trachea or bronchial cancer

656,850

7.9%

3

Road Traffic Accidents

573,953

6.9%

4

Self-inflicted

469,430

5.7%

5

HIV

334,425

4.0%

6

Cerebrovascular Disease

276,544

3.3%

7

COPD

244,401

2.9%

8

Homicide and Violence

221,000

2.7%

9

Cirrhosis of the liver

183,600

2.2%

10

Cancer colon or rectum

180,184

2.2%

11

Diabetes mellitus

173,405

2.1%

12

Conditions arising during the perinatal period

158,462

1.9%

13

Lower respiratory infections

158,231

1.9%

14

Congenital Abnomalities

135,970

1.6%

15

Poisoning

134,929

1.6%

16

Prostate cancer

128,058

1.5%

17

Inflammatory Cardiac

121,438

1.5%

18

Lymphomas

116,804

1.4%

19

Leukemias

99,137

1.2%

20

Cancer pancreas

89,780

1.1%

 

Sub-total

6,040,688

72.8%

 

Cause list

YLL

% total

 

Total White females

6,018,361

 

1

Ischaemic heart disease

895,819

14.9%

2

Lung trachea or bronchial cancer

460,651

7.7%

3

Breast cancer

370,855

6.2%

4

Cerebrovascular Disease

342,620

5.7%

5

Road Traffic Accidents

268,996

4.5%

6

COPD

240,803

4.0%

7

Diabetes mellitus

169,449

2.8%

8

Cancer colon or rectum

163,068

2.7%

9

Lower respiratory infections

153,465

2.5%

10

Conditions arising during the perinatal period

124,599

2.1%

11

Congenital Abnomalities

112,925

1.9%

12

Self-inflicted

112,621

1.9%

13

Ovarian cancer

108,262

1.8%

14

Lymphomas

87,677

1.5%

15

Cancer pancreas

83,238

1.4%

16

Cirrhosis of the liver

81,843

1.4%

17

Dementia and other degenerative and hereditary CNS disorders

76,867

1.3%

18

Leukemias

74,069

1.2%

19

Homicide and Violence

72,469

1.2%

20

Hypertension and hypertensive heart disease

72,258

1.2%

 

Sub-total

4,072,553

67.7%

Table 16

Leading causes of YLL by sex and race – Blacks

 

Cause list

YLL

% total

 

Total Black males

1,978,704

 

1

Homicide and Violence

250,257

12.6%

2

HIV

234,400

11.8%

3

Ischaemic heart disease

189,031

9.6%

4

Lung trachea or bronchial cancer

109,191

5.5%

5

Motor vehicle accidents

99,734

5.0%

6

Conditions arising during the perinatal period

92,854

4.7%

7

Cerebrovascular Disease

69,225

3.5%

8

Self-inflicted

47,940

2.4%

9

Hypertension and hypertensive heart disease

44,841

2.3%

10

Inflammatory Cardiac

41,409

2.1%

11

Diabetes mellitus

40,795

2.1%

12

Lower respiratory infections

38,675

2.0%

13

Congenital Abnomalities

30,182

1.5%

14

Cirrhosis of the liver

30,182

1.5%

15

Poisoning

30,101

1.5%

16

Prostate cancer

30,075

1.5%

17

Cancer colon or rectum

28,380

1.4%

18

COPD

21,382

1.1%

19

Sudden Infant Death Syndrome

19,017

1.0%

20

Nephritis or nephrosis

17,092

0.9%

 

Sub-total

1,464,762

74.0%

 

Cause list

YLL

% total

 

Total Black females

1,342,205

 

1

Ischaemic heart disease

141,305

10.5%

2

HIV

89,973

6.7%

3

Cerebrovascular Disease

74,323

5.5%

4

Conditions arising during the perinatal period

73,969

5.5%

5

Breast cancer

70,421

5.2%

6

Lung trachea or bronchial cancer

55,561

4.1%

7

Diabetes mellitus

54,669

4.1%

8

Homicide and Violence

52,280

3.9%

9

Motor vehicle accidents

42,499

3.2%

10

Hypertension and hypertensive heart disease

39,005

2.9%

11

Cancer colon or rectum

28,896

2.2%

12

Congenital Abnomalities

28,218

2.1%

13

Lower respiratory infections

28,108

2.1%

14

Inflammatory Cardiac

25,707

1.9%

15

Nephritis or nephrosis

15,811

1.2%

16

Cirrhosis of the liver

15,701

1.2%

17

COPD

14,858

1.1%

18

Cancer pancreas

14,132

1.1%

19

Sudden Infant Death Syndrome

13,841

1.0%

20

Cancer cervix

13,786

1.0%

 

Sub-total

893,064

66.5%

Table 17

Leading causes of YLL by sex and race – American Indians

 

Cause list

YLL

% total

 

Total American Indian males

83,713

 

1

Motor vehicle accidents

13,665

16.3%

2

Ischaemic heart disease

8,804

10.5%

3

Self-inflicted

6,472

7.7%

4

Homicide and Violence

5,287

6.3%

5

Cirrhosis of the liver

3,982

4.8%

6

Alcohol use

2,849

3.4%

7

Lung trachea or bronchial cancer

2,792

3.3%

8

Diabetes mellitus

2,610

3.1%

9

Lower respiratory infections

2,168

2.6%

10

Conditions arising during the perinatal period

2,078

2.5%

11

Poisoning

2,009

2.4%

12

HIV

1,952

2.3%

13

Cerebrovascular Disease

1,919

2.3%

14

Congenital Abnomalities

1,658

2.0%

15

Drowning

1,489

1.8%

16

Sudden Infant Death Syndrome

1,239

1.5%

17

Inflammatory Cardiac

1,193

1.4%

18

Cancer colon or rectum

816

1.0%

19

Falls

755

0.9%

20

COPD

719

0.9%

 

Sub-total

64,456

77.0%

 

Cause list

YLL

% total

 

Total Amerian Indian females

54,732

 

1

Motor vehicle accidents

6,429

11.7%

2

Ischaemic heart disease

4,247

7.8%

3

Cirrhosis of the liver

3,311

6.0%

4

Diabetes mellitus

2,970

5.4%

5

Cerebrovascular Disease

2,057

3.8%

6

Breast cancer

1,901

3.5%

7

Lung trachea or bronchial cancer

1,788

3.3%

8

Self-inflicted

1,786

3.3%

9

Homicide and Violence

1,534

2.8%

10

Conditions arising during the perinatal period

1,531

2.8%

11

Lower respiratory infections

1,523

2.8%

12

Congenital Abnomalities

1,182

2.2%

13

Alcohol use

1,156

2.1%

14

Sudden Infant Death Syndrome

907

1.7%

15

Cancer colon or rectum

851

1.6%

16

Poisoning

809

1.5%

17

COPD

731

1.3%

18

Ovarian cancer

678

1.2%

19

Inflammatory Cardiac

651

1.2%

20

Drowning

633

1.2%

 

Sub-total

36,675

67.0%

Table 18

Leading causes of YLL by sex and race – Asians

 

Cause list

YLL

% total

 

Total Asian males

173,201

 

1

Ischaemic heart disease

24,497

14.1%

2

Motor vehicle accidents

13,759

7.9%

3

Self-inflicted

10,032

5.8%

4

Homicide and Violence

9,584

5.5%

5

Lung trachea or bronchial cancer

8,892

5.1%

6

Cerebrovascular Disease

8,875

5.1%

7

Cancer liver

6,330

3.7%

8

Conditions arising during the perinatal period

6,188

3.6%

9

Congenital Abnomalities

4,590

2.7%

10

HIV

4,520

2.6%

11

Diabetes mellitus

3,684

2.1%

12

Lower respiratory infections

3,593

2.1%

13

Cancer colon or rectum

3,578

2.1%

14

Inflammatory Cardiac

3,276

1.9%

15

Drowning

3,256

1.9%

16

Cancer stomach

2,935

1.7%

17

Leukemias

2,601

1.5%

18

Hypertension and hypertensive heart disease

2,365

1.4%

19

COPD

2,272

1.3%

20

Cirrhosis of the liver

2,113

1.2%

 

Sub-total

126,941

73.3%

 

Cause list

YLL

% total

 

Total Asian females

121,261

 

1

Ischaemic heart disease

10,953

9.0%

2

Cerebrovascular Disease

8,881

7.3%

3

Road Traffic Accidents

7,970

6.6%

4

Breast cancer

7,150

5.9%

5

Lung trachea or bronchial cancer

5,455

4.5%

6

Conditions arising during the perinatal period

4,451

3.7%

7

Congenital Abnomalities

4,223

3.5%

8

Self-inflicted

4,112

3.4%

9

Cancer colon or rectum

3,761

3.1%

10

Diabetes mellitus

3,331

2.7%

11

Homicide and Violence

2,920

2.4%

12

Cancer stomach

2,873

2.4%

13

Ovarian cancer

2,776

2.3%

14

Lower respiratory infections

2,677

2.2%

15

Cancer liver

2,210

1.8%

16

Leukemias

2,126

1.8%

17

Cancer cervix

1,892

1.6%

18

Cancer pancreas

1,888

1.6%

19

Inflammatory Cardiac

1,602

1.3%

20

Lymphomas

1,479

1.2%

 

Sub-total

82,729

68.2%

Patterns by race

The share of YLL due to communicable diseases (which include HIV/AIDS), maternal causes, perinatal and nutritional conditions was twofold larger for Blacks (20 per cent) than it was for any of the other races. Injuries predominated among American Indians, causing one third of the total mortality burden, and one fifth or less in the other races.

The mortality burden was highest for Blacks and lowest for Asians, for both sexes and all ages. A few causes contributed about one third of total YLL in each race. These were IHD, lung cancer and motor vehicle accidents for Whites; IHD, HIV/AIDS and homicide and violence for Blacks; motor vehicle accidents, IHD and self-inflicted injuries for American Indians; and IHD, motor vehicle accidents, cerebrovascular diseases, and lung cancer for Asians (Tables 15, 16, 17, 18; Figures 12, 13).
Figure 12

Ten leading causes of mortality burden (YLL) and death, as a per cent of total, by race, US, 1996.

Figure 13

Ten leading causes of mortality burden (YLL) and death, as a per cent of total, by race, US, 1996.

Comparative rankings of mortality burden in the United States and selected industrialized countries

Relative YLL rankings observed in the United States and in ten selected industrialized countries (Australia, Canada, France, Germany, Greece, Italy, Japan, Netherlands, Spain and the United Kingdom) were similar for IHD, lung cancer and motor vehicle accidents for males, and IHD, breast cancer and cerebrovascular diseases for females, which ranked among the top five leading causes of YLL in all countries. In contrast, the range of rankings observed was widest for HIV/AIDS and inflammatory cardiac diseases (cardiomyopathy and endocarditis) for both sexes, appearing to cause a very high mortality burden in some countries, and a much lower mortality burden in others (Figures 14 and 15). The wide range observed for these two conditions may point to real differences in causes of death and their important risk factors, but may also indicate differences in cause of death reporting practices, particularly for inflammatory cardiac disease, which ultimately leads to congestive heart failure, and may not have been diagnosed as the underlying cause.
Figure 14

Comparative rankings for the twenty leading causes of YLL for males, US compared with selected non-US OECD countries. Note: Vertical red bars indicate the range between minimum and maximum rankings observed in the selected OECD countries (excluding the US). Blue horizontal lines indicate rankings for the US. The ten selected non-US OECD countries are: Australia, Canada, France, Germany, Greece, Italy, Japan, Netherlands, Spain and the United Kingdom.

Figure 15

Comparative rankings for the twenty leading causes of YLL for females, US compared with selected non-US OECD countries. Note: Vertical red bars indicate the range between minimum and maximum rankings observed in the selected OECD countries (excluding the US). Blue horizontal lines indicate rankings for the US. The ten selected OECD countries are: Australia, Canada, France, Germany, Greece, Italy, Japan, Netherlands, Spain and the United Kingdom.

US YLL rankings by race compared to selected industrialized countries

The higher share of YLL due to homicide and violence in the general population in the United States was observed in all races and both sexes (Figures 16 and 17). YLL rankings for all races and both sexes fell outside those observed in other countries for inflammatory cardiac diseases, pointing to a higher burden in the United States. Rankings for cerebrovascular diseases, on the other hand, pointed to a lower share of burden for males in all races. YLL rates exceeded rates for other countries for HIV/AIDS, homicide and violence, and inflammatory cardiac disease in both sexes, confirming findings based on the comparison of YLL rankings (Tables 19 and 20).
Figure 16

YLL rankings by race in the US compared with selected non-US OECD countries, males. Note: Vertical red bars indicate the range between minimum and maximum rankings observed in the selected OECD countries (excluding the US). Blue horizontal lines indicate rankings for the US. The ten selected OECD countries are: Australia, Canada, France, Germany, Greece, Italy, Japan, Netherlands, Spain and the United Kingdom

Figure 17

YLL rankings by race in the US compared with non-US OECD countries, females. Note: Vertical red bars indicate the range between minimum and maximum rankings observed in the selected OECD countries (excluding the US). Blue horizontal lines indicate rankings for the US. The ten selected OECD countries are: Australia, Canada, France, Germany, Greece, Italy, Japan, Netherlands, Spain and the United Kingdom

Table 19

Twenty leading causes of YLL in the United States: comparison of YLL rates per 100,000 between the United States and selected countries – Male

Twenty leading causes of YLL in the United States

United States

Australia

Canada

France

Germany

Greece

Italy

Japan

Netherlands

Spain

United Kingdom

IHD

1,392

269

950

578

1,249

1,337

974

504

942

826

2,154

Trachea, bronchus, lung cancer

599

105

469

666

611

756

683

387

595

638

714

MVA

547

106

292

515

325

690

438

242

233

550

350

HIV/AIDS

443

9

62

60

26

11

67

1

31

176

18

Self-inflicted

411

140

414

459

367

101

184

582

221

218

410

homicide and violence

375

15

57

21

19

37

38

14

38

35

55

Cerebroavascular disease

275

72

205

307

377

723

421

546

319

356

566

COPD

207

51

145

142

182

88

168

57

234

247

371

Perinatal conditions

200

43

115

120

87

115

90

39

116

78

215

Diabetes

170

33

146

97

125

54

144

76

120

93

99

Cirrhosis of the liver

169

25

104

281

372

85

228

161

85

195

258

Colon and rectum

164

68

187

213

267

160

225

231

220

235

338

Lower respiratory infections

156

19

66

134

99

49

80

281

152

97

524

Congenital anomalies

133

33

95

101

78

104

78

66

113

86

125

poisonings

130

51

87

12

28

104

11

12

30

71

111

Inflammatory heart disease

129

21

52

68

116

3

67

45

65

87

84

Prostate

123

41

118

145

142

119

110

50

151

121

241

Lymphoma and multiple myeloma

103

36

125

114

108

92

130

77

128

106

176

Hypertesive heart disease

99

7

21

51

77

48

117

15

24

38

54

Leukemia

88

25

82

91

87

105

100

70

78

86

115

Table 20

Twenty leading causes of YLL in the United States: comparison of YLL rates per 100,000 between the United States and selected countries – Female

Twenty leading causes of YLL in the United States

United States

Australia

Canada

France

Germany

Greece

Italy

Japan

Netherlands

Spain

United Kingdom

IHD

777

462

475

228

753

570

491

562

466

383

868

Trachea, bronchus, lung cancer

386

186

354

140

201

125

154

328

288

86

357

Breast cancer

332

285

326

389

404

313

363

396

457

288

492

Cerebroavascular disease

316

253

213

253

405

826

426

943

378

362

510

MVA

241

125

124

157

105

178

117

167

71

151

73

COPD

190

108

114

67

90

41

66

39

152

57

227

Diabetes

170

80

109

76

123

55

151

102

115

108

66

Perinatal conditions

151

108

87

89

64

75

70

70

94

63

115

Colon and rectum

145

164

145

155

217

153

171

381

189

174

201

Lower respiratory infections

137

50

56

91

79

34

61

418

147

71

412

Congenital anomalies

108

89

73

71

64

76

59

136

100

73

84

HIV/AIDS

106

2

13

16

6

2

17

0

8

43

4

homicide and violence

95

32

21

12

16

11

11

25

19

13

20

sel-inflicted

94

120

119

155

106

27

55

473

107

63

90

Ovarian cancer

90

69

79

90

114

82

88

148

99

74

144

Hypertesive heart disease

83

27

21

50

94

50

137

34

27

53

32

Cirrhosis of the liver

75

32

45

113

156

28

115

99

44

71

113

Cancer pancreas

74

56

67

66

94

73

85

187

78

62

84

Lymphoma and multiple myeloma

73

88

97

80

83

71

103

126

90

84

110

Inflammatory heart disease

67

31

29

24

44

3

30

53

42

45

32

The largest differentials between races for males pertained to COPD, cirrhosis of the liver, poisoning, hypertension and hypertensive heart disease. Rankings indicate a higher mortality burden due to COPD and cirrhosis of the liver in American Indians; hypertension and hypertensive heart disease in Blacks; and a lower mortality burden for poisoning in Asians. The largest rank differentials between races were observed in females for HIV/AIDS, self-inflicted injuries, COPD, hypertension and hypertensive heart disease, and cirrhosis of the liver. Rankings for Black females pointed to a higher mortality burden for HIV/AIDS, hypertension and hypertensive heart disease, and a lower mortality burden for self-inflicted injuries and ovarian cancer compared to White, American Indian and Asian females.

Morbidity burden

Leading causes of YLD

Non-fatal health outcomes resulted in 15 million YLD, which was only slightly less than the mortality burden (17 million YLL). For neuropsychiatric conditions, musculoskeletal conditions, chronic respiratory diseases, YLD contributed more than YLL. Neuropsychiatric conditions were the predominant cause of disability, causing 44 per cent of total YLD, regardless of sex and race (Figure 18). They comprise a wide array of conditions, sub-divided into mental disorders and diseases of the nervous system (DSM IV). Mental disorders include mood disorders (unipolar major depression, bipolar disorders), schizophrenia, anxiety disorders (PTSD, obsessive compulsive disorders, and panic disorders) affecting mostly young adults, and substance related disorders (alcohol and drug use) that increase in older adults. Nervous system disorders include Alzheimer's disease and other degenerative and hereditary CNS disorders, Parkinson's disease, epilepsy, and multiple sclerosis (Figure 19).
Figure 18

Distribution of YLD for non-communicable cause groupings.

Figure 19

Age patterns of mental disorders and diseases of the nervous system.

Unipolar major depression, alcohol use, osteoarthritis, dementia and other degenerative disorders of the CNS and cerebrovascular diseases were the five leading causes of YLD (Table 21). Unipolar major depression and alcohol use combined (2.4 million YLD) caused 16 per cent of total YLD, which represented almost the same burden as IHD (2.9 million YLL).
Table 21

Twenty leading causes of YLD, both sexes and all races combined

Rank

 

YLD

% of total

 

Total

15,024,113

 

1

Unipolar major depression

1,370,070

9.1%

2

Alcohol use

1,037,529

6.9%

3

Osteoarthritis

940,612

6.3%

4

Dementia and other degenerative and hereditary CNS disorders

755,925

5.0%

5

COPD

727,272

4.8%

6

Cerebrovascular Disease

725,844

4.8%

7

Asthma

593,233

3.9%

8

Drug use

504,718

3.4%

9

Diabetes mellitus

495,377

3.3%

10

Congenital Abnomalities

443,004

2.9%

11

Motor vehicle accidents

366,273

2.4%

12

Bipolar disorder

363,298

2.4%

13

Schizophrenia

315,720

2.1%

14

Ischaemic heart disease

275,988

1.8%

15

PTSD

260,337

1.7%

16

Panic disorder

259,904

1.7%

17

HIV

237,443

1.6%

18

Falls

221,036

1.5%

19

Rheumatoid arthritis

189,421

1.3%

20

Obsessive-compulsive disorders

169,067

1.1%

 

Sub-total

10,252,070

68.2%

Sex and age patterns

Sex differentials were much smaller for YLD than for YLL. The morbidity burden was slightly larger for females (7.7 million YLD) than for males (7.3 million YLD). The five leading causes of YLD were alcohol use, unipolar major depression, osteoarthritis, drug use, and chronic obstructive pulmonary disease (COPD) for males, and unipolar major depression, osteoarthritis, dementia and other degenerative and hereditary CNS disorders, and alcohol use for females (Table 22).
Table 22

Twenty leading causes of YLD by sex, US 1996

 

MALES

Rank

 

YLD

% total YLD

 

Total

7,330,853

 

1

Alcohol use

651,223

8.9%

2

Unipolar major depression

469,861

6.4%

3

Osteoarthritis

434,200

5.9%

4

Drug use

384,319

5.2%

5

COPD

372,927

5.1%

6

Dementia and other degenerative and hereditary CNS disorders

332,046

4.5%

7

Cerebrovascular Disease

317,366

4.3%

8

Asthma

272,898

3.7%

9

Congenital Abnomalities

237,988

3.2%

10

Motor vehicle accidents

232,687

3.2%

11

Diabetes mellitus

221,557

3.0%

12

Bipolar disorder

198,308

2.7%

13

HIV

188,519

2.6%

14

Schizophrenia

166,988

2.3%

15

Ischaemic heart disease

151,764

2.1%

16

Falls

132,485

1.8%

17

Obsessive-compulsive disorders

88,623

1.2%

18

Homicide and Violence

81,588

1.1%

19

Prostate cancer

78,870

1.1%

20

Panic disorder

77,701

1.1%

 

sub-total

5,091,918

69.5%

 

FEMALES

Rank

 

YLD

% total YLD

 

Total

7,693,260

 

1

Unipolar major depression

900,209

11.7%

2

Osteoarthritis

506,412

6.6%

3

Dementia and other degenerative and hereditary CNS disorders

423,878

5.5%

4

Cerebrovascular Disease

408,478

5.3%

5

Alcohol use

386,306

5.0%

6

COPD

354,345

4.6%

7

Asthma

320,336

4.2%

8

Diabetes mellitus

273,821

3.6%

9

Congenital Abnomalities

205,015

2.7%

10

PTSD

193,533

2.5%

11

Panic disorder

182,203

2.4%

12

Bipolar disorder

164,990

2.1%

13

Schizophrenia

148,732

1.9%

14

Motor vehicle accidents

133,586

1.7%

15

Rheumatoid arthritis

131,758

1.7%

16

STD's excluding HIV

125,418

1.6%

17

Ischaemic heart disease

124,224

1.6%

18

Drug use

120,399

1.6%

19

Maternal Conditions

105,155

1.4%

20

Falls

88,551

1.2%

 

sub-total

5,297,349

68.9%

The largest sex differentials pertained to the leading cause of YLD: alcohol use for males and unipolar major depression for females. The burden due to unipolar depression was almost double for females (900 thousand YLD) than it was for males (470 thousand YLD), whereas the burden due to alcohol was double for males (651 thousand YLD) than it was for females (386 thousand YLD). Together, alcohol use and unipolar depression caused 15 per cent of total YLD for males, and 17 per cent for females.

The share of total YLD due to neuropsychiatric conditions for males exceeded that for females. Morbidity due to substance abuse (alcohol and drug) in males was not entirely offset by the preponderance of mood and anxiety disorders in females. The slightly higher share of dementia and other degenerative and hereditary CNS disorders in females resulted from their higher life expectancy.

Major causes contributing to the morbidity burden changed with age. Mental disorders and injuries affected mostly young adults, whereas nervous system disorders, musculoskeletal conditions, cardiovascular diseases, and diabetes increased with age and were predominant among older adults. Chronic respiratory conditions affected all age groups. Congenital anomalies represented half of the non-fatal burden below age 5.

Patterns by race

Alcohol use was the leading cause of YLD for males in all races, with the exception of Asian males for whom unipolar depression was the leading cause. Unipolar major depression was the leading cause for females of all races, with the exception of American Indian females for whom alcohol use was the leading cause (Tables 23, 24, 25, 26).
Table 23

Leading causes of YLD – Whites

 

WHITE MALES

Rank

Cause list

YLD

% total YLD

 

Total YLD

5,963,710

 

1

Alcohol use

488,341

8.2%

2

Unipolar major depression

390,121

6.5%

3

Osteoarthritis

378,589

6.3%

4

Drug use

324,878

5.4%

5

COPD

319,049

5.3%

6

Dementia and other degenerative and hereditary CNS disorders

293,857

4.9%

7

Cerebrovascular Disease

258,909

4.3%

8

Asthma

216,831

3.6%

9

Motor vehicle accidents

195,590

3.3%

10

Congenital Abnomalities

189,083

3.2%

11

Diabetes mellitus

174,663

2.9%

12

Bipolar disorder

161,700

2.7%

13

Schizophrenia

134,190

2.3%

14

Ischaemic heart disease

130,502

2.2%

15

Falls

113,345

1.9%

16

HIV

111,533

1.9%

17

Obsessive-compulsive disorders

71,313

1.2%

18

Prostate cancer

68,023

1.1%

19

Panic disorder

63,735

1.1%

20

PTSD

55,968

0.9%

 

sub-total

4,140,220

69.4%

 

WHITE FEMALES

Rank

Cause list

YLD

% total YLD

 

Total YLD

6,234,020

 

1

Unipolar major depression

736,746

11.8%

2

Osteoarthritis

439,876

7.1%

3

Dementia and other degenerative and hereditary CNS disorders

375,458

6.0%

4

Cerebrovascular Disease

323,173

5.2%

5

COPD

307,237

4.9%

6

Alcohol use

291,334

4.7%

7

Asthma

253,904

4.1%

8

Diabetes mellitus

210,058

3.4%

9

Congenital Abnomalities

162,162

2.6%

10

PTSD

159,120

2.6%

11

Panic disorder

145,888

2.3%

12

Bipolar disorder

131,835

2.1%

13

Schizophrenia

118,134

1.9%

14

Rheumatoid arthritis

110,674

1.8%

15

Motor vehicle accidents

109,754

1.8%

16

STD's excluding HIV

101,298

1.6%

17

Ischaemic heart disease

100,510

1.6%

18

Drug use

98,319

1.6%

19

Maternal Conditions

82,750

1.3%

20

Falls

76,404

1.2%

 

Sub-total

4,334,635

69.5%

Table 24

Leading causes of YLD – Blacks

 

BLACK MALES

Rank

Simple cause list

YLD

% total YLD

 

Total YLD

1,086,407

 

1

Alcohol use

135,346

12.5%

2

HIV

73,292

6.7%

3

Unipolar major depression

57,653

5.3%

4

Cerebrovascular Disease

49,191

4.5%

5

Drug use

44,504

4.1%

6

Asthma

42,295

3.9%

7

Diabetes mellitus

39,783

3.7%

8

COPD

38,739

3.6%

9

Osteoarthritis

38,641

3.6%

10

Congenital Abnomalities

36,030

3.3%

11

Road Traffic Accidents

31,173

2.9%

12

Dementia and other degenerative and hereditary CNS disorders

28,292

2.6%

13

Homicide and Violence

26,846

2.5%

14

Bipolar disorder

26,799

2.5%

15

Schizophrenia

24,323

2.2%

16

Ischaemic heart disease

18,148

1.7%

17

Falls

15,894

1.5%

18

Diarrhoeal diseases

15,602

1.4%

19

Inflammatory Cardiac

13,178

1.2%

20

Obsessive-compulsive disorders

12,818

1.2%

 

sub-total

768,546

70.7%

 

BLACK FEMALES

Rank

Simple cause list

YLD

% total YLD

 

Total YLD

1,145,131

 

1

Unipolar major depression

119,471

10.4%

2

Alcohol use

74,248

6.5%

3

Cerebrovascular Disease

74,179

6.5%

4

Diabetes mellitus

54,409

4.8%

5

Asthma

50,869

4.4%

6

Osteoarthritis

48,521

4.2%

7

Dementia and other degenerative and hereditary CNS disorders

37,519

3.3%

8

HIV

31,719

2.8%

9

Congenital Abnomalities

31,654

2.8%

10

COPD

31,132

2.7%

11

PTSD

27,508

2.4%

12

Panic disorder

26,916

2.4%

13

Bipolar disorder

24,649

2.2%

14

Schizophrenia

22,823

2.0%

15

Ischaemic heart disease

21,685

1.9%

16

Road Traffic Accidents

19,754

1.7%

17

STD's excluding HIV

17,688

1.5%

18

Drug use

17,686

1.5%

19

Maternal Conditions

16,770

1.5%

20

Rheumatoid arthritis

15,521

1.4%

 

sub-total

764,722

66.8%

Table 25

Leading causes of YLD – American Indians

 

AMERICAN INDIAN MALES

Rank

Simple cause list

YLD

% total YLD

 

Total YLD

77,508

 

1

Alcohol use

22,997

29.7%

2

Unipolar major depression

4,160

5.4%

3

Drug use

3,042

3.9%

4

Osteoarthritis

2,940

3.8%

5

Asthma

2,745

3.5%

6

COPD

2,708

3.5%

7

Congenital Abnomalities

2,467

3.2%

8

Cerebrovascular Disease

2,014

2.6%

9

Bipolar disorder

1,948

2.5%

10

Road Traffic Accidents

1,902

2.5%

11

Schizophrenia

1,796

2.3%

12

Dementia and other degenerative and hereditary CNS disorders

1,775

2.3%

13

Diabetes mellitus

1,595

2.1%

14

HIV

1,190

1.5%

15

Cirrhosis of the liver

1,082

1.4%

16

Fires

1,027

1.3%

17

Obsessive-compulsive disorders

940

1.2%

18

Falls

921

1.2%

19

Ischaemic heart disease

881

1.1%

20

Panic disorder

743

1.0%

 

sub-total

58,874

76.0%

 

AMERICAN INDIAN FEMALES

Rank

Simple cause list

YLD

% total YLD

 

Total YLD

78,522

 

1

Alcohol use

19,417

24.7%

2

Unipolar major depression

7,655

9.7%

3

Asthma

3,233

4.1%

4

Osteoarthritis

3,020

3.8%

5

COPD

2,692

3.4%

6

Cerebrovascular Disease

2,251

2.9%

7

Congenital Abnomalities

2,182

2.8%

8

Dementia and other degenerative and hereditary CNS disorders

2,006

2.6%

9

Diabetes mellitus

1,895

2.4%

10

Panic disorder

1,851

2.4%

11

Bipolar disorder

1,717

2.2%

12

Schizophrenia

1,625

2.1%

13

PTSD

1,251

1.6%

14

Maternal Conditions

1,178

1.5%

15

STD's excluding HIV

1,157

1.5%

16

Road Traffic Accidents

1,115

1.4%

17

Rheumatoid arthritis

958

1.2%

18

Drug use

925

1.2%

19

Cirrhosis of the liver

918

1.2%

20

Obsessive-compulsive disorders

865

1.1%

 

Sub-total

57,910

73.8%

Table 26

Leading causes of YLD – Asians

 

ASIAN MALES

Rank

Simple cause list

YLD

% total YLD

 

Total YLD

203,229

 

1

Unipolar major depression

17,926

8.8%

2

Osteoarthritis

14,029

6.9%

3

COPD

12,431

6.1%

4

Drug use

11,895

5.9%

5

Asthma

11,027

5.4%

6

Congenital Abnomalities

10,408

5.1%

7

Dementia and other degenerative and hereditary CNS disorders

8,122

4.0%

8

Bipolar disorder

7,862

3.9%

9

Cerebrovascular Disease

7,251

3.6%

10

Schizophrenia

6,679

3.3%

11

Diabetes mellitus

5,516

2.7%

12

Alcohol use

4,539

2.2%

13

Road Traffic Accidents

4,022

2.0%

14

Obsessive-compulsive disorders

3,552

1.7%

15

Panic disorder

2,994

1.5%

16

HIV

2,505

1.2%

17

Epilepsy

2,470

1.2%

18

Falls

2,325

1.1%

19

Ischaemic heart disease

2,234

1.1%

20

Diarrhoeal diseases

2,057

1.0%

 

Sub-total

139,843

68.8%

 

ASIAN FEMALES

Rank

Simple cause list

YLD

% total YLD

 

Total YLD

235,588

 

1

Unipolar major depression

36,337

15.4%

2

Osteoarthritis

14,995

6.4%

3

COPD

13,285

5.6%

4

Asthma

12,329

5.2%

5

Congenital Abnomalities

9,018

3.8%

6

Dementia and other degenerative and hereditary CNS disorders

8,896

3.8%

7

Cerebrovascular Disease

8,876

3.8%

8

Panic disorder

7,548

3.2%

9

Diabetes mellitus

7,458

3.2%

10

Bipolar disorder

6,788

2.9%

11

Schizophrenia

6,150

2.6%

12

PTSD

5,654

2.4%

13

STD's excluding HIV

5,275

2.2%

14

Rheumatoid arthritis

4,605

2.0%

15

Maternal Conditions

4,456

1.9%

16

Drug use

3,469

1.5%

17

Obsessive-compulsive disorders

3,347

1.4%

18

Road Traffic Accidents

2,963

1.3%

19

Epilepsy

2,222

0.9%

20

Diarrhoeal diseases

1,745

0.7%

 

Sub-total

165,417

70.2%

Differentials in patterns of neuropsychiatric disorders by race were dominated by the large excess morbidity burden caused by substance abuse among American Indians, which accounted for half of total YLD, compared to approximately one third in the other race groups.

The distribution of YLD rates for selected disease groupings by age further illustrate major differences that existed between races. These were particularly prominent for neuropsychiatric conditions in young adults between the ages 15 and 44 years (Figure 20).
Figure 20

Patterns of YLD by age and race, US 1996.

Discussion

Quantifying the burden of disease is not a morally neutral exercise. All summary measures of health include several value choices. A strength of the GBD was to make value choices incorporated in the calculation of DALYs transparent. These include a standard duration of life at each age, an age weighting function, and discounting for time preference. GBD values for these parameters were not changed to ensure the international comparability of the USBODI.

The validation of GBD disability weights in different national contexts is particularly important to enhance the confidence of decision-makers in key findings of national disease burden estimates. The instrument used to derive the disability weights is called the Person Trade-Off (PTO). In the GBD the full PTO was executed for a set of 22 indicator conditions.

In order to assess whether groups of people from the United States might value these indicator conditions substantially differently than the benchmark values developed for the GBD, 35 volunteers that included staff from CDC, state health departments, other US federal agencies such as the National Institutes of Mental Health, as well as members of non-profit groups such as the American Heart Association and the Arthritis Foundation, were recruited to execute a PTO (PTO1 and PTO2) exercise as part of the US study. These participants were placed in 4 small groups of 8–12 members according to the GBD PTO (PTO1 and PTO2) protocol. Consistent with results from other such groups coordinated in a variety of international settings by the Burden of Disease Unit at Harvard, there was evidence of substantial inter-individual variation between the participants for conditions associated with milder disability (Table 4). For example, the median value for vitiligo of the face was 0.00, and the average disability weight was 0.04. The standard deviation for the disability weight associated with this condition was larger than the actual point estimate. The coefficients of variation (C.V. = standard deviation/point estimate) were much smaller for conditions associated with more severe disability such as quadriplegia and severe dementia. However, despite variation between individuals within these groups, the correlation between groups for the disability weight values was very strong. Nineteen conditions were included in every exercise. For each group the median disability weight value for each of these conditions was calculated. The correlations between pairs of groups for the 19 disability weight values were very high (Table 5, Range of Pearson's correlation coefficients = 0.82–0.99).
Table 4

Disability weights from person trade-off exercise conducted in Atlanta compared to composite scores from other exercises conducted at various international sites

Indicator Condition

Atlanta PTO (N = 35)

Composite scores (N = 192)

 

Median

Mean

S.D.*

C.V.+

Median

Mean

S.D.*

C.V.+

Vitiligo on Face

0

0.04

0.11

2.75

0

0.04

0.1

2.5

Watery Diarrhea

0.02

0.06

0.08

1.33

0.05

0.1

0.16

1.60

Fracture of Radius

0.06

0.1

0.11

1.10

0.09

0.13

0.16

1.23

Infertility

0.03

0.11

0.16

1.45

0.09

0.16

0.19

1.19

Erectile Dysfunction

0.09

0.19

0.22

1.16

0.17

0.22

0.23

1.05

Severe Sore Throat

0.13

0.19

0.18

0.95

0.13

0.23

0.26

1.13

Rheumatoid Arthritis

0.17

0.26

0.24

0.92

0.29

0.32

0.22

0.69

Below Knee Amputation

0.29

0.32

0.20

0.63

0.29

0.34

0.22

0.65

Deafness

0.44

0.43

0.28

0.65

0.36

0.4

0.24

0.60

Recto-vaginal Fistula

0.29

0.38

0.33

0.87

0.41

0.44

0.28

0.64

Angina

0.38

0.39

0.23

0.59

0.43

0.46

0.26

0.57

Mental Retardation

0.64

0.55

0.28

0.51

0.5

0.5

0.25

0.50

Blindness

0.5

0.53

0.25

0.47

0.63

0.58

0.21

0.36

Paraplegia

0.67

0.6

0.25

0.42

0.71

0.68

0.2

0.29

Major Depression

0.89

0.79

0.23

0.29

0.81

0.75

0.2

0.27

Severe Migraine

0.96

0.89

0.18

0.20

0.88

0.8

0.2

0.25

Dementia

0.9

0.85

0.16

0.19

0.9

0.86

0.13

0.15

Active Psychosis

0.95

0.9

0.12

0.13

0.91

0.87

0.14

0.16

Quadriplegia

0.93

0.9

0.09

0.10

0.91

0.87

0.14

0.16

* S.D. = standard deviation.

+ C.V. = Coefficient of Variation (standard deviation/mean)

Table 5

Pearson's correlation coefficients for median disability weights for each exercise based on 19 conditions common to all person trade-off exercises

Group

         

International I

International I

        

Netherlands

0.96

Netherlands

       

Maghreb-8

0.94

0.95

Maghreb

      

Japan

0.90

0.82

0.85

Japan

     

GBD

0.97

0.95

0.97

0.88

GBD

    

International II

0.99

0.97

0.94

0.89

0.97

International II

   

CDC

0.97

0.98

0.92

0.84

0.95

0.98

CDC

  

Brazil

0.90

0.91

0.87

0.83

0.87

0.90

0.90

Brazil

 

Mexico

0.95

0.93

0.92

0.90

0.93

0.96

0.96

0.95

Mexico

Composite

0.99

0.98

0.96

0.89

0.98

0.99

0.99

0.94

0.97

Based on the above results it seemed reasonable to use the set of disability weights from the GBD study for the US evaluation. In a few instances more detailed data on health conditions were available in the US on the distribution of severity for certain health conditions such as depression [see Additional file 2]. Disability weights for severity-specific stages were developed for many of these conditions as part of a burden of disease and injury study implemented in the Netherlands [20]. Therefore, the Dutch weights were used when stage specific information on severity was available.

In the mid-1990s chronic diseases such as cardiovascular diseases, cancers, depression, osteoarthritis, diabetes mellitus, and alcohol use and abuse were the leading causes of death and disability in the United States. In addition, injuries from motor-vehicle accidents and the HIV epidemic exacted a substantial toll on the US population. These findings are consistent with other assessments of disease burden in developed and developing countries. However, the use of DALYs to enumerate the impact of health conditions is notably different from a simple listing of causes of death. This metric captures the importance of mental conditions, such as depression and degenerative musculoskeletal disease that cause major health problems but result in few deaths, as well as the importance of premature deaths among young adults (Tables 27, and 28).
Table 27

Top twenty leading causes of Disability Adjusted Life Years (DALY), Years Lost to Disability (YLD), Years of Life Lost (YLL) and Deaths for Males – US 1996*

 

Cause

DALY (%)

YLD (%)

YLL (%)

Death (%)

1

Ischaemic heart disease

1,958 (11.0)

152 (2.1)

1,806(17.2)

287 (24.7)

2

Road traffic accidents

934 (5.2)

233 (3.2)

701 (6.7)

29 (2.5)

3

Lung trachea or bronchial cancer

813 (4.6)

35 (0.5)

778 (7.4)

102 (8.8)

4

HIV/AIDS

764 (4.3)

189 (2.6)

575 (5.5)

25 (2.2)

5

Alcohol use

732 (4.1)

651 (8.9)

81 (0.8)

5 (0.4)

6

Cerebrovascular Disease

674 (3.8)

317 (4.3)

357 (3.4)

63 (5.4)

7

COPD

642 (3.6)

373 (5.1)

269 (2.6)

52 (4.5)

8

Homicide and Violence

568 (3.2)

82 (1.1)

486 (4.6)

17 (1.5)

9

Self-inflicted injuries

541 (3.0)

8 (0.1)

534 (5.1)

26 (2.2)

10

Unipolar major depression

470 (2.6)

470 (6.4)

0 (0.0)

0 (0)

11

Diabetes mellitus

442 (2.5)

222 (3.0)

220 (2.1)

28 (2.4)

12

Osteoarthritis

435 (2.4)

434 (5.9)

1 (0.0)

0 (0)

13

Drug use

412 (2.3)

384 (5.2)

27 (0.3)

1 (0.1)

14

Congenital Abnormalities

410 (2.3)

238 (3.2)

172 (1.6)

6 (0.5)

15

Dementia and other degenerative and hereditary CNS disorders

382 (2.1)

332 (4.5)

50 (0.5)

14 (1.2)

16

Asthma

303 (1.7)

273 (3.7)

30 (0.3)

2 (0.2)

17

Cirrhosis of the liver

281 (1.6)

61 (0.8)

220 (2.1)

17 (1.4)

18

Conditions arising during the perinatal period

274 (1.5)

14 (0.2)

260 (2.5)

8 (0.7)

19

Cancer colon or rectum

249 (1.4)

37 (0.5)

213 (2.0)

30 (2.6)

20

Prostate cancer

239 (1.3)

79 (1.1)

160 (1.5)

37 (3.2)

-

Total number for each measure in the top 20 causes

11,523 (64.5)

4,584 (62.5)

6,940 (65.9)

749 (64.5)

-

Total number for each measure

17,861(100)

7,331(100)

10,530 (100)

1,164 (100)

*All counts for DALYs, Deaths, YLDs, and YLLs are in 1000's.

Table 28

Top twenty leading causes of Disability Adjusted Life Years (DALY), Years Lost to Disability (YLD), Years of Life Lost (YLL) and Deaths for Females – US 1996*

 

Cause

DALY (%)

YLD (%)

YLL (%)

Death (%)

1

Ischaemic heart disease

1,177 (7.7)

124 (1.6)

1,052(14.0)

249 (21.7)

2

Unipolar major depression

900 (5.9)

900 (11.7)

0 (0.0)

0 (0.0)

3

Cerebrovascular disease

836 (5.5)

408 (5.3)

428 (5.7)

99 (8.6)

4

COPD

612 (4.0)

354 (4.6)

257 (3.4)

48 (4.1)

5

Lung trachea or bronchial cancer

550 (3.6)

26 (0.3)

523 (6.9)

66 (5.7)

6

Breast cancer

515 (3.4)

64 (0.8)

450 (6.0)

47 (4.1)

7

Osteoarthritis

508 (3.3)

506 (6.6)

1 (0.0)

1(0.0)

8

Dementia and other degenerative and hereditary CNS disorders

507 (3.3)

424 (5.5)

83 (1.1)

29 (2.5)

9

Diabetes mellitus

504 (3.3)

274 (3.6)

230 (3.1)

34 (3.0)

10

Road traffic accidents

459 (3.0)

134 (1.7)

326 (4.3)

15 (1.3)

11

Alcohol use

409 (2.7)

386 (5.0)

23 (0.3)

1 (0.1)

12

Asthma

362 (2.4)

320 (4.2)

42 (0.6)

4 (0.3)

13

Congenital abnormalities

352 (2.3)

205 (2.7)

147 (1.9)

6 (0.5)

14

Cancer colon or rectum

234 (1.5)

38 (0.5)

197 (2.6)

31 (2.7)

15

Conditions arising during the perinatal period

220 (1.4)

16 (0.2)

205 (2.7)

6 (0.5)

16

Lower respiratory infections

195 (1.3)

10 (0.1)

186 (2.5)

46 (4.0)

17

PTSD

194 (1.3)

194 (2.5)

0 (0.0)

0 (0.0)

18

HIV/AIDS

193 (1.3)

49 (0.6)

144 (1.9)

6 (0.5)

19

Panic disorder

182 (1.2)

182 (2.4)

0 (0.0)

0 (0.0)

20

Bipolar disorder

165 (1.1)

165 (2.1)

0 (0.0)

0 (0.0)

Total number for each measure in the top 20 causes

9,074 (59.6)

4,779 (62.1)

4,294 (57.0)

688 (59.7)

Total number for each measure

15,230 (100)

7,693 (100)

7,537 (100)

1,151 (100)

*All counts for DALYs, Deaths, YLDs, and YLLs are in 1000's

The juxtaposition of the twenty leading causes of death, YLL, YLD and DALYs illustrates the extent to which an assessment of the relative importance of various causes based simply on total number of deaths differs from the assessment of leading causes of YLL, YLD and DALYs. For example, the total number of years lived with a disability resulting from unipolar major depression (1.3 million YLD) was equal to the number of years lost due to premature death from lung cancer (1.3 million YLL); and the burden resulting from osteoarthritis and motor vehicle accidents were similar (940.6 million YLD and 1 billion YLL respectively).

Osteoarthritis of the hip and knee (OA) and rheumatoid arthritis (RA) were the two leading musculoskeletal disorders. OA is an important public health problem that affects mostly older adults causing great pain and disability, and is one of the most rapidly growing causes of disability. The estimated 40 million prevalent cases in 1996 is projected to increase to 60 million cases by 2020 [22].

Substantial differences were found in the relative impact of individual conditions by gender and race. HIV/AIDS, alcohol dependence, as well as violent and unintentional injuries accounted for most of the worse health outcomes observed among Black and American Indian populations compared to White and Asian populations. Blacks fared much worse than the other race groups with regard to pregnancy outcomes. Blacks were the only group for which perinatal conditions ranked among the top ten causes of DALYs. Relatively high perinatal mortality rates persist in this population due to the combined effect of premature delivery and poor perinatal care.

Conditions associated with social issues in younger ages were much more common among Blacks and American Indians. For instance, YLL rates for HIV/AIDS were fivefold larger for Blacks than they were for any of the other races. YLL rates for homicide and violence were seven times higher for American Indians and twice as high for Blacks than they were for Whites and Asians.

One important objective of the study was to place the United States public health situation in a global context. Non-communicable diseases are the leading causes of deaths in all industrialized countries, where child and adult mortality are low. In developing regions, where child and adult mortality are still high, Group I represents a much larger share of the total. The dominance of HIV/AIDS observed in Blacks in the United States was akin to that in developing regions of the world. It was the third leading cause among black women in the US and the fifth leading cause among females in developing regions. HIV/AIDS accounted for a much smaller proportion of DALYs in other races in the US and did not figure among the top ten causes of DALYs in developed countries. Alcohol use for males in most racial subgroups in the United States exacted a high burden. This condition also ranked among the top five in other developed regions. Only Asian males and people living in developing countries did not have a large number of DALYs attributed to alcohol use.

US rankings clearly fell outside of the range observed elsewhere for a few causes: homicide and violence, HIV/AIDS, and perinatal conditions stand out regardless of race and gender. The United States has not been as successful in reducing the mortality burden due to violent injuries and perinatal conditions as were other industrialized countries with comparable levels of development.

In spite of the extensive population-based data available in the United States, there were limitations particularly in estimating disease burden by race due to smaller populations – Asians and American Indians. The major methodological limitations pertained to the different methods used to assign race and ethnicity in the census compared to death certificates; and to the limited population-based information that was available for many conditions for Asians and American Indians. For these last two groups, ratios of YLL to YLD for the overall US population were generally used to estimate the burden due to non-fatal health conditions. Such assumptions introduce a certain level of uncertainty in the estimates and call for caution in the interpretation of small absolute differences in the number of DALYs between different causes. This study provides a benchmark against which to assess future trends in health differentials in the United States and underscores the importance of further research to improve methods, provide stronger empirical evidence and better understanding of major risk factors for poor health outcomes.

Conclusion

This study provides a comprehensive picture of conditions that contribute most to poor health outcomes, and yields new evidence to the discussion of racial health inequalities in the United States. The existence of health inequalities is widely acknowledged and lies at the core of public health policy: reducing health inequalities is the major focus of Healthy People 2010 [23]. Previous studies have documented differentials in mortality by cause and have examined socio-economic determinants – income and education – of population health outcomes and health outcomes mediated through the health system: the utilization of health services, access, and quality of care [2426].

The main policy message emerging from this study is that cost-effective public health interventions are available to reduce the burden of the three conditions that contributed most to racial inequalities. It adds new evidence that greater investments of public health interventions have a much greater potential to reduce large health inequalities in the United States than do technology driven curative interventions. The fact that other countries, which have lower expenditures per capita have achieved better health outcomes than the United States indicates that the major goal of reducing health disparities by 2010 can be achieved.

Declarations

Acknowledgements

We wish to acknowledge:

James S. Marks for initiating the study and for his support throughout the study; Lee Anneston, George Cauthen and Ted Thompson who developed estimates for selected causes; William Eaton, Charles Helmick, Ronald Kessler, Alan Lopez, Colin Mathers, Wayne Rosamond, Richard Seelik and Bedirhan Ustun who contributed invaluable technical guidance and critically reviewed estimates; Yuliya Popova and J.A. Kurichety who contributed to the preparation of the final document; Emmanuela Gakidou and Stanislava Nikolova who edited the final document.

Disclaimer: "The views and opinions in this report represent those of the authors and not the Centers for Disease Control and Prevention."

This study was funded by an Association of Schools of Public Health; ASPH/Centers for Disease Control and Prevention (CDC)/Agency for Toxic Substances and Disease Registry (ATSDR) Cooperative Agreement. The funding source had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.

Authors’ Affiliations

(1)
Harvard Initiative for Global Health, Harvard University
(2)
Centers for Disease Control and Prevention
(3)
School of Population Health, The University of Queensland
(4)
Columbia University in the City of New York, Texas A&M University
(5)
Haas School of Business, 545 Student Services #1900, University of California
(6)
Bloomberg School of Public Health, Johns Hopkins University

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© Michaud et al; licensee BioMed Central Ltd. 2006

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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