Homicide/fatal violence in the
Global Burden of Disease 2010
Rafael Lozano MD
6th Milestones of a Global Campaign for
Violence Prevention
Mexico City November 13th 2013
Instituto Nacional
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What are we measuring ?
• The Global Burden of Interpersonal Violence
What is the global burden of disease, injuries and risk factors?
• A systematic scientific effort to quantify the comparative
magnitude of health loss due to diseases, injuries and risk
factors by age, sex, geographies for specific points in time
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Health loss is the key GBD concept:
how do we measure it?
• Usually we count deaths and events (cases) as health
loss, but we cannot add them.
• Thus, to combine them in a summary measure, we
calculate the time loss due to premature mortality
and the time lived with disability
DALYs = YLL + YLD
Health loss
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Health loss due to
premature mortality
Time lived with disability
3
GBD terminology
1) DALYs = Years of life lost due to premature mortality (YLLs)
and years lived with disability (YLDs).
2) Years of life lost due to premature mortality due to a death
at age x is the standard life expectancy at age x. A death at age
5 years counts as 81.4 YLLs, while a death at age 50 counts as
27.8 YLLs.
3) Years lived with disability for a cause in an age-sex group
equals the prevalence of the condition times the disability
weight for that condition.
4) Disability weights quantify the impact from any short-term
or long-term health loss.
5) In the GBD 2010, DALYs are not discounted or age-weighted.
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Background
– In 1991 the World Bank commissioned the
first study to C. Murray (Harvard U.) and A.
Lopez (WHO). In 1993, results were
published in the World Report "Investing
in Health“
– In 1996, final results were disseminated in
2 books and subsequently published in
The Lancet
– Under the leadership of Dr. Gro
Brundtland, WHO issued annual updates of
the GBD from 1998-2002
– This activity continued in 2004 and 2008
5
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GBD 2010: new methods, wider scope
• “GBD 2010 study” initiated in 2007 and was
funded by Bill & Melinda Gates Foundation.
• IHME head institution: shaped by University
of Queensland, WHO, Harvard University,
Johns Hopkins University, Imperial College
London, University of Tokyo.
• Final study with 486 authors from 50
countries.
• Seven summary papers and an overview
were published in a dedicated triple issue of
the Lancet on December, 2012; and more
• Systematic attempt to quantify
health loss from all major diseases,
than hundred detailed publications in
injuries and risk factors for 187
submission or preparation.
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countries overtime from 1990 to
2010.
• By the numbers: 291 diseases and
injuries; 1,160 sequelae of these
diseases and injuries; and 67 risk
factors or clusters of risk factors.
GBD Causes of Injury Categories
LEVEL II
LEVEL III
Transport Injury
Non-transport Injury
Unintentional
LEVEL IV
Road Injury
Other transport
Falls
Drowning
Fire
Poisonings
Exposure to mechanical forces
LEVEL V
Pedestrian
Bicyclist
Motorcyclist
Car occupant
Other
Firearm
Other
Adverse effects of medical Rx
Animal contact
venomous
non‐venomous
Exposure to forces of nature
Other unintentional injuries
Self-harm and interpersonal
violence
Self-harm
Interpersonal violence
Forces of nature, war & legal
intervention
Collective violence and legal
intervention
Intentional
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Forces of nature
Assault firearm
Assault sharp object
Assault other means
Sources and Methods for Interpersonal violence
Sources
Deaths:
•
•
•
•
•
•
Country Years
Vital Registration
2,705
Verbal Autopsy
71
Surveillance Systems
17
Survey/Census
49
Police Reports
1,070
Non fatal outcomes:
• Surveys for 61 countries
• tabulations of hospital admissions from 27
different countries disaggregated by age,
sex, external cause and sequela.
E/N code Matrrx
• Brazil SIHSUS (2006-2009), Canada DAD
data (2004-2009), Mexico SINAIS data
(2003-2009), and US NHDS data (19802008)
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Methods
Deaths:
Similar strategy to other GBD causes
•
Cause of death ensemble model (CODEM)
for Interpersonal violence, assault due to
firearms, sharp objects and other means.
Non fatal outcomes:
Same strategy to other injuries
• Incidence by external cause and
incidence by nature of the injury (23
conditions)
• N/E code matrix
• Probability of permanent disability
• DW from the household survey and
adjusted from cohort studies in order
to capture severity
Sources: Lozano R, et al 2012; Vos T. et al 2012; Murray CJL et al 2012
The Global Burden of Intentional Violence
9.0
8.0
Rate x 100,000 pop
• 86% in developing countries
• 43% related with firearms
• 28% related with sharp
objects
• 81% in males
• 70% occurred before 40
years old
10.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
1990
1995
2000
2005
2010
Mortality by age and sex, 2010
25.0
Rates x 100,000 pop
For 2010, we have
estimated 456.3 (359611) thousand homicides
in the world
Mortality (age-adj) due to homicides, both sexes
20.0
15.0
10.0
5.0
0.0
0
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10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
Male
Source: Lozano R, et al 2012
Female
The Global Burden of Intentional Violence
12.0
10.0
Rate per 1,000 pop
• In 2010, estimates displayed 25.5
(20-33) million of DALYs due to
interpersonal violence in the
world, meaning 1% of the total
burden
• Globally 94% were YLL and 6%
YLD. In developed countries,
health loss due to non fatal
outcomes was 10%
• GBD estimated 31.3 million
population with some sequelae
of interpersonal violence. 78%
male and 22% female.
• 55% were related with
lacerations, multiple wounds, eye
injuries; 26% fractures and 7%
long term sequelae
Percent of DALYs due to interpersonal violence, 2010
Global Prevalence rate of interpersonal
violence by age and sex, 2010
male
female
8.0
6.0
4.0
2.0
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0.0
< 10y
10-19y
20-49y
50-69
70+
Source: IHME, 2012
What is the leading cause of premature death in
men in 2010?
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Source: IHME, 2012
The place of homicide within the leading causes of premature
mortality in men, 2010
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Source: IHME, 2012
Mortality rate(age-adj) due to Homicides by sex and
mechanisms, GBD Regions 2010
Sub Saharan Africa Southern
Latin America Central
Latin America Tropical
Sub S Africa Southern
Caribbean
Sub S Africa Central
Europe Eastern
LatinAmericaAndean
Sub Saharan Africa East
Latin America Southern
Asia Central
Asia Southeast
Oceania
SubSaharan Africa-West
North America High…
Asia South
North Africa-Middle East
Europe Central
Asia East
Australasia
Europe Western
Asia Pacific High Income
Caribbean
Latin America Central
Europe Eastern
Latin America Tropical
Oceania
Sub Saharan Africa Central
Sub Saharan Africa East
SubSaharan Africa-West
LatinAmericaAndean
Asia Southeast
North America High Income
Asia Central
Latin America Southern
Asia South
Female
Europe Central
Australasia
Asia Pacific High Income
Asia East
Europe Western
0.0
20.0
40.0
Rate per 100,000 male
Firearm
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North Africa-Middle East
Male
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Sharp
Other
60.0
0.0
2.0
4.0
6.0
8.0
10.0
12.0
Rate per 100,000 female
Firearm
Sharp
Other
Source: IHME, 2012
14.0
The burden of Interpersonal Violence by Sex and Mechanism
in Latin American Countries, 2010
MALE
El Salvador
FEMALE
Honduras
Guatemala
El Salvador
Venezuela
Guatemala
Colombia
Jamaica
Honduras
Belice
Brasil
Colombia
Jamaica
Venezuela
Firearm
Mexico
Ecuador
R Dom
Paraguay
Other
Belice
Panama
Sharp
Ecuador
Other
Panama
Mexico
R Dom
Paraguay
Nicaragua
Bolivia
C Rica
Nicaragua
Argentina
Cuba
Bolivia
Peru
Chile
Argentina
Peru
C Rica
Cuba
Uruguay
Uruguay
Chile
0.0
20.0
40.0
Rate per 1,000 male
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60.0
Firearm
Brasil
Sharp
80.0
0.0
2.0
4.0
6.0
8.0
10.0
Rate per 100,000 female
Source: IHME, 2012
12.0
To understand where you are, you have to know
where you come from
90
Rate of YLL (age-adj) due to Interpersonal Violence in Male,
1990- 2010
80
YLL per 1000 pop
70
El Salvador
60
Guatemala
Venezuela
50
Colombia
40
South Africa
30
Brazil
Mexico
20
Russia
10
0
1990
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1995
2000
2005
2010
Source: IHME, 2012
Rate per 100,000 men
Homicide mortality in Male, Mexico 1955-2011
90.0
What happens after 2004?
80.0
What did you do to decrease homicides
in the second half of the last century?
70.0
60.0
50.0
40.0
30.0
y = -1.1489x + 77.729
R² = 0.948
20.0
10.0
0.0
1955
1960
1965
1970
1975
1980
2005-2011
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1985
1990
1995
2000
2005
2010
1955-2004
*Rate per 100,000 males (age adj)
Sources: WHO, 1955-1978; SSA/INEGI, 1979-2011. CONAPO, Population Estimates 1955-2011
National Averages hide disparities
Homicide mortality both sexes, Mexico 2012
Guerrero
Chihuahua
Sinaloa
Durango
Tamaulipas
Coahuila
Colima
Nuevo León
Morelos
Zacatecas
Nayarit
NACIONAL
Jalisco
Sonora
Oaxaca
Michoacán
México
Baja California
San Luis Potosí
Veracruz
Guanajuato
Distrito Federal
Quintana Roo
Campeche
Tabasco
Puebla
Chiapas
Tlaxcala
Querétaro
Hidalgo
Baja California Sur
Aguascalientes
Yucatán
Guatemala 62 x 100,000
Colombia 46 x 100,000
Brazil 31 x 100,000
USA 6 x 100,000
Central Europe 2.2 x 100,000
0
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10
20
30
40
50
60
Rate per 100,000 pop
Source: INEGI, Boletín de Prensa 288/13
70
80
As all the world, homicides in Mexico are a
matter of young males
Male
1980
Female
2011
1980
0
30-40% of
all deaths
are due to
homicides
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2011
Interpersonal Violence is the lead cause of DALYS in
Mexico in males, 2010
http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-arrow-diagram
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Leading causes of DALYs for both sexes in Latin
American and Caribbean countries, 2010
http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-arrow-diagram
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Final remarks
• For purposes of violence prevention, it would be convenient to
incorporate the GBD framework.
– Using an holistic approach, interpersonal violence is located at the top of
the health losses in several countries
– We have to measure the burden by type of violence and not only by
mechanism
• Premature mortality and young population are key for measurable
targets
• Violence related with firearms is spreading significantly in LAC
countries. The burden of this mechanism is over 70% in Venezuela,
Colombia and El Salvador.
• An update of the “GBD 2010 study” is coming soon (GBD2013), but
it demands more collaboration
• To analyze health disparities it is imperative to do subnational
studies (Mexico, UK and China are on track)
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Crime and violence statistics portrait
reality crudely, but we must not ignore
that behind each number there is a
person, a family, and therefore, a
tragedy that we must respect ....
when we prevent and avoid violence
we show respect
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