Homicide/fatal violence in the Global Burden of Disease 2010

1. 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

2. What are we measuring ? • The Global Burden of Interpersonal Violence What is the global burden of disease, injuries and risk factors? • A systematicscientificeffort to quantify the comparative magnitude of health lossdue to diseases, injuries and risk factors by age, sex, geographies for specific points in time

3. 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 Health loss due to premature mortality Time lived with disability

4. GBD terminology • DALYs = Years of life lost due to premature mortality (YLLs) and years lived with disability (YLDs). • 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. • 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. • Disability weights quantify the impact from any short-term or long-term health loss. • In the GBD 2010, DALYs are not discounted or age-weighted.

5. 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

6. GBD 2010: new methods, wider scope • “GBD 2010 study” initiated in 2007and 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 than hundred detailed publications in submission or preparation. • Systematic attempt to quantify health loss from all major diseases, injuries and risk factors for 187 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.

7. GBD Causes of Injury Categories LEVEL II LEVEL III LEVEL IV LEVEL V

8. Sources and Methods for Interpersonal violence • Methods • Deaths: • Similar strategy to other GBD causes • Cause of death ensemble model (CODEM) forInterpersonal 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 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 (1980-2008) Sources: Lozano R, et al 2012; Vos T. et al 2012; Murray CJL et al 2012

9. The Global Burden of Intentional Violence • For 2010, we have estimated 456.3 (359-611) thousand homicides in the world • 86% in developing countries • 43% related with firearms • 28% related with sharp objects • 81% in males • 70% occurred before 40 years old Mortality (age-adj) duetohomicides, bothsexes Source: Lozano R, et al 2012

10. The Global Burden of Intentional Violence Global Prevalence rate of interpersonal violence by age and sex, 2010 Percent of DALYs due to interpersonal violence, 2010 • In 2010, estimates displayed 25.5 (20-33) million of DALYs due to interpersonal violence in the world, meaning1% of the total burden • Globally 94% were YLL and 6% YLD. In developed countries, health loss due to non fatal outcomes was10% • 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 Rate per 1,000 pop Source: IHME, 2012

11. What is the leading cause of premature death in men in 2010? Source: IHME, 2012

12. The place of homicide within the leading causes of premature mortality in men, 2010 Source: IHME, 2012

13. Mortality rate(age-adj) due to Homicides by sex and mechanisms, GBD Regions 2010 Male Female Rate per 100,000 male Rate per 100,000 female Source: IHME, 2012

14. The burden of Interpersonal Violence by Sex and Mechanism in Latin American Countries, 2010 MALE FEMALE Rate per 1,000 male Rate per 100,000 female Source: IHME, 2012

15. To understand where you are, you have to know where you come from Rate of YLL (age-adj) due to Interpersonal Violence in Male, 1990- 2010 Source: IHME, 2012

16. Homicide mortality in Male, Mexico 1955-2011 What happens after 2004? What did you do to decrease homicides in the second half of the last century? *Rate per 100,000 males (age adj) Sources: WHO, 1955-1978; SSA/INEGI, 1979-2011. CONAPO, Population Estimates 1955-2011

17. National Averages hide disparities Homicide mortality both sexes, Mexico 2012 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 Rate per 100,000 pop Source: INEGI, Boletín de Prensa 288/13

18. As all the world, homicides in Mexico are a matter of young males Male Female 1980 2011 1980 2011 0 30-40% of all deaths are due to homicides 80

19. Interpersonal Violenceisthe lead cause of DALYS in Mexico in males, 2010 http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-arrow-diagram

20. Leading causes of DALYs for both sexes in Latin American and Caribbean countries, 2010 http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-arrow-diagram

21. 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)

22. 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