The Lancet
Nov 12, 2016 Volume 388 Number 10058 p2323-2448
http://www.thelancet.com/journals/lancet/issue/current
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Editorial
Brexit’s effect on access to new medicines
The Lancet
Articles
Dissonant health transition in the states of Mexico, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013
Héctor Gómez-Dantés, Nancy Fullman, Héctor Lamadrid-Figueroa, Lucero Cahuana-Hurtado, Blair Darney, Leticia Avila-Burgos, Ricardo Correa-Rotter, Juan A Rivera, Simon Barquera, Eduardo González-Pier, Tania Aburto-Soto, Elga Filipa Amorin de Castro, Tonatiuh Barrientos-Gutiérrez, Ana C Basto-Abreu, Carolina Batis, Guilherme Borges, Ismael Campos-Nonato, Julio C Campuzano-Rincón, Alejandra de Jesús Cantoral-Preciado, Alejandra G Contreras-Manzano, Lucia Cuevas-Nasu, Vanessa V de la Cruz-Gongora, Jose L Diaz-Ortega, María de Lourdes García-García, Armando Garcia-Guerra, Teresita González de Cossío, Luz D González-Castell, Ileana Heredia-Pi, Marta C Hijar-Medina, Alejandra Jauregui, Aida Jimenez-Corona, Nancy Lopez-Olmedo, Carlos Magis-Rodríguez, Catalina Medina-Garcia, Maria E Medina-Mora, Fabiola Mejia-Rodriguez, Julio C Montañez, Pablo Montero, Alejandra Montoya, Grea L Moreno-Banda, Andrea Pedroza-Tobías, Rogelio Pérez-Padilla, Amado D Quezada, Vesta L Richardson-López-Collada, Horacio Riojas-Rodríguez, Maria J Ríos Blancas, Christian Razo-Garcia, Martha P Romero Mendoza, Tania G Sánchez-Pimienta, Luz M Sánchez-Romero, Astrid Schilmann, Edson Servan-Mori, Teresa Shamah-Levy, Martha M Téllez-Rojo, José L Texcalac-Sangrador, Haidong Wang, Theo Vos, Mohammad H Forouzanfar, Mohsen Naghavi, Alan D Lopez, Christopher J L Murray, Rafael Lozano
Summary
Background
Child and maternal health outcomes have notably improved in Mexico since 1990, whereas rising adult mortality rates defy traditional epidemiological transition models in which decreased death rates occur across all ages. These trends suggest Mexico is experiencing a more complex, dissonant health transition than historically observed. Enduring inequalities between states further emphasise the need for more detailed health assessments over time. The Global Burden of Diseases, Injuries, and Risk Factors Study 2013 (GBD 2013) provides the comprehensive, comparable framework through which such national and subnational analyses can occur. This study offers a state-level quantification of disease burden and risk factor attribution in Mexico for the first time.
Methods
We extracted data from GBD 2013 to assess mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) in Mexico and its 32 states, along with eight comparator countries in the Americas. States were grouped by Marginalisation Index scores to compare subnational burden along a socioeconomic dimension. We split extracted data by state and applied GBD methods to generate estimates of burden, and attributable burden due to behavioural, metabolic, and environmental or occupational risks. We present results for 306 causes, 2337 sequelae, and 79 risk factors.
Findings
From 1990 to 2013, life expectancy from birth in Mexico increased by 3·4 years (95% uncertainty interval 3·1–3·8), from 72·1 years (71·8–72·3) to 75·5 years (75·3–75·7), and these gains were more pronounced in states with high marginalisation. Nationally, age-standardised death rates fell 13·3% (11·9–14·6%) since 1990, but state-level reductions for all-cause mortality varied and gaps between life expectancy and years lived in full health, as measured by HALE, widened in several states. Progress in women’s life expectancy exceeded that of men, in whom negligible improvements were observed since 2000. For many states, this trend corresponded with rising YLL rates from interpersonal violence and chronic kidney disease. Nationally, age-standardised YLL rates for diarrhoeal diseases and protein-energy malnutrition markedly decreased, ranking Mexico well above comparator countries. However, amid Mexico’s progress against communicable diseases, chronic kidney disease burden rapidly climbed, with age-standardised YLL and DALY rates increasing more than 130% by 2013. For women, DALY rates from breast cancer also increased since 1990, rising 12·1% (4·6–23·1%). In 2013, the leading five causes of DALYs were diabetes, ischaemic heart disease, chronic kidney disease, low back and neck pain, and depressive disorders; the latter three were not among the leading five causes in 1990, further underscoring Mexico’s rapid epidemiological transition. Leading risk factors for disease burden in 1990, such as undernutrition, were replaced by high fasting plasma glucose and high body-mass index by 2013. Attributable burden due to dietary risks also increased, accounting for more than 10% of DALYs in 2013.
Interpretation
Mexico achieved sizeable reductions in burden due to several causes, such as diarrhoeal diseases, and risks factors, such as undernutrition and poor sanitation, which were mainly associated with maternal and child health interventions. Yet rising adult mortality rates from chronic kidney disease, diabetes, cirrhosis, and, since 2000, interpersonal violence drove deteriorating health outcomes, particularly in men. Although state inequalities from communicable diseases narrowed over time, non-communicable diseases and injury burdens varied markedly at local levels. The dissonance with which Mexico and its 32 states are experiencing epidemiological transitions might strain health-system responsiveness and performance, which stresses the importance of timely, evidence-informed health policies and programmes linked to the health needs of each state.
Funding
Bill & Melinda Gates Foundation, Instituto Nacional de Salud Pública.
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Viewpoint
Assessment of economic vulnerability to infectious disease crisesAssessment of economic vulnerability to infectious disease crises
Peter Sands, Anas El Turabi, Philip A Saynisch, Victor J Dzau
Summary
Infectious disease crises have substantial economic impact. Yet mainstream macroeconomic forecasting rarely takes account of the risk of potential pandemics. This oversight contributes to persistent underestimation of infectious disease risk and consequent underinvestment in preparedness and response to infectious disease crises. One reason why economists fail to include economic vulnerability to infectious disease threats in their assessments is the absence of readily available and digestible input data to inform such analysis. In this Viewpoint we suggest an approach by which the global health community can help to generate such inputs, and a framework to use these inputs to assess the economic vulnerability to infectious disease crises of individual countries and regions. We argue that incorporation of these risks in influential macroeconomic analyses such as the reports from the International Monetary Fund’s Article IV consultations, rating agencies and risk consultancies would simultaneously improve the quality of economic risk forecasting and reinforce individual government and donor incentives to mitigate infectious disease risks.
vaccines and global health :: ethics and policy 