Health in times of uncertainty in the eastern Mediterranean region, 1990�2013: a systematic analysis for the Global Burden of Disease Study 2013

Mokdad, A.H. and Forouzanfar, M.H. and Daoud, F. and El Bcheraoui, C. and Moradi-Lakeh, M. and Khalil, I. and Afshin, A. and Tuffaha, M. and Charara, R. and Barber, R.M. and Wagner, J. and Cercy, K. and Kravitz, H. and Coates, M.M. and Robinson, M. and Estep, K. and Steiner, C. and Jaber, S. and Mokdad, A.A. and O'Rourke, K.F. and Chew, A. and Kim, P. and El Razek, M.M.A. and Abdalla, S. and Abd-Allah, F. and Abraham, J.P. and Abu-Raddad, L.J. and Abu-Rmeileh, N.M.E. and Al-Nehmi, A.A. and Akanda, A.S. and Al Ahmadi, H. and Al Khabouri, M.J. and Al Lami, F.H. and Al Rayess, Z.A. and Alasfoor, D. and AlBuhairan, F.S. and Aldhahri, S.F. and Alghnam, S. and Alhabib, S. and Al-Hamad, N. and Ali, R. and Ali, S.D. and Alkhateeb, M. and AlMazroa, M.A. and Alomari, M.A. and Al-Raddadi, R. and Alsharif, U. and Al-Sheyab, N. and Alsowaidi, S. and Al-Thani, M. and Altirkawi, K.A. and Amare, A.T. and Amini, H. and Ammar, W. and Anwari, P. and Asayesh, H. and Asghar, R. and Assabri, A.M. and Assadi, R. and Bacha, U. and Badawi, A. and Bakfalouni, T. and Basulaiman, M.O. and Bazargan-Hejazi, S. and Bedi, N. and Bhakta, A.R. and Bhutta, Z.A. and Bin Abdulhak, A.A. and Boufous, S. and Bourne, R.R.A. and Danawi, H. and Das, J. and Deribew, A. and Ding, E.L. and Durrani, A.M. and Elshrek, Y. and Ibrahim, M.E. and Eshrati, B. and Esteghamati, A. and Faghmous, I.A.D. and Farzadfar, F. and Feigl, A.B. and Fereshtehnejad, S.-M. and Filip, I. and Fischer, F. and Gankpé, F.G. and Ginawi, I. and Gishu, M.D. and Gupta, R. and Habash, R.M. and Hafezi-Nejad, N. and Hamadeh, R.R. and Hamdouni, H. and Hamidi, S. and Harb, H.L. and Hassanvand, M.S. and Hedayati, M.T. and Heydarpour, P. and Hsairi, M. and Husseini, A. and Jahanmehr, N. and Jha, V. and Jonas, J.B. and Karam, N.E. and Kasaeian, A. and Kassa, N.A. and Kaul, A. and Khader, Y. and Khalifa, S.E.A. and Khan, E.A. and Khan, G. and Khoja, T. and Khosravi, A. and Kinfu, Y. and Defo, B.K. and Balaji, A.L. and Lunevicius, R. and Obermeyer, C.M. and Malekzadeh, R. and Mansourian, M. and Marcenes, W. and Farid, H.M. and Mehari, A. and Mehio-Sibai, A. and Memish, Z.A. and Mensah, G.A. and Mohammad, K.A. and Nahas, Z. and Nasher, J.T. and Nawaz, H. and Nejjari, C. and Nisar, M.I. and Omer, S.B. and Parsaeian, M. and Peprah, E.K. and Pervaiz, A. and Pourmalek, F. and Qato, D.M. and Qorbani, M. and Radfar, A. and Rafay, A. and Rahimi, K. and Rahimi-Movaghar, V. and Rahman, S.U. and Rai, R.K. and Rana, S.M. and Rao, S.R. and Refaat, A.H. and Resnikoff, S. and Roshandel, G. and Saade, G. and Saeedi, M.Y. and Sahraian, M.A. and Saleh, S. and Sanchez-Riera, L. and Satpathy, M. and Sepanlou, S.G. and Setegn, T. and Shaheen, A. and Shahraz, S. and Sheikhbahaei, S. and Shishani, K. and Sliwa, K. and Tavakkoli, M. and Terkawi, A.S. and Uthman, O.A. and Westerman, R. and Younis, M.Z. and El Sayed Zaki, M. and Zannad, F. and Roth, G.A. and Wang, H. and Naghavi, M. and Vos, T. and Al Rabeeah, A.A. and Lopez, A.D. and Murray, C.J.L. (2016) Health in times of uncertainty in the eastern Mediterranean region, 1990�2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet Global Health, 4 (10). e704-e713.

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Abstract

Background The eastern Mediterranean region is comprised of 22 countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, and Yemen. Since our Global Burden of Disease Study 2010 (GBD 2010), the region has faced unrest as a result of revolutions, wars, and the so-called Arab uprisings. The objective of this study was to present the burden of diseases, injuries, and risk factors in the eastern Mediterranean region as of 2013. Methods GBD 2013 includes an annual assessment covering 188 countries from 1990 to 2013. The study covers 306 diseases and injuries, 1233 sequelae, and 79 risk factors. Our GBD 2013 analyses included the addition of new data through updated systematic reviews and through the contribution of unpublished data sources from collaborators, an updated version of modelling software, and several improvements in our methods. In this systematic analysis, we use data from GBD 2013 to analyse the burden of disease and injuries in the eastern Mediterranean region specifically. Findings The leading cause of death in the region in 2013 was ischaemic heart disease (90·3 deaths per 100�000 people), which increased by 17·2 since 1990. However, diarrhoeal diseases were the leading cause of death in Somalia (186·7 deaths per 100�000 people) in 2013, which decreased by 26·9 since 1990. The leading cause of disability-adjusted life-years (DALYs) was ischaemic heart disease for males and lower respiratory infection for females. High blood pressure was the leading risk factor for DALYs in 2013, with an increase of 83·3 since 1990. Risk factors for DALYs varied by country. In low-income countries, childhood wasting was the leading cause of DALYs in Afghanistan, Somalia, and Yemen, whereas unsafe sex was the leading cause in Djibouti. Non-communicable risk factors were the leading cause of DALYs in high-income and middle-income countries in the region. DALY risk factors varied by age, with child and maternal malnutrition affecting the younger age groups (aged 28 days to 4 years), whereas high bodyweight and systolic blood pressure affected older people (aged 60�80 years). The proportion of DALYs attributed to high body-mass index increased from 3·7 to 7·5 between 1990 and 2013. Burden of mental health problems and drug use increased. Most increases in DALYs, especially from non-communicable diseases, were due to population growth. The crises in Egypt, Yemen, Libya, and Syria have resulted in a reduction in life expectancy; life expectancy in Syria would have been 5 years higher than that recorded for females and 6 years higher for males had the crisis not occurred. Interpretation Our study shows that the eastern Mediterranean region is going through a crucial health phase. The Arab uprisings and the wars that followed, coupled with ageing and population growth, will have a major impact on the region's health and resources. The region has historically seen improvements in life expectancy and other health indicators, even under stress. However, the current situation will cause deteriorating health conditions for many countries and for many years and will have an impact on the region and the rest of the world. Based on our findings, we call for increased investment in health in the region in addition to reducing the conflicts. Funding Bill & Melinda Gates Foundation. © 2016 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license

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