A massive new accounting of the health of humans on Earth, collating and inferring stats on hundreds of diseases and injuries across 204 nations, has mostly good news. People are healthier, and they stay that way for longer. The bad news: That’s not true if those people are poor, are people of color, live in the United States, and there’s a pandemic.
Then they’re screwed.
The ongoing work of thousands of international researchers, the Global Burden of Disease project is based at the University of Washington—it’s a big part of the work of the Institute for Health Metrics and Evaluation, which you might remember from its hyper-pessimistic but highly motivating models of the coronavirus pandemic earlier in the year. With GBD, that modeling experience fills in the gaps from countries that don’t gather all the same data, but overall the work slurps in all kinds of epidemiological and health outcome numbers from governments and health care organizations, and tabulates who gets what illness by age and sex. That’s 286 causes of death, 369 diseases and injuries, and 87 risk factors in 204 countries and territories, with numbers going back to 1990. The latest bolus of data, published in the medical journal The Lancet, brings that up through 2019. (The Bill and Melinda Gates Foundation is the major source of funding.)
In a way, the Global Disease Burden report is a blast from the past, a look at the health of a planet now gone—the best of Before Times and the worst of Before Times. Chronic diseases were undermining the gains of modern medicine and public health. But 10 months into a pandemic, the GBD report is a map to the vulnerabilities that Covid-19 would exploit. It’s also a laser-pointer showing the way to a brighter timeline.
Overall, the things that kill the most people aren’t communicable diseases like Covid-19. The number-one killer worldwide is high blood pressure; number two is disease related to tobacco use. In fact, everything on the top-10 list is the same population-scale stuff that takes systemic change to fix. That’s air pollution; nutritional gaps that lead to diabetes, obesity, and heart disease; and alcohol abuse. Childhood and maternal mortality still sneaks into the top 10 worldwide, too.
Smoking has actually declined over the past decade, while “metabolic risks”—obesity, high blood sugar, high blood pressure, high cholesterol—have gone in the other direction. Together those four were responsible for 26.9 million deaths in 2019 and nearly 20 percent of what the GBD report describes as health loss worldwide. That’s loss of life, but also loss of healthy years at the end of life, a statistic captured by death-adjusted life years, or DALYs. That number has gone up 50 percent since 1990.
Of course, as the GBD authors note, these effects vary geographically. The nutritional and tobacco effects are worse in Asia, Europe, and Latin America. Their Oceania group suffers most from malnutrition and air pollution; in sub-Saharan Africa, the worst things are malnutrition and lack of access to clean water and sanitation. “It shows a global crisis of chronic diseases,” says Ali Mokdad, a professor of health metrics sciences at IHME and one of the GBD’s authors, “and quite honestly a failure of our public health system to deal with these rapidly increasing risk factors that are preventable, that are making our population sick, killing a lot of us, and causing a lot of health emergencies.”
But the really interesting breakdown is along economic lines. Lower-income countries are actually doing a better job of reducing DALYs than middle- and high-income ones like the US. And the burden of illness in the US falls disproportionately on poor people and people who aren’t white. “In the United States, when you compare us to the rest of our peers—the countries who are very rich, similar to us—we do poorly,” Mokdad says. “Very poorly.”