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IHME IMPACT INSTITUTE FOR HEALTH METRICS AND EVALUATION

ISSUE 4 / FALL 2011

BENEATH THE SURFACE INSIDE THIS ISSUE

2 The Director’s View

Dr. Christopher Murray underlines the importance of research such as the Global Burden of Disease Study 2010

3 Deep Dive

IHME researchers explore the latest trends in breast and cervical cancer around the world

4 Connections

New fellows and faculty join IHME; partnerships pursue progress in health equity

7 Innovations

IHME’s recently published work examines HIV prevention, changing life expectancies, malaria reduction, and more

10 Out and About

Discover where IHME has been in the last couple of months in this roundup of events

11 Ripple Effect

HME research prompts action from public health officials

For more information, please visit IHME’s website: www.healthmetricsandevaluation.org or contact us at comms@healthmetricsandevaluation.org or +1-206-897-2800 ©Copyright IHME 2011

New data and methods enable more comprehensive picture of Millennium Development Goal progress When 189 countries adopted the Millennium Development Goals (MDGs) in 2000, to reduce needless deaths among mothers and children among the goals, targets that seemed ambitious for many are now within reach. IHME’s latest research on maternal and child mortality trends suggests countries are approaching health-related goals for women and children at a faster pace than they were previously. IHME used a welter of updated data—and new methods for analyzing country-level data from the past few decades—and found some encouraging news: More than half of the countries in the world are lowering the death rates of children under age 5, and the death rate of women due to complications during pregnancy and childbirth has also been decreasing. Most notably, improvement in both of these areas is happening at an accelerated pace. The study, conducted by IHME with the University of Queensland, Australia, assessed progress on MDG 4, which calls for the death rate of children under age 5 to be reduced by two-thirds by 2015, and MDG 5, with the goal of reducing by threequarters the ratio of maternal deaths, which is the number of women per 100,000 live births who die as a result of child-bearing and obstetric complications. Policymakers have been concerned in recent years about slow progress in saving women’s lives and improving child survival. Researchers relied on new data that allow for detailed tracking of progress over time: surveys, censuses, vital registration, and verbal autopsies, or interviews with family members to determine a relative’s cause

of death in places lacking vital registration information. Their detailed analysis showed that 31 countries appear to be on track to reduce their rate of child mortality by twothirds, while 13 will meet the goal of reducing the maternal death ratio by two-thirds by the target date. Of those countries, nine are on target to achieve both goals: China, Egypt, Iran, Libya, Maldives, Mongolia, Peru, Syria, and Tunisia. Dr. Alan Lopez, Head of the University of Queensland School of Population Health and one of the report’s co-authors, emphasized that other countries can learn from this progress. Another author of the study, Dr. Haidong Wang, Assistant Professor of Global Health at IHME, agreed, stating that the richness of the data helps to “identify where bottlenecks in implementation may be occurring.” Wang noted that closer attention to prenatal and postnatal care and safe motherhood practices

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THE DIRECTOR’S VIEW

With the Fourth High Level Forum on Aid Effectiveness wrapping up last week in Busan, South Korea, issues of tracking and assessing the impact of development assistance for health were brought to the forefront. IHME is dedicated to informing these issues by providing rigorous measurement of health problems and evaluating the strategies used to address them. Our researchers are currently involved in a number of projects that will help determine where we are making progress and where the gaps are in improving health around the world. Our recent research evaluation of Avahan, an HIV/AIDS prevention program in India, is just one example. The study showed that Avahan, which targeted high-risk groups, averted an estimated 100,000 HIV infections in the broader population between 2003 and 2008. This study was the first of its kind showing the effectiveness of such a large-scale intervention. Other work underway to help evaluate effectiveness is the Global Burden of Diseases, Injuries, and Risk Factors Study 2010. This groundbreaking project, which IHME is leading, involves 800 researchers worldwide and is the first major effort since the GBD Study 1990 to carry out a complete systematic assessment of the data on all diseases and injuries, producing comprehensive and comparable estimates of the burden of diseases, injuries, and risk factors for the years 1990, 2005, and 2010. The results of the study are scheduled for release in spring 2012 and will help policymakers understand how

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BENEATH THE SURFACE (continued)

well the world is doing in addressing health problems and evaluating the effectiveness of aid.

is needed. Too many children are dying needlessly, with an estimated 7.2 million under-5 child deaths in 2011.

With these new GBD estimates and IHME’s research, such as our estimates on countries’ progress toward meeting international targets for saving the lives of mothers and children, we continue working toward our goals. In this issue of IHME Impact, you can read more about our latest research.

By building their analysis on longitudinal data covering the past few decades (“longitudinal” meaning to track the same type of information on the same subjects at multiple points in time), the researchers showed – for the first time – that 106 countries were able to make faster progress in the area of maternal and child health over the last 10 years as compared to the rate between 1990 and 2000. “Overall, the data tell us that progress is speeding up in most countries,” Wang said.

1. In Beneath the Surface, we look at new methods of estimating progress toward Millennium Development Goals for deaths of mothers and children. 2. Deep Dive tells how IHME researchers figured out a new and better way to capture the number of women developing – and dying from – breast and cervical cancer, showing important trends in the developing world. 3. In Connections, we introduce our new cohorts of Post-Bachelor Fellows and Post-Graduate Fellows and highlight some of our recent collaborations with other global organizations. 4. Innovations summarizes our most recent research, including our work on verbal autopsy analysis, which makes identifying deaths in countries without vital registration systems faster, cheaper, and more reliable than what exists now. 5. Out and About describes selected events where IHME shared recent research and received awards. 6. In Ripple Effect, we look at how IHME’s research on US county-level life expectancy has spurred policy action from health officials at the local level. I hope you enjoy this issue, and on behalf of the rest of the IHME team, I wish you a happy holiday season. Sincerely,

IHME’s analysis also suggests that MDG targets will continue to remain out of reach for some countries, especially in sub-Saharan Africa and South Asia, which account for the majority of child deaths. No country in the poorest parts of Africa is on course to meet either MDG 4 or 5. Globally, India had the highest percentage of under-5 deaths at 23%, and Nigeria at 12.4%. The partnership effort by global researchers has enabled a more accurate, long-term picture of MDG progress. Policymakers are now able to drill down to see where improvements in implementation can be made. The picture the data show is that progress is underway; yet several countries still have a long way to go if they are to meet their targets by 2015. The study, titled “Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis,” was published in The Lancet in September 2011 and was cited by media such as the BBC, Agence France-Presse, and the New York Times in the run-up to the United Nations High-Level Meeting on NonCommunicable Diseases.

Christopher J.L. Murray Institute Director and Professor of Global Health

Laura Cooley, IHME Communications Office

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DEEP DIVE

More women are dying from breast and cervical cancer at a younger age in developing countries At first the task seemed daunting. Some sources of data were either unreliable or nonexistent. Getting a handle on the impact of breast cancer and cervical cancer across the world, especially in developing countries, was going to be a challenge. Researchers suspected that more women were dying from these two deadly diseases, but it took a concerted and rigorous team effort by IHME and the University of Queensland, Australia, to confirm it. IHME and the Australian university’s researchers collected data from vital registries around the world and used verbal autopsies, among other information, to help them formulate a global portrait of cancer incidence and mortality. In countries that lacked vital registration systems, it helped immensely to elicit data from verbal autopsies, involving interviews with relatives of deceased women to determine the cause of death.

Komen founder and CEO Nancy G. Brinker with international breast cancer survivors at the 2009 Race for the Cure.

By looking at a host of relevant data, including age, they found that the number of women dying from breast cancer and cervical cancer at a younger age is on the rise in the developing world. Of the total cases of breast cancer worldwide in 2010, over half were in the developing world: 23% of the cases were in women aged www.healthmetricsandevaluation.org

15 to 49, while 28% were in women over 50. By contrast, women in the developed world have seen a steady decline in cases of breast cancer, with the total number of cases dropping over the last 20 years to 39% among women over 50, and to 10% among women aged 15 to 49. “This confirms what many had thought was a trend,” said Dr. Rafael Lozano, Professor of Global Health at IHME and one of the co-authors of the study “Breast and cervical cancer in 187 countries between 1980 and 2010: a systematic analysis,” published in The Lancet. “The burden of breast cancer and cervical cancer is shifting to countries in Africa and Asia,” he said. Lozano noted that these two diseases are rapidly becoming the most deadly diseases for women in the developing world. The joint study of the 187 countries was released at the same time as a major analysis IHME prepared with funding from Susan G. Komen for the Cure® entitled, The Challenge Ahead: Progress and Setbacks in Breast and Cervical Cancer.

mortality in women of reproductive age in developing countries. Our research was unique in allowing us to correct for some of the many cancer deaths that were previously either inaccurately coded or inappropriately categorized.” The study shows a sobering picture of increased risk of a woman developing breast cancer before age 50 in the developing world, and the ongoing challenges to all women battling cervical cancer, despite some prevention and treatment gains. The hope among researchers and policymakers alike is that by having a better understanding of the severity of these two diseases, better planning and prevention efforts will result, so that detection and treatment can effectively take on this global challenge. Laura Cooley, IHME Communications Office

Based on current trends of breast and cervical cancer, Dr. Mohsen Naghavi, Associate Professor of Global Health at IHME and a co-author of the study, said, “These diseases may soon replace maternal causes as a critical driver of

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CONNECTIONS

IHME welcomes new fellows and faculty, congratulates graduates

Photos by Corwyn Ellison

IHME welcomed new cohorts to our PostBachelor Fellowship and Post-Graduate Fellowship programs in fall 2011. We extend best wishes to the Master of Public Health graduates, who were with IHME from 2008 to 2011, as they embark on their careers. Three new research faculty also joined IHME during the year.

Post-Bachelor Fellows

(pictured above, left to right): Greg Freedman is from Atlanta, GA, and received his Bachelor of Arts in Economics from Northwestern University. He is on the US County Performance research team. Emily Dansereau is from Seattle, WA, and received her Bachelor of Arts in Human Biology from Stanford University. She is on the Health Service Delivery Constraints research team. Benjamin Brooks is from Silver Spring, MD, and earned his Bachelor of Science in Biomedical Engineering from the University of Virginia. He is on the Health Financing research team. K. Ellicott Colson is from Dorset, VT, and received her Bachelor of Arts in Mathematics and Global Health from Tufts University. She is working on the Inter-American Development Bank project. Peter Serina is from Denver, CO, and received his Bachelor of Arts in Biology from Colby College. He is on the Verbal Autopsy research team.

Post-Bachelor Fellows

Post-Graduate Fellows

Rebecca Engell is from Longmeadow, MA, and earned her Bachelor of Arts in Anthropology at Mount Holyoke College. She is on the US County Performance research team. Ruben Conner is from Seattle, WA, and received his Bachelor of Arts in Economics and Bachelor of Arts in Public Health from the University of Washington. He is on the Monitoring Costs research team.

Gulnoza Usmanova is from Tashkent, Uzbekistan, and earned her Master of Public Health from Braun School of Public Health & Community Medicine at the Hebrew University of Jerusalem, Israel. She received her Master of Health Administration from Tashkent Medical Academy. She is on the Integrated Surveillance Systems research team.

Hannah Peterson is from Sycamore, IL, and earned her Bachelor of Science in Physics from the Rensselaer Polytechnic Institute. She is on the Optimal Resource Allocation research team.

Rouselle Lavado is from Manila, Philippines, and is affiliated with the Philippine Institute for Development Studies. She earned her master’s degree and PhD in Public Policy at Hitotsubashi University in Tokyo, Japan. She is with the Health Financing Team.

Ian Bolliger is from Issaquah, WA, and received his Bachelor of Arts in Applied Mathematics at Harvard University. At IHME, he is working on the Monitoring Disparities in Chronic Conditions Study. Carly Levitz is from Iowa City, IA, and received her Bachelor of Arts in Sociology from the University of Pennsylvania. She is on the Demographics research team.

Post-Graduate Fellows (pictured above, left to right): Emelda Okiro is from Nairobi, Kenya, and earned her PhD in Epidemiology from the Open University (UK) under the KEMBRIWellcome Trust Research Programme Kilifi, Kenya, in collaboration with the University of Warwick. She is on the Demographics research team.

Anne Gasasira is from Kampala, Uganda, and earned her PhD in Epidemiology at the University of California, Berkeley. She is part of the Impact Evaluations research team.

For more information about the Institute’s fellowship programs, please visit: PBF program: http://www.healthmetrics andevaluation.org/what/training/fellowships/pbfs/pbf.html PGF program: http://www.healthmetrics andevaluation.org/what/training/fellowships/pgfs/pgf.html

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CONNECTIONS (continued)

Alison Levin-Rector was on the Mortality research team. She focused on improving methods for estimating population health status. Alison is a co-author of the paper “Assessment of population-level effect of Avahan, an HIV-prevention initiative in India,” published by The Lancet.

Faculty additions Michael Hanlon is an IHME Lecturer researching the cost structures of different health service delivery systems. Prior to his academic career, Dr. Hanlon was one of Amazon.com’s first employees, working as a software developer among a variety of duties. Photo by Corwyn Ellison

Master of Public Health graduates (pictured above, left to right): Jacob Marcus was a member of the Mortality research team and researched how countries make progress toward one of the Millennium Development Goals of reducing the mortality of children under age 5. He is a co-author of the paper “Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970– 2010: a systematic analysis of progress towards Millennium Development Goal 4,” published by The Lancet. Krycia Cowling was on IHME’s Social Determinants research team. She examined education as a determinant of health and quantified wealth inequality using permanent income. Krycia is a co-author of the paper “Increased educational attainment and its effect on child mortality in 175 countries between 1970 and 2009: a systematic analysis,” published in The Lancet. Now in Delhi, India, Krycia is working for IHME and the Public Health Foundation of India, researching mortality and causes of death at the national and subnational levels in India. Nancy Fullman focused on malaria while at IHME, tracking intervention coverage, quantifying intervention effectiveness, and evaluating malaria control policy in Zambia. She is a co-author of the paper “Net benefits: a multicountry analysis of www.healthmetricsandevaluation.org

Master of Public Health graduates

observational data examining associations between insecticide-treated mosquito nets and health outcomes” published by PLoS Medicine. Kyle Foreman worked with the Causes of Death research team, creating a model to determine the number of people who die every year from a wide variety of causes. He is a co-author of the paper “Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis,” published by The Lancet. Kyle is pursuing a PhD at Imperial College in London. Matthew Schneider was part of the Effective Coverage, Impact Evaluation, and Health Financing research teams. He researched the vaccination of children for measles as well as the effect that external health aid has on government spending for health. Matthew is a co-author of “Public financing of health in developing countries: a cross-national systematic analysis,” published by The Lancet. Rebecca Myerson was a member of the Effective Coverage research team, focusing on birth care in developing countries. She is a co-author of the paper “Sceptical optimism: a new take on global health data,” published by The Lancet. Rebecca has entered the PhD program at University of Chicago’s Harris School of Public Policy.

Bernardo Hernández Prado is a Clinical Associate Professor working with IHME’s Integrated Surveillance Systems research team to find ways to improve health system performance and build capacity in Mesoamerica. Prior to his work with IHME, Dr. Hernández Prado had a long and distinguished career on the faculty of the National Institute of Public Health in Cuernavaca, Mexico. Santosh Kumar is an IHME Lecturer and is part of the Impact Evaluations and Health Service Delivery Constraints research teams, where he identifies the supplyside and demand-side barriers to effective health care in developing countries. Before joining the faculty at IHME, Dr. Kumar was a post-doctoral research fellow at the Harvard Center for Population and Development Studies.

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CONNECTIONS (continued)

IHME collaborates with global health partners on improving health equity Inter-American Development Bank – Salud Mesoamérica 2015

UNICEF – Access, Bottlenecks, Costs, and Equity project

For the Salud Mesoamérica 2015 initiative, IHME is providing technical assistance to the Inter-American Development Bank, the largest source of development financing for Latin America and the Caribbean. The initiative’s goal is to reduce health inequities affecting the poorest populations in Central America and Southern Mexico. Salud Mesoamérica 2015 also supports the efforts of the governments of this region to achieve the health Millennium Development Goals. Additional partners are the Bill & Melinda Gates Foundation, the Carlos Slim Health Institute, and the government of Spain.

IHME and UNICEF are collaborating on the Access, Bottlenecks, Costs, and Equity (ABCE) project. ABCE is a multicountry and multipronged initiative designed to provide high-quality cost and cost-effectiveness evidence that will promote the development of equitable, effective, and efficient systems for health care delivery around the world. ABCE’s results and analyses will assist policymakers, development partners, and national stakeholders as they seek to reduce the barriers to health care access, increase health service coverage, and facilitate more equitable health outcomes.

As part of this collaboration, IHME developed household and health facility surveys covering key indicators pertaining to reproductive health, child nutrition, and immunization. Key indicators include coverage of contraceptives, antenatal and postnatal care access for women and newborns, access to skilled-birth attendants in an institutional setting, coverage of MMR vaccination in children ages 1 to 3, and quality assessments of several medical interventions related to delivery, antenatal and postnatal care, and immunization. IHME researchers programmed multilingual surveys and performed real-time quality checks and baseline analyses of data from 3,800 households and 65 health facilities in El Salvador. Using the data from the surveys and other sources, the researchers helped set health targets for Salud Mesoamérica 2015. IHME researchers are finalizing the report of baseline results from El Salvador. The Inter-American Development Bank plans to launch similar baseline studies in southern Mexico, Guatemala, Belize, Honduras, Nicaragua, Costa Rica, and Panama in 2012 and follow up evaluations at 36 and 54 months after completion of the baseline studies.

ABCE will be conducted in approximately 15 countries, with several already underway, including Ghana. In Ghana, IHME is partnering with UNICEF and Ghanaian health institutions to implement the study. A major component includes primary data collection from over 200 health facilities to create a comprehensive picture of the cost of health service delivery within Ghana, providing analyses at the facility, district, and national level. This data will be combined and analyzed with all ABCE countries to explain the causes of varying costs of health care around the world. As another component of ABCE, researchers are employing IHME’s novel small-area estimation techniques to produce district-level estimates of skilled birth attendance at childbirth. These estimates are key for policymakers attempting to precisely allocate resources within the country to decrease maternal and infant deaths.

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INNOVATIONS

IHME’s recently published work New method improves evidence for underlying cause of death from heart failure Research by IHME demonstrated how the quality of mortality data can be improved by redistributing deaths attributed to heart failure to their underlying causes of death. A newly developed method of redistributing deaths due to heart failure provides better evidence on a major cause of death and ultimately will enable policymakers to make more informed decisions regarding priority health interventions and resource allocation, and thus hone the global response to the rising cardiovascular epidemic. Innovation: High-quality, cause-specific mortality data are often not available for heart failure, as deaths due to heart failure are frequently improperly coded. Because prevention, detection, and treatment efforts differ for different underlying causes of heart failure, it is important to know the root causes of the heart failure deaths in a population. Researchers developed a method to redistribute deaths attributed to heart failure to their underlying causes of death according to statistically derived redistribution proportions. This new method reassigned a majority of the deaths coded to heart failure to ischemic heart disease, a disease characterized by reduced blood supply to the heart, and the research shows that the cardiovascular disease epidemic is growing in low- and middle-income countries, where public health efforts have historically focused on infectious diseases. Ahern RM, Lozano R, Naghavi M, Foreman K, Gakidou E, Murray CJL. Improving the public health utility of global cardiovascular mortality data: the rise of ischemic heart disease. Population Health Metrics, March 2011

New approach can more accurately estimate HIV/AIDS deaths in South Africa A study from IHME found that more than 90% of HIV/AIDS deaths in South Africa from 1996 to 2006 were incorrectly attributed to other causes. The researchers

suggest that the empirical method they used could improve data quality and help to accurately estimate HIV/AIDS mortality in South Africa, where HIV/AIDS is highly prevalent. Innovation: Studying HIV mortality using data from South Africa’s vital registration system is difficult because the data are often based on inaccurate cause of death coding. Researchers developed a way to quantify deaths from HIV/AIDS that are wrongly attributed to other causes in South Africa’s death registration data and to adjust for this bias. This new approach could be transferable to other settings with moderate-to-large epidemics of HIV infection where death registration data may not accurately reflect HIV/AIDS mortality. Birnbaum JK, Murray CJL, Lozano R. Exposing misclassified HIV/AIDS deaths in South Africa. Bulletin of the World Health Organization, April 2011

Global economic downturn jeopardizes funding for health programs The global economic crisis that began in 2008 has raised serious concerns about the ability of developing countries to meet targets for improving their populations’ health, and about the ability of developed countries to meet their commitments to fund health programs in developing countries. IHME researchers indicate that this uncertainty underscores the importance of tracking spending on global health, to ensure resources are directed efficiently to the world’s most pressing health issues. Murray CJL, Anderson B, Burstein R, LeachKemon K, Schneider M, Tardif A, Zhang R. Development assistance for health: trends and prospects. The Lancet, July 2011

Life expectancy varies widely among US counties The most current county-level analysis by IHME reveals large disparities nationwide. Women fare worse than men, and people in Appalachia, the Deep South, and Northern Texas live the shortest lives.

Researchers found that while people in Japan, Canada, and other nations are enjoying significant gains in life expectancy every year, most counties within the United States are falling behind. Innovation: The researchers used newly released mortality data to compute life expectancies separately for each sex, for all races combined, for whites, and for blacks by county from 1987 to 2007. To compare mortality in US counties with the rest of the world, researchers compared county life expectancy to an international frontier time series, defined as the average life expectancy of the 10 countries with the best life expectancies in the world. These data, which have never been available at the county level, show that the change in life expectancy is so uneven that within some states there is now a decade difference between the counties with the longest lives and those with the shortest. Kulkarni SC, Levin-Rector A, Ezzati M, Murray CJL. Falling behind: life expectancy in US counties from 2000 to 2007 in an international context. Population Health Metrics, June 2011

After decades of improvement, the pace of declining mortality slows in Japan IHME observed that while Japan experienced huge reductions in mortality in the 1950s and 1960s, since 1995 Japan’s pace of declining mortality for men and women has fallen behind several high-income countries, such as Sweden. There may be many explanations for Japan’s worsening performance relative to other countries, including high tobacco consumption, a modest rise in body mass index, and high and rising rates of suicide. Another reason could be that while Japan has a universal health care system, the quality of the care delivered might be low. Japan’s aging population is among the challenges the country faces. Murray CJL. Why is Japanese life expectancy so high? The Lancet, August 2011

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INNOVATIONS (continued)

Fast, affordable methods help countries better identify causes of death in populations

Insecticide-treated bed nets significantly reduce child mortality in sub-Saharan Africa

IHME researchers co-authored nine papers published in the Population Health Metrics thematic series, “Verbal autopsy: innovations, applications, opportunities.” Identifying the causes of death in a population is critical to inform planning, resource allocation, program implementation, monitoring, and evaluation. Since many countries lack complete vital registration systems with medical certification of deaths, cause of death information is often missing. Verbal autopsy, in which a trained interviewer uses a questionnaire to collect information about the signs, symptoms, and demographic characteristics of the deceased from individuals who knew them, can be used to determine individuals’ causes of death and causespecific mortality fractions in areas without complete vital registration systems.

An IHME study, the most comprehensive analysis to date, shows as bed net distribution efforts have rapidly scaled up in sub-Saharan Africa deaths from malaria have declined significantly. Children who live in households that own an insecticidetreated mosquito net are less likely to be infected with malaria and less likely to die from the disease, according to an IHME study. Ownership of at least one ITN was associated with a 23% reduction in mortality in children under the age of 5.

Innovation: Methods used to analyze interviews and assign a cause of death include physician certification, whereby physicians review each questionnaire to assign a cause, and new automated methods where the VA interview is conducted on a hand-held device and a cause of death is automatically generated at the end of the interview. Until now, there has been no clear evidence as to how accurate the methods were, and some methods were costly and time consuming. One new method developed by IHME, the Random Forest method, performed better than physician review, which traditionally has been seen as the gold standard, and is also cheaper and provides faster results. The Random Forest method can be used on a hand-held device with the cause of death automatically generated at the conclusion of the interview, in contrast to physician review, in which a team of physicians may take days to complete an analysis. The IHME authors of VA papers are Atkinson C, Birnbaum JK, Campbell B, Dandona L, Flaxman AD, Freeman MK, Green S, Hernandez B, James SL, Lopez AD, Lozano R, Murray CJL, Naghavi M, Ohno SL, Vahdatpour A. The papers are published in “Verbal autopsy: innovations, applications, opportunities”. Population Health Metrics, August 2011. www.healthmetricsandevaluation.org

Innovation: Previous studies examining the relationship between bed nets and health outcomes have been limited to a few countries and were from randomized controlled trials, which do not reflect real world conditions. In this study, researchers analyzed the association between household ownership of bed nets and health outcomes by using 29 demographic and health surveys and malaria indicator surveys routinely collected since 2000 in 22 sub-Saharan African countries. In order to show only the effects of the bed nets, they controlled for a wide range of potential confounders, including mother’s education level, wealth of the household, and wet or dry season. Lim SS, Fullman N, Stokes A, Ravishankar N, Masiye F, Murray CJL, Gakidou E. Net benefits: a multicountry analysis of observational data examining associations between insecticide-treated mosquito nets and health outcomes. PLoS Medicine, September 2011

More women die of breast and cervical cancer at a younger age in developing countries Researchers from IHME analyzed data on mortality and incidence for breast and cervical cancer, showing that while more women developed breast or cervical cancer in 2010 than in 1980, the probability that women will die from either disease has decreased. Coinciding with the study release, IHME published a policy report, which provides global, regional, and country data for cases, deaths, and risks over the past three decades.

Innovation: In order to estimate mortality from and incidence of breast and cervical cancer, researchers collected data on mortality and incidence from cancer registries and vital registration systems between 1980 and 2010. IHME methods differ from other published studies, as IHME researchers used methods to fix inaccurately coded or ill-defined deaths, assigning deaths to the correct causes. For countries that lack vital registration systems, IHME used data from verbal autopsies to identify deaths from breast and cervical cancer. Forouzanfar MH, Foreman KJ, Delossantos AM, Lozano R, Lopez AD, Murray CJL, Naghavi M. Breast and cervical cancer in 187 countries between 1980 and 2010: a systematic analysis. The Lancet, September 2011. Institute for Health Metrics and Evaluation. The Challenge Ahead: Progress and Setbacks in Breast and Cervical Cancer. Seattle, WA: IHME, 2011.

Countries worldwide are saving mothers’ and children’s lives at a faster pace A recent study by IHME researchers found the international efforts to address maternal and child health challenges appear to be working, yet few countries will meet Millennium Development Goals for maternal mortality and child mortality. The data showed that 31 developing countries will achieve Millennium Development Goal (MDG) 4, which calls for a two-thirds reduction in the child mortality rate between 1990 and 2015, and 13 developing countries will achieve MDG 5, which calls for a three-fourths reduction in the maternal mortality ratio over the same period. Innovation: For these new estimates of child and maternal mortality, researchers used the most recent data and advancements in statistical tools to provide policymakers with more precise information as the world intensifies efforts to achieve international targets for maternal and child health. The authors updated research published by IHME in 2010, using additional surveys, censuses, and vital registration and verbal autopsy data. Child mortality estimates were Continued on page 9

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INNOVATIONS (continued)

updated with new data for 163 countries. For maternal mortality, an additional 1,000 site-years of data were included in the estimates. Lozano R, Wang H, Foreman KJ, Rajaratnam JK, Naghavi M, Marcus JR, Dwyer-Lindgren L, Lofgren KT, Phillips D, Atkinson C, Lopez AD, Murray CJL. Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis. The Lancet, September 2011

Ambitious HIV/AIDS prevention program reduces infections and deaths in India Avahan, a large-scale public health program aimed at preventing HIV in India, averted an estimated 100,000 HIV infections between 2003 and 2008, IHME researchers found in a recent study. The program increased prevention interventions in high-risk groups. Understanding the effect of large-scale HIV prevention programs like Avahan is critical, as research on the effect of such initiatives is sparse. Innovation: Previous research showed that Avahan has successfully scaled up interventions to prevent HIV and that there was a subsequent decline in HIV rates among sex workers in some parts of Karnataka, but no previous study has measured the effect of the program on the general population. Under ideal conditions, a prospective evaluation of the impact of Avahan in the general population would have been initiated simultaneously with the program, allowing for comparison between interventions and control districts with people not receiving the Avahan interventions. Because this evaluation was not built into the program, the researchers devised a way to estimate the effect of Avahan on the general public through an observational study.

High blood pressure a growing concern in a changing Iranian population Among five modifiable risk factors affecting health in Iran, high blood pressure was the leading cause of death and shorter life expectancy among both men and women. An IHME study demonstrated the need for interventions to manage blood pressure, as well as other lifestyle risk factors, such as smoking. Innovation: The authors conducted a population-level comparative risk assessment for five modifiable risk factors to estimate the number of deaths that would have been prevented if past and current exposure to these risk factors were reduced to a hypothetical alternative and optimal distribution, as well as the life expectancy lost due to these risk factors. Means and standard deviations for the metabolic risk factors were estimated with data from the Non-Communicable Disease Surveillance Survey, which includes nationally and provincially representative data. Since death registration data are often incomplete or inaccurately coded, the authors used new death distribution methods to correct for incompleteness and logistic regression methods to estimate the true underlying medical causes of deaths. Farzadfar F, Danaei G, Namdaritabar H, Rajaratnam JK, Marcus JR, Khosravi A, Alikhani S, Murray CJL, Ezzati M. National and subnational mortality effects of metabolic risk factors and smoking in Iran: a comparative risk assessment. Population Health Metrics, October 2011

Ng M, Gakidou E, Levin-Rector A, Khera A, Murray CJL, Dandona L. Assessment of population-level effect of Avahan, an HIV-prevention initiative in India. The Lancet, October 2011

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OUT AND ABOUT

IHME shares its research innovations in global health research at international conferences, forums, and seminars. Over the past several of months, we have attracted attention and awards. Following is a selection of events in which IHME participated.

Graduate Fellow Dr. Tom Achoki shared the initial findings on maternal and child health intervention coverage in the country to provide policymakers with the most up-to-date information on trends in the provinces and districts of Zambia.

Results of the Population Health Metrics Research Consortium study shared in Mexico In November, IHME professors Dr. Rafael Lozano and Dr. Bernardo Hernández Prado led three seminars summarizing the principal results of the Population Health Metrics Research Consortium Mexico Study. Held in Mexico City and Cuernavaca, these seminars brought together collaborators on the study and opened discussion of future cooperative initiatives to develop better instruments and methods for measuring population health, particularly in resource-poor settings.

Participation at the Bill & Melinda Gates Foundation 2011 Malaria Forum

Year one report in Zambia on the Malaria Control Policy Assessment project Researchers from IHME and the University of Zambia reported the first year’s findings in the Malaria Control Policy Assessment project to local government officials, academics, and non-profit organizations in Lusaka, Zambia, in August. IHME Post-

www.healthmetricsandevaluation.org

At the 8th World Congress in Health Economics, held in July in Toronto, IHME Lecturer Dr. Michael Hanlon described how training in using machine learning models – the way computers acquire knowledge – can allow researchers to generate better predictions of mortality and, ultimately, more accurate metrics around hospitals’ performance. IHME’s research on the cost structures of different health service delivery systems helps policymakers reach informed decisions on funding critical health initiatives and allocating domestic resources to health.

Award from the American Association for Public Opinion Research

IHME Post-Graduate Fellow Tom Achoki, speaking to policymakers in Lusaka, Zambia.

IHME presented the Institute’s latest malaria research in the Malaria Forum entitled “Optimism and Urgency,” hosted by the Bill & Melinda Gates Foundation in October in Seattle, WA. Dr. Christopher Murray was among the top global health leaders participating on the “Estimating Malaria Burden and Impact” panel. IHME Post-Graduate Fellow Dr. Tom Achoki presented a poster with findings from the first phase of IHME’s Malaria Control Policy Assessment project in Zambia.

Speaking at the 8th World Congress in Health Economics

Workshops offered for Ministry of Health in Brazil IHME Professor Dr. Ali Mokdad and PostGraduate Fellow Dr. Casey Olives spoke at the Ministry of Health in Brasilia, Brazil, in August. Dr. Olives led a workshop on small-area estimation methods currently being used in the US and presented estimates of infant mortality for Brazilian municipalities. Dr. Mokdad led a two-day workshop on the Access, Bottlenecks, Costs, and Equity project, a multicountry and multipronged project designed to provide quality evidence for improving the equity and cost effectiveness of health systems. Dr. Mokdad discussed the project’s implementation in Brazil, including identifying potential data sources.

IHME professor Dr. Ali Mokdad received the prestigious 2011 Warren J. Mitofsky Innovators Award from the American Association for Public Opinion Research. The honor was in recognition for developing an effective method of randomly surveying populations by using residential mail delivery locations as an alternative to random-digit dialing. Dr. Mokdad first helped develop this innovative method while working at the US Centers for Disease Control and Prevention, and has continued to improve the method through his work at IHME.

Special Achievement award for GIS tool In July IHME received a Special Achievement in GIS (SAG) Award at the 2011 Esri International User Conference in San Diego. The award recognizes IHME’s development of its GIS tool, which maps global health indicators and trends in mortality, disease, health financing, and other factors across countries and animates the trends over time. IHME was one of the recipients selected from a pool of more than 300,000 organizations worldwide. Peter Speyer, IHME’s Director for Data Development, accepted the award on IHME’s behalf. IHME IMPACT / FALL 2011 10


RIPPLE EFFECT

US county life expectancy research spurs action by public health officials IHME’s study “Falling behind: life expectancy in US counties from 2000 to 2007 in an international context,” published in June in Population Health Metrics, received media coverage in all 50 states, from the Washington Post to Ruby Radio in Elko, Nevada. The research spawned commentaries from policy advocates and health leaders, and in some cases, has spurred policy action from county officials. More counties in Missouri have shown slower improvement, no improvement, or an actual decline in life expectancy in the most recent decade. In response to this, the Missouri Center for Local Public Health Services, part of the Missouri Department of Health and Senior Services, consulted with IHME on how to best use the data in the research paper, and sent county-level information to public health offices in every county in Missouri. In Cowlitz County, Washington, county health experts set up a task force to improve life expectancy in the county after these data were released from IHME, including the fact that women in Croatia can expect to live longer, on average, than Cowlitz County females. Because the researchers point to high rates of obesity, tobacco use, and other preventable risk factors for an early death as the leading drivers of the gap between life expectancy in the US and other nations, counties are scrutinizing their populations to determine how best to improve life expectancies. For example, in Cowlitz County, research shows that 36% of adults are obese, compared to 26% statewide. In response, county health officials are working to ensure more access to parks and trails and make more healthy food options available to their populations.

The study authors hoped that efforts like those in Missouri and Washington would develop from their research. “Health changes can only occur in a profound way if local solutions are implemented,” said Dr. Ali Mokdad, the head of IHME’s US County Performance team. “We

are providing numbers for counties so they can have a benchmark to monitor progress over time and then to dive deep into the local community to understand the particular dynamics that are driving these trends.” Kate Muller, IHME Communications Office

www.healthmetricsandevaluation.org

IHME IMPACT / FALL 2011 11

IHME Impact Fall/Winter 2011  

In IHME Impact Fall 2011, we share our latest research and projects that are helping to determine where we are making progress and where the...

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