Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

Valorisation des petits bois rouges en Région wallonne

La forêt wallonne offre aujourd'hui une quantité limitée mais cependant significative de bois rouges de petites dimensions. Malheureusement, ceux-ci ne trouvent généralement pas acquéreur à des prix raisonnables. Cet état de fait tient à une série de griefs, justifiés ou non, attribués à ces produits et sur lesquels nous souhaitons nous arrêter ici

Memory Fragmentation from Below and Beyond the State: Uses of the Past in Conflict and Post-Conflict Settings

This volume suggests a model of collective memory that distinguishes between two conceptual logics of memory fragmentation, vertical fragmentation and horizontal fragmentation. It offers a series of case studies of conflict and post-conflict collective memory, shedding light on the ways various actors participate in the production, dissemination and contestation of memory discourses. With attention to the characteristics of both vertical and horizontal memory fragmentation, the book addresses the plurality of diverging, and often conflicting, memory discourses that are produced within the public sphere of a given community. It analyses the juxtaposition, tensions and interactions between narratives produced beyond or below the central state, often transcending national boundaries. The book is structured according to the type of actors involved in a memory fragmentation process. It explores how states have been trying to produce and impose memory discourses on civil societies, sometimes even against the experiences of their own citizens, and how this process has led to horizontal and vertical memory fragmentation. Furthermore, it considers the attempts by states’ representatives to reassert control of national memory discourses and the subsequent resistances they face. As such, this volume will appeal to sociology and political science scholars interested in memory studies in post-conflict societies

Global workshops in midwifery competency-based educational methodologies: lessons learned

The Lancet Series on Midwifery and The State of the World's Midwifery 2014 called on countries to expand the midwifery workforce as a key strategy to improve the health of women and newborns and lower maternal and newborn morbidity and mortality. Well-prepared midwife teachers and preceptors are required to prepare midwives to provide competent, high quality care for women and childbearing families. This article describes the design of competency-based education (CBE) capacity development workshops building on the International Confederation of Midwives' (ICM) essential competencies and education standards, led by eight English-, Spanish-, and French-speaking CBE Master Educators (MEs). Common content and processes used in three English, one Spanish, and one French workshop are briefly described, noting the influence of participants' backgrounds, location, and teacher preferences in modifications to common content. As of December 2016, 30 CBE Master Teachers and 22 CBE Teachers have attended a CBE capacity development workshop and, in turn, have provided CBE continuing education (CE) sessions for more than 300 midwife teachers and preceptors in over 20 countries in the Caribbean, Latin America, and Anglophone and Francophone Africa. Lessons learned are shared along with suggestions for next steps in assessment and evaluation of the use of CBE in midwifery education programs

Health systems factors impacting the integration of midwifery: an evidence-informed framework on strengthening midwifery associations

Introduction Midwifery associations are organisations that represent midwives and the profession of midwifery. They support midwives to reduce maternal and newborn mortality and morbidity by promoting the overall integration of midwifery in health systems. Our objective was to generate a framework for evidence-informed midwifery association strengthening.Methods A critical interpretive synthesis complemented by key informant interviews, focus groups, observations, and document review was used to inform the development of concepts and theory. Three electronic bibliographical databases (CINAHL, EMBASE and MEDLINE) were searched through to 2 September 2020. A coding structure was created to guide the synthesis across the five sources of evidence.Results A total of 1634 records were retrieved through electronic searches and 57 documents were included in the critical interpretive synthesis. Thirty-one (31) key informant interviews and five focus groups were completed including observations (255 pages) and audio recordings. Twenty-four (24) programme documents were reviewed. The resulting theoretical framework outlines the key factors by context, describes the system drivers that impact the sustainability of midwifery associations and identifies the key-enabling elements involved in designing programmes that strengthen midwifery associations.Conclusion Midwifery associations act as the web that holds the profession together and are key to the integration of the profession in health systems, supporting enabling environments and improving gender inequities. Our findings highlight that in order to strengthen midwifery (education, regulation and services), we have to lead with association strengthening. Building strong associations is the foundation necessary to create formal quality midwifery education systems and to support midwifery regulation and accreditation mechanisms

Extracellular Na+ levels regulate formation and activity of the NaX/alpha1-Na+/K+-ATPase complex in neuronal cells.

MnPO neurons play a critical role in hydromineral homeostasis regulation by acting as sensors of extracellular sodium concentration ([Na+]out). The mechanism underlying Na+-sensing involves Na+-flow through the NaX channel, directly regulated by the Na+/K+-ATPase α1-isoform which controls Na+-influx by modulating channel permeability. Together, these two partners form a complex involved in the regulation of intracellular sodium ([Na+]in). Here we aim to determine whether environmental changes in Na+ could actively modulate the NaX/Na+/K+-ATPase complex activity.We investigated the complex activity using patch-clamp recordings from rat MnPO neurons and Neuro2a cells. When the rats were fed with a high-salt-diet, or the [Na+] in the culture medium was increased, the activity of the complex was up-regulated. In contrast, drop in environmental [Na+] decreased the activity of the complex. Interestingly under hypernatremic condition, the colocalization rate and protein level of both partners were up-regulated. Under hyponatremic condition, only NaX protein expression was increased and the level of NaX/Na+/K+-ATPase remained unaltered. This unbalance between NaX and Na+/K+-ATPase pump proportion would induce a bigger portion of Na+/K+-ATPase-control-free NaX channel. Thus we suggest that hypernatremic environment increases NaX/Na+/K+-ATPase α1-isoform activity by increasing the number of both partners and their colocalization rate, whereas hyponatremic environment down-regulates complex activity via a decrease in the relative number of NaX channels controlled by the pump

Stronger together: midwifery twinning between Tanzania and Canada

Abstract This article describes a twinning relationship between the Canadian Association of Midwives (CAM) and the Tanzania Midwives Association (TAMA). It argues that the twinning relationship strengthened both associations. The article briefly reviews the existing literature on professional associations and association strengthening to demonstrate that professional associations are a vital tool for improving the performance of healthcare workers and increasing their capacity to contribute to national and international policy-making. It then suggests that midwifery associations are particularly significant given the frequent professional marginalization of midwives. The article then describes in depth the relationship between CAM and TAMA, highlighting the accomplishments of the twinned partners, and analyzing the factors that contributed to the success of the relationship. The findings demonstrate that twinning can successfully strengthen associations, increasing their ability to support their membership, care for the public, and shape national policy-making. The article therefore proposes twinning as a successful and cost-effective model for encouraging the growth of the midwifery profession

Long-term associations between inflammatory dietary scores in relation to long-term C-reactive protein status measured 12 years later: findings from the Supplementation en Vitamines et Mineraux Antioxydants (SU.VI.MAX) cohort

Chronic low-grade inflammation has been recognised as a key underlying mechanism for several chronic diseases, including cancer and CVD. Nutrition represents a host of key modifiable factors that influence chronic inflammation. Dietary inflammatory scores were developed to assess the inflammatory potential of the diet and have been associated with inflammatory biomarkers in cross-sectional and short-term longitudinal studies. The objective of this study was to investigate the relationship between the dietary inflammatory index (DII), the alternate dietary inflammatory index (ADII) and long-term C-reactive protein (CRP). We also tested age as an effect modifier of this relationship. Participants were selected in the Supplementation en Vitamines et Mineraux Antioxydants study, which included subjects aged 45-60 years old for men and 35-60 years old for women in 1994. Participants with 3 24-h dietary records at baseline and a CRP measurement at the 12-year follow-up evaluation were included in the present study (n 1980). The relationships between the DII and ADII and elevated CRP (>3 mg/l) were investigated using logistic multivariable regression. All analyses were stratified by age (cut-off at median age=50 years old). The overall associations between DII and ADII and long-term CRP were not statistically significant (P-trend across tertiles=016 for DII and 010 for ADII). A quantitative interaction was found between ADII score and age (P=016 for ADII, 036 for DII). In stratified analyses the ADII was significantly prospectively associated with CRP only in younger participants: OR tertile 3 v. tertile 1: 179 (95 % CI 104, 307). Pro-inflammatory diets may have long-term effect on CRP only in younger subjects

Long-term association between the dietary inflammatory index and cognitive functioning: findings from the SU.VI.MAX study

Inflammation is a ubiquitous underlying mechanism of the links between diet and cognitive functioning. No study has yet evaluated the overall inflammatory potential of the diet, using the dietary inflammatory index (DII), in relation to cognitive functioning. In a French cohort of middle-aged adults, we evaluated the association between the DII, assessed in midlife, and cognitive performance evaluated 13 years later. The DII is a literature-derived dietary index developed to determine the inflammatory potential of diet. The DII was estimated at baseline (1994-1996) among 3080 subjects of the SU.VI.MAX (supplementation with antioxidant vitamins and minerals) cohort. Cognitive performance was assessed in 2007-2009 via a battery of standardized neuropsychological tests. Principal component analysis was performed to extract a summary score of cognitive performance. Multivariable-adjusted linear regression analyses were performed to provide regression coefficients and 95 % confidence intervals (95 % CI). In a multivariate model, a strong inverse association was observed between a higher DII (reflecting a more inflammatory diet) and overall cognitive functioning (mean difference Q4 vs. Q1 = -1.76; 95 % CI = -2.81, -0.72, P for trend =0.002). With regard to specific cognitive domains, similar associations were observed with scores reflecting verbal memory, but not executive functioning. This study suggests that a pro-inflammatory diet at midlife might be associated with subsequent lower cognitive functioning. A diet exhibiting anti-inflammatory properties may help to maintain cognitive health during aging. Clinicaltrials.gov (number NCT00272428)

The inflammatory potential of the diet is associated with depressive symptoms in different subgroups of the general population

Background: Low-grade chronic inflammation, which can be modulated by diet, has been suggested as an important risk factor for depression, but few studies have investigated the association between the inflammatory potential of the diet and depression. Objective: We investigated the prospective association between the inflammatory potential of the diet, measured by the Dietary Inflammatory Index (DII), and incident depressive symptoms and tested the potential modulating effect of sex, age, physical activity, and smoking status. Methods: This study included 3523 participants (aged 35-60 y) from the SU. VI. MAX (Supplementation en Vitamines et Mineraux Antioxydants) cohort, who were initially free of depressive symptoms. Baseline DII (1994-1996) was computed by using repeated 24-h dietary records. Incident depressive symptoms were defined by a Center for Epidemiologic Studies-Depression Scale score >= 17 for men and >= 23 for women in 2007-2009. We used multivariable logistic regression models to estimate ORs and 95% CIs, and modeled the DII as a continuous variable and as sex-specific quartiles. Results: A total of 172 cases of incident depressive symptoms were identified over a mean follow-up of 12.6 y. The DII was not associated with incident depressive symptoms in the full sample. In sex-specific models, men with a higher DII had a higher risk of incident depressive symptoms (quartile 4 compared with quartile 1-OR: 2.32; 95% CI: 1.01, 5.35), but the association was only marginally significant (P-trend = 0.06). When analyses were performed across smoking status, current and former smokers with a higher DII had a higher risk of incident depressive symptoms (quartile 4 compared with quartile 1-OR: 2.21; 95% CI: 1.08, 4.52). A positive association was also observed among less physically active participants (quartile 4 compared with quartile 1-OR: 2.07; 95% CI: 1.05, 4.07). Conclusion: The promotion of a healthy diet with anti-inflammatory properties may help to prevent depressive symptoms, particularly among men, smokers, or physically inactive individuals. This trial was registered at clinicaltrials.gov as NCT0027242