Global, regional, and national burden of disorders affecting the nervous system, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BackgroundDisorders affecting the nervous system are diverse and include neurodevelopmental disorders, late-life neurodegeneration, and newly emergent conditions, such as cognitive impairment following COVID-19. Previous publications from the Global Burden of Disease, Injuries, and Risk Factor Study estimated the burden of 15 neurological conditions in 2015 and 2016, but these analyses did not include neurodevelopmental disorders, as defined by the International Classification of Diseases (ICD)-11, or a subset of cases of congenital, neonatal, and infectious conditions that cause neurological damage. Here, we estimate nervous system health loss caused by 37 unique conditions and their associated risk factors globally, regionally, and nationally from 1990 to 2021.MethodsWe estimated mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs), with corresponding 95% uncertainty intervals (UIs), by age and sex in 204 countries and territories, from 1990 to 2021. We included morbidity and deaths due to neurological conditions, for which health loss is directly due to damage to the CNS or peripheral nervous system. We also isolated neurological health loss from conditions for which nervous system morbidity is a consequence, but not the primary feature, including a subset of congenital conditions (ie, chromosomal anomalies and congenital birth defects), neonatal conditions (ie, jaundice, preterm birth, and sepsis), infectious diseases (ie, COVID-19, cystic echinococcosis, malaria, syphilis, and Zika virus disease), and diabetic neuropathy. By conducting a sequela-level analysis of the health outcomes for these conditions, only cases where nervous system damage occurred were included, and YLDs were recalculated to isolate the non-fatal burden directly attributable to nervous system health loss. A comorbidity correction was used to calculate total prevalence of all conditions that affect the nervous system combined.FindingsGlobally, the 37 conditions affecting the nervous system were collectively ranked as the leading group cause of DALYs in 2021 (443 million, 95% UI 378–521), affecting 3·40 billion (3·20–3·62) individuals (43·1%, 40·5–45·9 of the global population); global DALY counts attributed to these conditions increased by 18·2% (8·7–26·7) between 1990 and 2021. Age-standardised rates of deaths per 100 000 people attributed to these conditions decreased from 1990 to 2021 by 33·6% (27·6–38·8), and age-standardised rates of DALYs attributed to these conditions decreased by 27·0% (21·5–32·4). Age-standardised prevalence was almost stable, with a change of 1·5% (0·7–2·4). The ten conditions with the highest age-standardised DALYs in 2021 were stroke, neonatal encephalopathy, migraine, Alzheimer's disease and other dementias, diabetic neuropathy, meningitis, epilepsy, neurological complications due to preterm birth, autism spectrum disorder, and nervous system cancer.InterpretationAs the leading cause of overall disease burden in the world, with increasing global DALY counts, effective prevention, treatment, and rehabilitation strategies for disorders affecting the nervous system are needed

Global, regional, and national burden of disorders affecting the nervous system, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background Disorders affecting the nervous system are diverse and include neurodevelopmental disorders, late-life neurodegeneration, and newly emergent conditions, such as cognitive impairment following COVID-19. Previous publications from the Global Burden of Disease, Injuries, and Risk Factor Study estimated the burden of 15 neurological conditions in 2015 and 2016, but these analyses did not include neurodevelopmental disorders, as defined by the International Classification of Diseases (ICD)-11, or a subset of cases of congenital, neonatal, and infectious conditions that cause neurological damage. Here, we estimate nervous system health loss caused by 37 unique conditions and their associated risk factors globally, regionally, and nationally from 1990 to 2021. Methods We estimated mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs), with corresponding 95% uncertainty intervals (UIs), by age and sex in 204 countries and territories, from 1990 to 2021. We included morbidity and deaths due to neurological conditions, for which health loss is directly due to damage to the CNS or peripheral nervous system. We also isolated neurological health loss from conditions for which nervous system morbidity is a consequence, but not the primary feature, including a subset of congenital conditions (ie, chromosomal anomalies and congenital birth defects), neonatal conditions (ie, jaundice, preterm birth, and sepsis), infectious diseases (ie, COVID-19, cystic echinococcosis, malaria, syphilis, and Zika virus disease), and diabetic neuropathy. By conducting a sequela-level analysis of the health outcomes for these conditions, only cases where nervous system damage occurred were included, and YLDs were recalculated to isolate the non-fatal burden directly attributable to nervous system health loss. A comorbidity correction was used to calculate total prevalence of all conditions that affect the nervous system combined. Findings Globally, the 37 conditions affecting the nervous system were collectively ranked as the leading group cause of DALYs in 2021 (443 million, 95% UI 378–521), affecting 3·40 billion (3·20–3·62) individuals (43·1%, 40·5–45·9 of the global population); global DALY counts attributed to these conditions increased by 18·2% (8·7–26·7) between 1990 and 2021. Age-standardised rates of deaths per 100 000 people attributed to these conditions decreased from 1990 to 2021 by 33·6% (27·6–38·8), and age-standardised rates of DALYs attributed to these conditions decreased by 27·0% (21·5–32·4). Age-standardised prevalence was almost stable, with a change of 1·5% (0·7–2·4). The ten conditions with the highest age-standardised DALYs in 2021 were stroke, neonatal encephalopathy, migraine, Alzheimer's disease and other dementias, diabetic neuropathy, meningitis, epilepsy, neurological complications due to preterm birth, autism spectrum disorder, and nervous system cancer. Interpretation As the leading cause of overall disease burden in the world, with increasing global DALY counts, effective prevention, treatment, and rehabilitation strategies for disorders affecting the nervous system are needed. Funding Bill & Melinda Gates Foundation

The promise of the city: space, identity, and politics in contemporary social thought

The Promise of the City proposes a new theoretical framework for the study of cities and urban life. Finding the contemporary urban scene too complex to be captured by radical or conventional approaches, Kian Tajbakhsh offers a threefold, interdisciplinary approach linking agency, space, and structure. First, he says, urban identities cannot be understood through individualistic, communitarian, or class perspectives but rather through the shifting spectrum of cultural, political, and economic influences. Second, the layered, unfinished city spaces we inhabit and within which we create meaning are best represented not by the image of bounded physical spaces but rather by overlapping and shifting boundaries. And third, the macro forces shaping urban society include bureaucratic and governmental interventions not captured by a purely economic paradigm. Tajbakhsh examines these dimensions in the work of three major critical urban theorists of recent decades: Manuel Castells, David Harvey, and Ira Katznelson. He shows why the answers offered by Marxian urban theory to the questions of identity, space, and structure are unsatisfactory and why the perspectives of other intellectual traditions such as poststructuralism, feminism, Habermasian Critical Theory, and pragmatism can help us better understand the challenges facing contemporary cities

The Promise Of The City : Space, Identity And Politics In Contemporary Social Thought

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Mixed-Income Housing: Unanswered Question” Cityscape: A

Abstract Mixed-income housing represents the current direction of U.S. housing policy, but little is actually known about its social benefits, its costs, and the preconditions for its viability. Until these key questions are answered, advocacy of mixed-income housing will be based largely on faith and on dissatisfaction with the previous thrust of housing policy. This article examines various types of mixed-income housing and develops a simple analytic framework for exploring critical questions about it. The feasibility of mixed-income housing is shaped by local housing market conditions and by the physical and demographic characteristics of individual housing developments. The article also reviews the literature regarding the key questions and frames a research agenda. After decades of using public housing and other federally subsidized housing developments to shelter the poor and only the poor, the Federal Government is shifting toward policies that mix households with varying incomes. Responding both to the growing awareness of the social problems connected to concentrated poverty and to the economic burden of warehousing the very poor in large developments, housing policy increasingly emphasizes two approaches that deconcentrate the poor. The dominant method is to disperse the poor throughout a metropolitan region by providing them with rental vouchers for use in privately owned housing. The other approach is to combine low-income and higher income households in the same development. Although they share the objective of deconcentrating poverty, the two approaches operate in different ways. Dispersal strategies try to move the poor into more affluent neighborhoods, while mixed-income housing attempts to attract higher income households to developments that are also occupied by the poor. Dispersal programs are built on the Section 8 Existing Housing program, which authorizes housing authorities to issue portable rental vouchers for use in the private market. By the late 1980s, tenant-based subsidies (Section 8 certificates and vouchers) constituted the Schwartz and Tajbakhsh Cityscape single largest form of Federal housing assistance. Because the subsidy is tied to the household and not to a specific building, rental vouchers enable recipients to seek out housing in any neighborhood, provided the landlord accepts them and the rent does not exceed the area's fair market rent. Mixed-income housing is not new. Some States and localities have promoted it since at least the 1970s, through land-use regulations and tax-exempt financing. In New York City, mixed-income housing has long been a way of life as a result of rent regulation and public housing management that selected relatively higher income families from the public housing waiting list. However, the Federal Government has only recently embraced the concept of mixed-income housing developments, largely in an effort to revitalize public housing. Since mixed-income housing has not been evaluated as closely as dispersal-based policies and programs, it will be the focus of this article. Much of the rationale for dispersal and mixed-income strategies is based on the increasing consensus among policymakers and scholars that high concentrations of poor households in a neighborhood or housing development lead to negative social and behavioral outcomes. William Julius Wilson, most notably, has argued that the isolation of the poor from middle-and working-class institutions and role models encourages and reinforces nonmainstream behavioral characteristics such as weak labor force participation and results in an "underclass" culture Despite the consensus about the underclass perspective, other scholars have raised questions regarding the strength of the evidence supporting the concentrated poverty thesis and some of its underlying assumptions (Briggs, 1997; Cityscape 73 questions about mixed-income housing: its social effects, the costs of providing it, and the essential preconditions that make it financially viable. The article develops a simple analytic framework for discussing these topics. It then reviews the literature to determine which of the critical questions about mixed-income housing have been addressed and concludes by framing a research agenda for the remaining questions. Types of Mixed-Income Housing The term mixed-income housing can refer to many different kinds of housing. Mixedincome developments vary in the number of income groups included, the amount of income mixing that occurs, and the quality of housing occupied by various income groups. Low-income households may occupy from 20 percent to more than 60 percent of the units. The most affluent households in a mixed-income project may have incomes as low as 51 percent of the area median income or as high as 200 percent. Sometimes each building-or even each floor-of a mixed-income development includes households from every income group. In other instances the income groups occupy different sections of the development, with lower income households positioned apart from higher income residents. Similarly, some developments provide the same quality of housing-in terms of size and amenities-for residents from all income groups, while others offer smaller, less-lavish homes for lower income households. Mixed-income housing has been sponsored by public, nonprofit, and for-profit organizations and can include homeowners as well as renters. Any assessment of mixed-income housing must consider the variety of forms it can assume. Most mixed-income housing falls into four broad categories (see appendix for examples of each type). First, some State and local governments (for example, New Jersey and Montgomery County, Maryland) foster mixed-income housing through density bonuses, inclusionary zoning ordinances, and other land-use regulations that encourage developers to reserve a portion of the total amount of new housing (usually 20 percent) for low-and moderate-income households. Second, public housing authorities have recently experimented with mixed-income housing. HOPE VI, the Federal program for the physical and social revitalization of distressed public housing, has strongly promoted mixed-income housing. One-half of the program's implementation grants, totaling about $1 billion, have funded proposals to transform public housing into mixed-income developments ("McCormick Baron Teams with PHA," 1996). Prior to HOPE VI, individual housing authorities obtained Federal waivers to redevelop selected public housing projects such as Chicago's Lake Parc Place and Boston's Harbor Point into mixed-income developments. Third, some State and local housing programs require mixed-income occupancy as a condition for funding proposed developments. For example, State housing finance agencies in Massachusetts, New York, and elsewhere provide tax-exempt financing for projects that reserve at least 20 percent of their units for low-and moderateincome households. Finally, not all mixed-income housing originates with government programs designed to encourage this type of housing; some results from the independent efforts of individuals and agencies. For example, a few private developers have drawn on local tax abatements, tax-increment financing, Federal block grants (HOME, Community Development Block Grants), and Low Income Housing Tax Credits to help finance mixed-income developments Schwartz and Tajbakhsh Cityscape Key Questions Social Effects The first question concerns the possible social benefits of mixed-income housing. Does it improve the life chances of low-income residents? How? To what extent do the social effects differ in the various types of mixed-income housing outlined above? For example, is the social interaction between income groups the same, whether they reside across the hall or across the street? Although the shortcomings of public housing and other project-based, low-income housing programs are well documented, little research is available on the social benefits of mixed-income housing. Its advocates seem to believe that if concentrating poverty in public housing engenders chronic welfare dependency and other social pathologies, then mixing differing income groups will produce more desirable social outcomes. Exposure to the routines of working families, it is suggested, may make the children of poor families more likely to adopt the values, expectations, and behavior necessary for formal employment. However, there is inconclusive research on the extent to which physical proximity between the poor and the nonpoor leads to desired outcomes. There also is little research on the effect of mixed-income housing on the delivery of public services. Does the introduction of more affluent households to a development or area previously occupied exclusively by the poor lead to improved sanitation, police protection, schooling, and other services? 3 Also unknown is the minimum income of the more affluent residents that is necessary to achieve the desired social effects. Need they be middle income, moderate income, or simply employed, regardless of their income? This question, which is important because the higher the income of the best-off residents the more difficult it is to attract and retain them, is examined in more detail below. Costs The second question concerns the cost of developing and maintaining mixed-income housing. Although it has not been discussed as extensively as the social benefits of income mixing, proponents seem to assume that mixed-income housing is less costlythat is, involves a smaller public subsidy-than low-income housing. The Reagan and Bush administrations required that most public housing and Section 8 subsidies be targeted to very low-income households that had excessive housing cost burdens (at least 50 percent of total income) and lived in physically deficient housing or were homeless. Because household income partly determines the subsidy per household, it costs more to support the very poor than those with higher incomes. By giving housing subsidies only to the very poor, the Federal Government spends more per household than it would if households with a wider range of incomes were assisted. Moreover, because most subsidy programs require that tenants pay a fixed percentage of their income for rent, inclusion of more affluent households lowers the cost of subsidized housing by increasing the amount of rental income collected from tenants and reducing the amount the government pays. If a mixed-income housing development contains unsubsidized market-rate units, it might be possible for these units to cross-subsidize lowincome units within the development, thereby reducing the need for government funding. 4 Indeed, this is the logic of so-called 80-20 housing finance programs and density bonuses. In New York State's 80-20 tax-exempt bond-financing program, which is often coupled with New York City's density-bonus and tax abatement programs, 80 percent of the units in highrise Manhattan apartment buildings are rented at high-end market prices, enabling the owner to charge reduced rents for the 20 percent of the units occupied by low-and moderate-income tenants (Oser, 1995). Similarly, the density bonuses utilized by New Mixed-Income Housing: Unanswered Questions Cityscape 75 Jersey developers enable them to sell or rent one-fifth of their units to low-and moderateincome households (see appendix). While the inclusion of higher income households may reduce the subsidy necessary to sustain mixed-income housing projects, one must not overlook possible additional costs. There is little research, for example, on the vacancy losses and turnover costs for marketrate units in mixed-income housing developments. When occupied, such units may indeed generate surplus revenue, but developments may not always be able to attract or retain tenants for them. Because the demand for market-rate units in mixed-income housing could be weaker than for lower income units, it could take considerably longer to rent out these units. Furthermore, if market-rate households become dissatisfied with their homes or surroundings, they are more likely to move out than are their lower income neighbors. In short, because households with higher incomes have more housing choices, market-rate units are vulnerable to vacancy losses and rapid turnover. Depending on their duration and frequency, vacancy losses may offset the additional revenue generated when market-rate units are occupied. To attract market-rate tenants and minimize vacancy losses, sponsors of mixed-income housing may need to invest more resources in construction and maintenance than they would if their housing were occupied solely by the poor. 5 Moderate-and middle-income households may be more interested in mixed-income developments if the housing offers high-quality amenities-for example, architectural details, better appliances, landscaping, and services-as well as superb maintenance and management. All of these attractions, however, increase the development and operating costs of the housing. Essential Preconditions Potential vacancy losses and higher development and operating costs raise a host of contextual questions. The ability to attract higher income households is contingent on such issues as the location, size, design, and condition of the development; the racial and ethnic composition of the development and the surrounding neighborhood; and the state of the regional housing market. These considerations are illustrated in figure 1. The columns refer to the physical and demographic characteristics of a mixed-income housing development-the combination of location, size, design, condition, amenities, and other physical and demographic attributes that make developments more or less desirable. The rows refer to the state of the area's housing market, from extremely strong markets characterized by low vacancies and high prices to weak markets with high vacancies and low prices. The combination of physical characteristics and market conditions shapes the feasibility of any mixed-income housing development. Whereas its physical characteristics influence a development's appeal to moderate-and middle-income households, the Figure 1 Determinants of Mixed-Income Housing Feasibility Cityscape housing market influences the range of housing options these households may consider beyond the mixed-income development. The weaker the housing market, the more difficult it is for mixed-income housing developments to compete for moderate-and middleincome households and the more desirable their location and other physical attributes must be. Not all subsidized low-income developments are equally suited to mixed-income occupancy. Middle-and moderate-income households obviously have many more housing options than the poor. When subsidized housing becomes available, it is usually much easier to rent units to low-income households than to eligible households with higher incomes. Unless the regional housing market is extremely tight and there is a severe scarcity of affordable units, moderate-and middle-income households can easily opt not to reside in mixed-income housing. And they will decline to do so unless the development is appealing in some way-perhaps more appealing than conventional middle-income housing. Therefore the size, design, condition, location, and cost of the housing (and perhaps the demographic characteristics of its occupants) are extremely important in attracting higher income households. These factors are important individually and in combination, but there has been little research on the way their interaction creates viable mixed-income housing. As with all real estate, the location of mixed-income housing is a critical determinant of market appeal. Other things being equal, mixed-income housing in desirable neighborhoods will be more attractive to moderate-and middle-income households than will poorly located developments. Housing located in areas with abandoned buildings, street crime, limited transportation access, and poor services is less attractive to higher income residents than developments situated in "good" neighborhoods. While this statement is self evident, it underscores the difficulty of converting a significant amount of the Nation's public housing to mixed-income housing. Much public housing is located in the most remote and least desirable sections of the Nation's cities (Bratt, 1989; Kotlowitz, 1991). It is no surprise that in Chicago, where mixed-income housing programs are perhaps more advanced than in any other major U.S. city, the public housing projects being converted to mixed-income occupancy are located in potentially desirable areas. Lake Parc Place, for example, although situated in one of the city's poorest neighborhoods, is adjacent to Lake Michigan and only minutes away from downtown. Cabrini Green, once one of the Nation's most infamous public housing projects, is being redeveloped as a mixed-income housing community Real estate speculation has driven up the cost of land throughout the area In Boston, the Massachusetts Housing Finance Agency (MHFA) has backed a number of mixed-income housing developments in some of Boston's more popular neighborhoods. Here, mixed-income housing may be one of the few ways for moderateincome households to live in neighborhoods they could otherwise not afford. Size, design, and physical characteristics such as amenities and condition also influence the attraction of mixed-income housing. It goes without saying that the stereotypical highrise public housing with "skip-floor" elevators, doorless closets, bleak design, poor construction, and inadequate maintenance is unlikely to attract households of any income level. It is not surprising that much of the extant mixed-income housing, even that which is public housing, involves new construction or substantial rehabilitation A development's physical configuration is of particular significance, in that low-density developments may be less intimidating to higher income households than highrises occupied by many low-income families. Other considerations are the race and ethnicity of the residents. What effect does the potential stigma associated with poor minorities have on the project's ability to attract mixed-income households of all races? It is not clear whether all income groups must be of the same race in order to foster social interaction among households with differing incomes. The viability of mixed-income housing depends at least as much on the state of the region's housing market as it does on the physical attributes of the development. The greater the supply of affordable moderate-and middle-income housing, the greater the range of housing options available to these households and the more difficult it is for mixed-income housing to attract them. The importance of housing markets is well illustrated in New York City, where housing affordable to low-and moderate-income households has long been scarce With a chronic shortage of affordable housing, New York City stands to be a favorable environment for mixed-income housing. Indeed, the city offers numerous examples of relatively successful mixed-income housing. Above all, as mentioned earlier, New York's public housing stands out nationally for its inclusion of working families. The lack of other housing options, combined with benefits such as good management and a sense of community, has discouraged many working families from leaving public housing. In addition to public housing, New York's Department of Housing Preservation and Development has devised a number of mixed-income housing programs using tax-foreclosed properties, low-interest loans, and tenant-based Section 8 vouchers. For example, in the Vacant Cluster program (see appendix), there are few differences in the vacancy rates and turnover frequency of units reserved for formerly homeless, low-income, and moderateincome households The Literature on Project-Based Mixed-Income Housing Despite the importance and popularity of the concept of mixed-income housing in national housing policy circles, very few studies have attempted to evaluate the conditions under which programs have succeeded or failed and the implications for future programs. A clear understanding of which variables are important is critical to an understanding of the Schwartz and Tajbakhsh 78 Cityscape general usefulness of this approach and to indentification of variables that will help policymakers design more effective programs. To assess the state of knowledge about mixed-income housing strategies and to identify the questions that remain to be answered, this section briefly reviews the methodology and main findings of the few studies on mixed-income housing programs that we have located. 7 s Increased social interaction between the low-income ("project") and moderateincome ("nonproject") groups. 8 s Institutional maintenance and support of the management by moderate-income groups, through participation in volunteer programs and support of rules and rule enforcement by management. s A positive effect on the employment rate of low-income residents. 9 With regard to the general viability of the development, the authors found that the project had succeeded in attracting moderate-income working households 10 and that after several years in operation it is considered safe and without serious management difficulties. However, the evidence for the three substantive goals was mixed. First, they examined the extent of social isolation in terms of the extent to which residents interacted with their neighbors. They found tha

Inner hybridity in the city: Toward a critique of multiculturalism

Muddled as an idea and flawed as a public policy, multiculturalism in Canada advocates conformity to a unitary culture in the public place and tolerance of diverse cultures in the private place. This tolerance of cultural heterogeneity in the sphere of the intimate is often upheld as a defining characteristic of Canadian society. Yet multiculturalism is not without criticisms. For one, multiculturalism is at odds with the desire of the children and grandchildren of the Chinese immigrants in Canada to adapt themselves to their host society, thus transforming themselves as well as the laglecrv society. A multicultural policy that continues to hark back to the past turns a blind eye to the fierce generation and gender politics within the Chinese family. Neither does the multicultural policy square well with a more progressive social theory of self, identity, and culture that is cognizant of the duality of the psychological make-up of human beings: that one looks backward and forward, committed to preserving roots of the past and exploring routes to the future. As such, the Canadian multicultural policy suffers in a two-fold way: empirical and theoretical. A possible way out is to pursue a Hegelian dialectics that sees culture as an aftermath of a collision of dissimilar cultures, a kind of forced entanglement of things different We need a new urban social theory that sees integration, fusion, and hybridization—not assimilation, and not cultural pluralism—as possible and desirable outcomes. This is a completely different vision of society altogether, a kind of Utopia. We need a public policy that sees a distinct promise of the city in designing institutions and public spaces that promote hybridism in the mind, an inner deliberation, a mental turmoil—which is not afraid of confronting modern life's many moments of contradictions, ironies and paradoxes.Multiculturalism, pluralism, public/private divide, assimilation, hybridism,