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

doi:10.1016/S2214-109X(16)30168-1

. 2016 Oct;4(10):e704-13.

doi: 10.1016/S2214-109X(16)30168-1. Epub 2016 Aug 25.

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

Ali H Mokdad¹, Mohammad Hossein Forouzanfar², Farah Daoud², Charbel El Bcheraoui², Maziar Moradi-Lakeh³, Ibrahim Khalil², Ashkan Afshin², Marwa Tuffaha², Raghid Charara², Ryan M Barber², Joseph Wagner², Kelly Cercy², Hannah Kravitz², Matthew M Coates², Margaret Robinson², Kara Estep², Caitlyn Steiner², Sara Jaber², Ali A Mokdad⁴, Kevin F O'Rourke², Adrienne Chew², Pauline Kim², Mohamed Magdy Abd El Razek⁵, Safa Abdalla⁶, Foad Abd-Allah⁷, Jerry P Abraham⁸, Laith J Abu-Raddad⁹, Niveen M E Abu-Rmeileh¹⁰, Abdulwahab A Al-Nehmi¹¹, Ali S Akanda¹², Hanan Al Ahmadi¹³, Mazin J Al Khabouri¹⁴, Faris H Al Lami¹⁵, Zulfa A Al Rayess¹⁶, Deena Alasfoor¹⁴, Fadia S AlBuhairan¹⁷, Saleh F Aldhahri¹⁸, Suliman Alghnam¹⁹, Samia Alhabib²⁰, Nawal Al-Hamad²¹, Raghib Ali²², Syed Danish Ali²³, Mohammad Alkhateeb²⁴, Mohammad A AlMazroa²⁵, Mahmoud A Alomari²⁶, Rajaa Al-Raddadi²⁵, Ubai Alsharif²⁷, Nihaya Al-Sheyab²⁸, Shirina Alsowaidi²⁹, Mohamed Al-Thani³⁰, Khalid A Altirkawi³¹, Azmeraw T Amare³², Heresh Amini³³, Walid Ammar³⁴, Palwasha Anwari³⁵, Hamid Asayesh³⁶, Rana Asghar³⁷, Ali M Assabri³⁸, Reza Assadi³⁹, Umar Bacha⁴⁰, Alaa Badawi⁴¹, Talal Bakfalouni⁴², Mohammed O Basulaiman²⁵, Shahrzad Bazargan-Hejazi⁴³, Neeraj Bedi⁴⁴, Amit R Bhakta⁴⁵, Zulfiqar A Bhutta⁴⁶, Aref A Bin Abdulhak⁴⁷, Soufiane Boufous⁴⁸, Rupert R A Bourne⁴⁹, Hadi Danawi⁵⁰, Jai Das⁵¹, Amare Deribew⁵², Eric L Ding⁵³, Adnan M Durrani⁵⁴, Yousef Elshrek⁵⁵, Mohamed E Ibrahim⁵⁶, Babak Eshrati⁵⁷, Alireza Esteghamati⁵⁸, Imad A D Faghmous⁵⁹, Farshad Farzadfar⁶⁰, Andrea B Feigl⁶¹, Seyed-Mohammad Fereshtehnejad⁶², Irina Filip⁶³, Florian Fischer⁶⁴, Fortuné G Gankpé⁶⁵, Ibrahim Ginawi⁶⁶, Melkamu Dedefo Gishu⁶⁷, Rahul Gupta⁶⁸, Rami M Habash²⁵, Nima Hafezi-Nejad⁵⁸, Randah R Hamadeh⁶⁹, Hayet Hamdouni⁷⁰, Samer Hamidi⁷¹, Hilda L Harb³⁴, Mohammad Sadegh Hassanvand⁷², Mohammad T Hedayati⁷³, Pouria Heydarpour⁷⁴, Mohamed Hsairi⁷⁵, Abdullatif Husseini⁷⁶, Nader Jahanmehr⁷⁷, Vivekanand Jha⁷⁸, Jost B Jonas⁷⁹, Nadim E Karam⁸⁰, Amir Kasaeian⁸¹, Nega Assefa Kassa⁸², Anil Kaul⁸³, Yousef Khader⁸⁴, Shams Eldin A Khalifa³⁰, Ejaz A Khan⁸⁵, Gulfaraz Khan⁸⁶, Tawfik Khoja⁸⁷, Ardeshir Khosravi⁸⁸, Yohannes Kinfu⁸⁹, Barthelemy Kuate Defo⁹⁰, Arjun Lakshmana Balaji⁹¹, Raimundas Lunevicius⁹², Carla Makhlouf Obermeyer⁹³, Reza Malekzadeh⁹⁴, Morteza Mansourian⁹⁵, Wagner Marcenes⁹⁶, Habibolah Masoudi Farid⁹⁷, Alem Mehari⁹⁸, Abla Mehio-Sibai⁹⁹, Ziad A Memish¹⁰⁰, George A Mensah¹⁰¹, Karzan A Mohammad¹⁰², Ziad Nahas¹⁰³, Jamal T Nasher¹⁰⁴, Haseeb Nawaz¹⁰⁵, Chakib Nejjari¹⁰⁶, Muhammad Imran Nisar¹⁰⁷, Saad B Omer¹⁰⁸, Mahboubeh Parsaeian¹⁰⁹, Emmanuel K Peprah¹¹⁰, Aslam Pervaiz¹¹¹, Farshad Pourmalek¹¹², Dima M Qato¹¹³, Mostafa Qorbani¹¹⁴, Amir Radfar¹¹⁵, Anwar Rafay¹¹⁶, Kazem Rahimi²², Vafa Rahimi-Movaghar¹¹⁷, Sajjad Ur Rahman¹¹⁸, Rajesh K Rai¹¹⁹, Saleem M Rana¹²⁰, Sowmya R Rao¹²¹, Amany H Refaat¹²², Serge Resnikoff¹²³, Gholamreza Roshandel¹²⁴, Georges Saade¹²⁵, Mohammad Y Saeedi²⁵, Mohammad Ali Sahraian⁷⁴, Shadi Saleh¹²⁶, Lidia Sanchez-Riera¹²⁷, Maheswar Satpathy¹²⁸, Sadaf G Sepanlou⁹⁴, Tesfaye Setegn¹²⁹, Amira Shaheen¹³⁰, Saeid Shahraz¹³¹, Sara Sheikhbahaei⁵⁸, Kawkab Shishani¹³², Karen Sliwa¹³³, Mohammad Tavakkoli¹³⁴, Abdullah S Terkawi¹³⁵, Olalekan A Uthman¹³⁶, Ronny Westerman¹³⁷, Mustafa Z Younis¹³⁸, Maysaa El Sayed Zaki¹³⁹, Faiez Zannad¹⁴⁰, Gregory A Roth², Haidong Wang², Mohsen Naghavi², Theo Vos², Abdullah A Al Rabeeah²⁵, Alan D Lopez¹⁴¹, Christopher J L Murray²

Affiliations

¹ Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. Electronic address: mokdaa@uw.edu.
² Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
³ Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Community Medicine, Preventive Medicine and Public Health Research Center, Iran University of Medical Sciences, Tehran, Iran.
⁴ Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
⁵ Aswan University Hospital, Aswan Faculty of Medicine, Aswan, Egypt.
⁶ Sudanese Public Health Consultancy Group, Solihull, UK.
⁷ Department of Neurology, Cairo University, Cairo, Egypt.
⁸ Family Medicine Residency Program at California Hospital, University of Southern California, Los Angeles, CA, USA; Institute for Global Health, Harvard University, Boston, MA, USA.
⁹ Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Doha, Qatar.
¹⁰ Institute of Community and Public Health, Birzeit University, Ramallah, Palestine.
¹¹ Ministry of Health, Sana'a, Yemen.
¹² University of Rhode Island, Kingston, RI, USA.
¹³ Majlis Al Shura, Riyadh, Saudi Arabia.
¹⁴ Ministry of Health, Muscat, Oman.
¹⁵ College of Medicine, University of Baghdad, Baghdad, Iraq.
¹⁶ The Saudi Center for Evidence Based Healthcare, Riyadh, Saudi Arabia.
¹⁷ King Abdullah Specialized Children's Hospital, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
¹⁸ King Saud University, Riyadh, Saudi Arabia; King Fahad Medical City, Riyadh, Saudi Arabia.
¹⁹ King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
²⁰ King Abdullah Bin Abdulaziz University Hospital, Riyadh, Saudi Arabia.
²¹ Public Authority for Food and Nutrition, Kuwait.
²² University of Oxford, Oxford, UK.
²³ University of London, London, UK; Institute and Faculty of Actuaries, Oxford, UK.
²⁴ Pediatric Department, King Khalid University Hospital, Riyadh, Saudi Arabia.
²⁵ Kingdom of Saudi Arabia Ministry of Health, Riyadh, Saudi Arabia.
²⁶ Division of Physical Therapy, Department of Rehabilitation Sciences, Irbid, Jordan.
²⁷ Charité Universitätsmedizin, Berlin, Germany.
²⁸ Maternal and Child Health Department, Irbid, Jordan.
²⁹ Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates.
³⁰ Supreme Council of Health, Doha, Qatar.
³¹ King Saud University, Riyadh, Saudi Arabia.
³² Discipline of Psychiatry, School of Medicine, University of Adelaide, Adelaide, SA, Australia; College of Medicine and Health Sciences, Bahir Dar, Ethiopia.
³³ Environmental Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran; Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
³⁴ Ministry of Public Health, Beirut, Lebanon.
³⁵ Kabul, Afghanistan.
³⁶ Department of Medical Emergency, School of Paramedic, Qom University of Medical Sciences, Qom, Iran.
³⁷ South Asian Public Health Forum, Islamabad, Pakistan.
³⁸ Faculty of Medicine and Health Sciences, Sana'a University, Sana'a, Yemen.
³⁹ Mashhad University of Medical Sciences, Mashhad, Iran.
⁴⁰ School of Health Sciences, University of Management and Technology, Lahore, Pakistan.
⁴¹ Public Health Agency of Canada, Toronto, ON, Canada.
⁴² Ministry of Health, Damascus, Syria.
⁴³ Charles R Drew University of Medicine and Science, Los Angeles, CA, USA.
⁴⁴ College of Public Health and Tropical Medicine, Jazan, Saudi Arabia.
⁴⁵ National Institute of Mental Health, Montgomery Village, MD, USA.
⁴⁶ Centre of Excellence in Women and Child Health, Karachi, Pakistan; Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada.
⁴⁷ University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
⁴⁸ Transport and Road Safety (TARS) Research, University of New South Wales, Sydney, NSW, Australia.
⁴⁹ Vision & Eye Research Unit, Anglia Ruskin University, Cambridge, UK.
⁵⁰ Walden University, Minneapolis, MN, USA.
⁵¹ Department of Paediatrics and Child Health, Karachi, Pakistan.
⁵² Nuffield Department of Medicine, Oxford, UK; KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.
⁵³ Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA.
⁵⁴ National Institutes of Health, Montgomery Village, MD, USA.
⁵⁵ Food Science Department, Faculty of Agriculture, University of Tripoli, Tripoli, Libya.
⁵⁶ Cardiovascular Diseases Control and Prevention Program, Riyadh, Saudi Arabia.
⁵⁷ Ministry of Health and Medical Education, Tehran, Iran; Arak University of Medical Sciences, Arak, Iran.
⁵⁸ Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran.
⁵⁹ London School of Hygiene & Tropical Medicine, London, UK.
⁶⁰ Non-Communicable Diseases Research Center, Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran.
⁶¹ Department of Global Health and Population, Harvard University, Boston, MA, USA.
⁶² Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden.
⁶³ Kaiser Permanente Psychiatry Residency Program, Fontana, CA, USA.
⁶⁴ Bielefeld University, Bielefeld, Germany.
⁶⁵ Leras Afrique, Cotonou, Benin; CHU Hassan II, Fez, Morocco.
⁶⁶ College of Medicine, University of Hail, Hail, Saudi Arabia.
⁶⁷ Haramaya University, Dira Dawa, Ethiopia; Kersa Health and Demographic Surveillance System, Harar, Ethiopia.
⁶⁸ West Virginia Bureau for Public Health, Charleston, WV, USA.
⁶⁹ Arabian Gulf University, Manama, Bahrain.
⁷⁰ Direction des Soins de Santé de Base, Ministry of Health, Tunis, Tunisia.
⁷¹ Hamdan Bin Mohammed Smart University, Dubai, United Arab Emirates.
⁷² Center for Air Pollution Research, Institute for Environmental Research, Tehran University of Medical Sciences, Tehran, Iran.
⁷³ Department of Medical Mycology and Parasitology, School of Medicine, Mazndaran University of Medical Sciences, Sari, Iran.
⁷⁴ Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran.
⁷⁵ Salah Azaiz Institute, Tunis, Tunisia.
⁷⁶ Qatar University, Doha, Qatar.
⁷⁷ School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
⁷⁸ The George Institute for Global Health India, University of Oxford, New Delhi, India.
⁷⁹ Ruprecht-Karls-University Heidelberg, Department of Ophthalmology, Medical Faculty Mannheim, Mannheim, Germany.
⁸⁰ University of Balamand, Beirut, Lebanon.
⁸¹ Non-Communicable Diseases Research Center, Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran; Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran.
⁸² Haramaya University, Harari, Ethiopia.
⁸³ Oklahoma State University Center for Health Sciences, Tulsa, OK, USA.
⁸⁴ Jordan University of Science and Technology, Irbid, Jordan.
⁸⁵ Health Services Academy, Islamabad, Pakistan.
⁸⁶ Department of Microbiology and Immunology, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates.
⁸⁷ Health Ministers' Council for Cooperation Council States, Riyadh, Saudi Arabia.
⁸⁸ Non-Communicable Diseases Research Center, Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran; Iranian Ministry of Health and Medical Education, Tehran, Iran.
⁸⁹ Centre for Research & Action in Public Health, Faculty of Health, University of Canberra, Canberra, ACT, Australia.
⁹⁰ Department of Demography and Public Health Research Institute, University of Montreal, Montreal, QC, Canada; Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, QC, Canada.
⁹¹ Indegene, Bangalore, India.
⁹² Aintree University Hospital National Health Service Foundation Trust, Liverpool, UK; School of Medicine, University of Liverpool, Liverpool, UK.
⁹³ Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
⁹⁴ Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
⁹⁵ Department of Health Education and Promotion, School of Health, Iran University of Medical Sciences, Tehran, Iran.
⁹⁶ Queen Mary University of London, London, UK.
⁹⁷ State Welfare Organisation, Tehran, Iran.
⁹⁸ Howard University College of Medicine, Washington, DC, USA.
⁹⁹ Department of Epidemiology & Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
¹⁰⁰ Kingdom of Saudi Arabia Ministry of Health, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
¹⁰¹ Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, Montgomery Village, MD, USA.
¹⁰² University of Salahaddin, Erbil, Iraq.
¹⁰³ Medical Center, American University of Beirut, Beirut, Lebanon.
¹⁰⁴ Ministry of Public Health and Population, Sana'a, Yemen.
¹⁰⁵ Southern Illinois University, Springfield, IL, USA.
¹⁰⁶ Faculty of Medicine, Fez, Morocco.
¹⁰⁷ Aga Khan University, Karachi, Pakistan.
¹⁰⁸ Emory University, Atlanta, GA, USA.
¹⁰⁹ Non-Communicable Diseases Research Center, Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran; Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
¹¹⁰ National Heart, Lung, and Blood Institute, Bethesda, MD, USA.
¹¹¹ Postgraduate Medical Institute, Lahore, Pakistan.
¹¹² University of British Columbia, Vancouver, BC, Canada.
¹¹³ College of Pharmacy, University of Illinois, Chicago, IL, USA.
¹¹⁴ Department of Community Medicine, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran.
¹¹⁵ A T Still University of Health Sciences, Kirksville, MO, USA.
¹¹⁶ Contech International Health Consultants, Lahore, Pakistan.
¹¹⁷ Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.
¹¹⁸ Hamad Medical Corporation, Doha, Qatar.
¹¹⁹ Society for Health and Demographic Surveillance, Suri, India.
¹²⁰ Contech International Health Consultants, Lahore, Pakistan; Contech School of Public Health, Lahore, Pakistan.
¹²¹ Department of Surgery, Boston University School of Medicine, Boston, MA, USA.
¹²² Walden University, Minneapolis, MN, USA; Suez Canal University, Ismailia, Egypt.
¹²³ Brien Holden Vision Institute, University of New South Wales, Sydney, NSW, Australia; International Health and Development, Geneva, Switzerland.
¹²⁴ Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran.
¹²⁵ Lebanese University, Beirut, Lebanon; Bellevue Medical Center, Mansourieh El Metn, Lebanon.
¹²⁶ Department of Health Management and Policy, American University of Beirut, Beirut, Lebanon.
¹²⁷ Institut d'Investigacio Biomedica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
¹²⁸ All India Institute of Medical Sciences, New Delhi, India.
¹²⁹ Bahir Dar University, Bahir Dar, Ethiopia.
¹³⁰ Department of Public Health, An-Najah University, Nablus, Palestine.
¹³¹ Tufts Medical Center, Boston, MA, USA.
¹³² Washington State University, Spokane, WA, USA.
¹³³ Faculty of Health Sciences, Hatter Institute for Cardiovascular Research in Africa, University of Cape Town, Cape Town, South Africa.
¹³⁴ Westchester Medical Center, Valhalla, NY, USA.
¹³⁵ Department of Anesthesiology, Riyadh, Saudi Arabia; Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA.
¹³⁶ Warwick Medical School, University of Warwick, Coventry, UK.
¹³⁷ Federal Institute for Population Research, Wiesbaden, Germany; German National Cohort Consortium, Heidelberg, Germany.
¹³⁸ Jackson State University, Jackson, MS, USA.
¹³⁹ Faculty of Medicine, Mansoura University, Mansoura, Egypt.
¹⁴⁰ Clinical Investigation Centre INSERM, Université de Lorraine, Vandoeuvre les Nancy, France; CHU de Nancy, Vandoeuvre les Nancy, France.
¹⁴¹ Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia.

PMID: 27568068
PMCID: PMC6660972
DOI: 10.1016/S2214-109X(16)30168-1

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

Ali H Mokdad et al. Lancet Glob Health. 2016 Oct.

. 2016 Oct;4(10):e704-13.

doi: 10.1016/S2214-109X(16)30168-1. Epub 2016 Aug 25.

Authors

Affiliations

¹ Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. Electronic address: mokdaa@uw.edu.
² Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
³ Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Department of Community Medicine, Preventive Medicine and Public Health Research Center, Iran University of Medical Sciences, Tehran, Iran.
⁴ Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
⁵ Aswan University Hospital, Aswan Faculty of Medicine, Aswan, Egypt.
⁶ Sudanese Public Health Consultancy Group, Solihull, UK.
⁷ Department of Neurology, Cairo University, Cairo, Egypt.
⁸ Family Medicine Residency Program at California Hospital, University of Southern California, Los Angeles, CA, USA; Institute for Global Health, Harvard University, Boston, MA, USA.
⁹ Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Doha, Qatar.
¹⁰ Institute of Community and Public Health, Birzeit University, Ramallah, Palestine.
¹¹ Ministry of Health, Sana'a, Yemen.
¹² University of Rhode Island, Kingston, RI, USA.
¹³ Majlis Al Shura, Riyadh, Saudi Arabia.
¹⁴ Ministry of Health, Muscat, Oman.
¹⁵ College of Medicine, University of Baghdad, Baghdad, Iraq.
¹⁶ The Saudi Center for Evidence Based Healthcare, Riyadh, Saudi Arabia.
¹⁷ King Abdullah Specialized Children's Hospital, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
¹⁸ King Saud University, Riyadh, Saudi Arabia; King Fahad Medical City, Riyadh, Saudi Arabia.
¹⁹ King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
²⁰ King Abdullah Bin Abdulaziz University Hospital, Riyadh, Saudi Arabia.
²¹ Public Authority for Food and Nutrition, Kuwait.
²² University of Oxford, Oxford, UK.
²³ University of London, London, UK; Institute and Faculty of Actuaries, Oxford, UK.
²⁴ Pediatric Department, King Khalid University Hospital, Riyadh, Saudi Arabia.
²⁵ Kingdom of Saudi Arabia Ministry of Health, Riyadh, Saudi Arabia.
²⁶ Division of Physical Therapy, Department of Rehabilitation Sciences, Irbid, Jordan.
²⁷ Charité Universitätsmedizin, Berlin, Germany.
²⁸ Maternal and Child Health Department, Irbid, Jordan.
²⁹ Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates.
³⁰ Supreme Council of Health, Doha, Qatar.
³¹ King Saud University, Riyadh, Saudi Arabia.
³² Discipline of Psychiatry, School of Medicine, University of Adelaide, Adelaide, SA, Australia; College of Medicine and Health Sciences, Bahir Dar, Ethiopia.
³³ Environmental Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran; Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
³⁴ Ministry of Public Health, Beirut, Lebanon.
³⁵ Kabul, Afghanistan.
³⁶ Department of Medical Emergency, School of Paramedic, Qom University of Medical Sciences, Qom, Iran.
³⁷ South Asian Public Health Forum, Islamabad, Pakistan.
³⁸ Faculty of Medicine and Health Sciences, Sana'a University, Sana'a, Yemen.
³⁹ Mashhad University of Medical Sciences, Mashhad, Iran.
⁴⁰ School of Health Sciences, University of Management and Technology, Lahore, Pakistan.
⁴¹ Public Health Agency of Canada, Toronto, ON, Canada.
⁴² Ministry of Health, Damascus, Syria.
⁴³ Charles R Drew University of Medicine and Science, Los Angeles, CA, USA.
⁴⁴ College of Public Health and Tropical Medicine, Jazan, Saudi Arabia.
⁴⁵ National Institute of Mental Health, Montgomery Village, MD, USA.
⁴⁶ Centre of Excellence in Women and Child Health, Karachi, Pakistan; Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada.
⁴⁷ University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
⁴⁸ Transport and Road Safety (TARS) Research, University of New South Wales, Sydney, NSW, Australia.
⁴⁹ Vision & Eye Research Unit, Anglia Ruskin University, Cambridge, UK.
⁵⁰ Walden University, Minneapolis, MN, USA.
⁵¹ Department of Paediatrics and Child Health, Karachi, Pakistan.
⁵² Nuffield Department of Medicine, Oxford, UK; KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.
⁵³ Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA.
⁵⁴ National Institutes of Health, Montgomery Village, MD, USA.
⁵⁵ Food Science Department, Faculty of Agriculture, University of Tripoli, Tripoli, Libya.
⁵⁶ Cardiovascular Diseases Control and Prevention Program, Riyadh, Saudi Arabia.
⁵⁷ Ministry of Health and Medical Education, Tehran, Iran; Arak University of Medical Sciences, Arak, Iran.
⁵⁸ Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran.
⁵⁹ London School of Hygiene & Tropical Medicine, London, UK.
⁶⁰ Non-Communicable Diseases Research Center, Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran.
⁶¹ Department of Global Health and Population, Harvard University, Boston, MA, USA.
⁶² Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden.
⁶³ Kaiser Permanente Psychiatry Residency Program, Fontana, CA, USA.
⁶⁴ Bielefeld University, Bielefeld, Germany.
⁶⁵ Leras Afrique, Cotonou, Benin; CHU Hassan II, Fez, Morocco.
⁶⁶ College of Medicine, University of Hail, Hail, Saudi Arabia.
⁶⁷ Haramaya University, Dira Dawa, Ethiopia; Kersa Health and Demographic Surveillance System, Harar, Ethiopia.
⁶⁸ West Virginia Bureau for Public Health, Charleston, WV, USA.
⁶⁹ Arabian Gulf University, Manama, Bahrain.
⁷⁰ Direction des Soins de Santé de Base, Ministry of Health, Tunis, Tunisia.
⁷¹ Hamdan Bin Mohammed Smart University, Dubai, United Arab Emirates.
⁷² Center for Air Pollution Research, Institute for Environmental Research, Tehran University of Medical Sciences, Tehran, Iran.
⁷³ Department of Medical Mycology and Parasitology, School of Medicine, Mazndaran University of Medical Sciences, Sari, Iran.
⁷⁴ Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran.
⁷⁵ Salah Azaiz Institute, Tunis, Tunisia.
⁷⁶ Qatar University, Doha, Qatar.
⁷⁷ School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
⁷⁸ The George Institute for Global Health India, University of Oxford, New Delhi, India.
⁷⁹ Ruprecht-Karls-University Heidelberg, Department of Ophthalmology, Medical Faculty Mannheim, Mannheim, Germany.
⁸⁰ University of Balamand, Beirut, Lebanon.
⁸¹ Non-Communicable Diseases Research Center, Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran; Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran.
⁸² Haramaya University, Harari, Ethiopia.
⁸³ Oklahoma State University Center for Health Sciences, Tulsa, OK, USA.
⁸⁴ Jordan University of Science and Technology, Irbid, Jordan.
⁸⁵ Health Services Academy, Islamabad, Pakistan.
⁸⁶ Department of Microbiology and Immunology, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates.
⁸⁷ Health Ministers' Council for Cooperation Council States, Riyadh, Saudi Arabia.
⁸⁸ Non-Communicable Diseases Research Center, Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran; Iranian Ministry of Health and Medical Education, Tehran, Iran.
⁸⁹ Centre for Research & Action in Public Health, Faculty of Health, University of Canberra, Canberra, ACT, Australia.
⁹⁰ Department of Demography and Public Health Research Institute, University of Montreal, Montreal, QC, Canada; Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, QC, Canada.
⁹¹ Indegene, Bangalore, India.
⁹² Aintree University Hospital National Health Service Foundation Trust, Liverpool, UK; School of Medicine, University of Liverpool, Liverpool, UK.
⁹³ Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
⁹⁴ Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
⁹⁵ Department of Health Education and Promotion, School of Health, Iran University of Medical Sciences, Tehran, Iran.
⁹⁶ Queen Mary University of London, London, UK.
⁹⁷ State Welfare Organisation, Tehran, Iran.
⁹⁸ Howard University College of Medicine, Washington, DC, USA.
⁹⁹ Department of Epidemiology & Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
¹⁰⁰ Kingdom of Saudi Arabia Ministry of Health, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
¹⁰¹ Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, Montgomery Village, MD, USA.
¹⁰² University of Salahaddin, Erbil, Iraq.
¹⁰³ Medical Center, American University of Beirut, Beirut, Lebanon.
¹⁰⁴ Ministry of Public Health and Population, Sana'a, Yemen.
¹⁰⁵ Southern Illinois University, Springfield, IL, USA.
¹⁰⁶ Faculty of Medicine, Fez, Morocco.
¹⁰⁷ Aga Khan University, Karachi, Pakistan.
¹⁰⁸ Emory University, Atlanta, GA, USA.
¹⁰⁹ Non-Communicable Diseases Research Center, Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran; Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
¹¹⁰ National Heart, Lung, and Blood Institute, Bethesda, MD, USA.
¹¹¹ Postgraduate Medical Institute, Lahore, Pakistan.
¹¹² University of British Columbia, Vancouver, BC, Canada.
¹¹³ College of Pharmacy, University of Illinois, Chicago, IL, USA.
¹¹⁴ Department of Community Medicine, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran.
¹¹⁵ A T Still University of Health Sciences, Kirksville, MO, USA.
¹¹⁶ Contech International Health Consultants, Lahore, Pakistan.
¹¹⁷ Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.
¹¹⁸ Hamad Medical Corporation, Doha, Qatar.
¹¹⁹ Society for Health and Demographic Surveillance, Suri, India.
¹²⁰ Contech International Health Consultants, Lahore, Pakistan; Contech School of Public Health, Lahore, Pakistan.
¹²¹ Department of Surgery, Boston University School of Medicine, Boston, MA, USA.
¹²² Walden University, Minneapolis, MN, USA; Suez Canal University, Ismailia, Egypt.
¹²³ Brien Holden Vision Institute, University of New South Wales, Sydney, NSW, Australia; International Health and Development, Geneva, Switzerland.
¹²⁴ Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran.
¹²⁵ Lebanese University, Beirut, Lebanon; Bellevue Medical Center, Mansourieh El Metn, Lebanon.
¹²⁶ Department of Health Management and Policy, American University of Beirut, Beirut, Lebanon.
¹²⁷ Institut d'Investigacio Biomedica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
¹²⁸ All India Institute of Medical Sciences, New Delhi, India.
¹²⁹ Bahir Dar University, Bahir Dar, Ethiopia.
¹³⁰ Department of Public Health, An-Najah University, Nablus, Palestine.
¹³¹ Tufts Medical Center, Boston, MA, USA.
¹³² Washington State University, Spokane, WA, USA.
¹³³ Faculty of Health Sciences, Hatter Institute for Cardiovascular Research in Africa, University of Cape Town, Cape Town, South Africa.
¹³⁴ Westchester Medical Center, Valhalla, NY, USA.
¹³⁵ Department of Anesthesiology, Riyadh, Saudi Arabia; Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA.
¹³⁶ Warwick Medical School, University of Warwick, Coventry, UK.
¹³⁷ Federal Institute for Population Research, Wiesbaden, Germany; German National Cohort Consortium, Heidelberg, Germany.
¹³⁸ Jackson State University, Jackson, MS, USA.
¹³⁹ Faculty of Medicine, Mansoura University, Mansoura, Egypt.
¹⁴⁰ Clinical Investigation Centre INSERM, Université de Lorraine, Vandoeuvre les Nancy, France; CHU de Nancy, Vandoeuvre les Nancy, France.
¹⁴¹ Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA; Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia.

PMID: 27568068
PMCID: PMC6660972
DOI: 10.1016/S2214-109X(16)30168-1

Abstract

Background: The eastern Mediterranean region is comprised of 22 countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, and Yemen. Since our Global Burden of Disease Study 2010 (GBD 2010), the region has faced unrest as a result of revolutions, wars, and the so-called Arab uprisings. The objective of this study was to present the burden of diseases, injuries, and risk factors in the eastern Mediterranean region as of 2013.

Methods: GBD 2013 includes an annual assessment covering 188 countries from 1990 to 2013. The study covers 306 diseases and injuries, 1233 sequelae, and 79 risk factors. Our GBD 2013 analyses included the addition of new data through updated systematic reviews and through the contribution of unpublished data sources from collaborators, an updated version of modelling software, and several improvements in our methods. In this systematic analysis, we use data from GBD 2013 to analyse the burden of disease and injuries in the eastern Mediterranean region specifically.

Findings: The leading cause of death in the region in 2013 was ischaemic heart disease (90·3 deaths per 100 000 people), which increased by 17·2% since 1990. However, diarrhoeal diseases were the leading cause of death in Somalia (186·7 deaths per 100 000 people) in 2013, which decreased by 26·9% since 1990. The leading cause of disability-adjusted life-years (DALYs) was ischaemic heart disease for males and lower respiratory infection for females. High blood pressure was the leading risk factor for DALYs in 2013, with an increase of 83·3% since 1990. Risk factors for DALYs varied by country. In low-income countries, childhood wasting was the leading cause of DALYs in Afghanistan, Somalia, and Yemen, whereas unsafe sex was the leading cause in Djibouti. Non-communicable risk factors were the leading cause of DALYs in high-income and middle-income countries in the region. DALY risk factors varied by age, with child and maternal malnutrition affecting the younger age groups (aged 28 days to 4 years), whereas high bodyweight and systolic blood pressure affected older people (aged 60-80 years). The proportion of DALYs attributed to high body-mass index increased from 3·7% to 7·5% between 1990 and 2013. Burden of mental health problems and drug use increased. Most increases in DALYs, especially from non-communicable diseases, were due to population growth. The crises in Egypt, Yemen, Libya, and Syria have resulted in a reduction in life expectancy; life expectancy in Syria would have been 5 years higher than that recorded for females and 6 years higher for males had the crisis not occurred.

Interpretation: Our study shows that the eastern Mediterranean region is going through a crucial health phase. The Arab uprisings and the wars that followed, coupled with ageing and population growth, will have a major impact on the region's health and resources. The region has historically seen improvements in life expectancy and other health indicators, even under stress. However, the current situation will cause deteriorating health conditions for many countries and for many years and will have an impact on the region and the rest of the world. Based on our findings, we call for increased investment in health in the region in addition to reducing the conflicts.

Funding: Bill & Melinda Gates Foundation.

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Figures

**Figure 1**
DALYs attributed to risk factors in countries of the eastern Mediterranean region, 1990 and 2013 DALYs=disability-adjusted life-years.

**Figure 2**
Projected versus observed life expectancy at birth of males in Egypt, Libya, Syria, Tunisia, and Yemen, 2000–13 GBD=Global Burden of Disease.

**Figure 3**
Projected versus observed life expectancy at birth of females in Egypt, Libya, Syria, Tunisia, and Yemen, 2000–13 GBD=Global Burden of Disease.

See this image and copyright information in PMC

Comment in

Health in times of uncertainty.
Lafta RK. Lafta RK. Lancet Glob Health. 2016 Oct;4(10):e666-7. doi: 10.1016/S2214-109X(16)30184-X. Epub 2016 Aug 25. Lancet Glob Health. 2016. PMID: 27568067 No abstract available.

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References

1. WHO WHO Regional Office for the Eastern Mediterranean. http://www.emro.who.int/entity/about-us/index.html (accessed May 22, 2016).
1. Mandil A, Chaaya M, Saab D. Health status, epidemiological profile and prospects: Eastern Mediterranean region. Int J Epidemiol. 2013;42:616–626. - PubMed
1. Mokdad AH, Jaber S, Aziz MIA. The state of health in the Arab world, 1990–2010: an analysis of the burden of diseases, injuries, and risk factors. Lancet. 2014;383:309–320. - PubMed
1. Naghavi M, Wang H, Lozano R. Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;385:117–171. - PMC - PubMed
1. Murray CJL, Barber RM, Foreman KJ. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological transition. Lancet. 2015;386:2145–2191. - PMC - PubMed

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[1] WHO WHO Regional Office for the Eastern Mediterranean. http://www.emro.who.int/entity/about-us/index.html (accessed May 22, 2016).

[2] WHO WHO Regional Office for the Eastern Mediterranean. http://www.emro.who.int/entity/about-us/index.html (accessed May 22, 2016).

[3] Mandil A, Chaaya M, Saab D. Health status, epidemiological profile and prospects: Eastern Mediterranean region. Int J Epidemiol. 2013;42:616–626. - PubMed

[4] Mandil A, Chaaya M, Saab D. Health status, epidemiological profile and prospects: Eastern Mediterranean region. Int J Epidemiol. 2013;42:616–626. - PubMed

[5] Mokdad AH, Jaber S, Aziz MIA. The state of health in the Arab world, 1990–2010: an analysis of the burden of diseases, injuries, and risk factors. Lancet. 2014;383:309–320. - PubMed

[6] Mokdad AH, Jaber S, Aziz MIA. The state of health in the Arab world, 1990–2010: an analysis of the burden of diseases, injuries, and risk factors. Lancet. 2014;383:309–320. - PubMed

[7] Naghavi M, Wang H, Lozano R. Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;385:117–171. - PMC - PubMed

[8] Naghavi M, Wang H, Lozano R. Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;385:117–171. - PMC - PubMed

[9] Murray CJL, Barber RM, Foreman KJ. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological transition. Lancet. 2015;386:2145–2191. - PMC - PubMed

[10] Murray CJL, Barber RM, Foreman KJ. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological transition. Lancet. 2015;386:2145–2191. - PMC - PubMed

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

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