Since The Lancet published the first Global Burden of Disease Study (GBD) over 10 years ago, every new iteration has brought improvements in data quality and quantity. With the sharpening of these estimates came a reassuring message: year on year, they portrayed an ever-healthier world. Careful reading of the results of GBD 2017 shatter this comforting trend of gradual improvement and instead show plateauing mortality rates on a background of faltering and uneven progress, era-defining epidemics, and dramatic health worker shortages. Instead of the progress updates we have become accustomed to, GBD 2017 comes as an urgent warning signal from a fragile and fragmented world.
In 2017, global adult mortality rates decreases plateaued, and, in some cases, mortality rates increased. Alarmingly, conflict and terrorism have become two of the fastest growing causes of death globally (increasing by 118% between 2007 and 2017). Alongside this alarming growth in violence, our era is characterised by epidemics such as opioid dependence, noncommunicable diseases, depression, and dengue fever. Opioid dependence has grown to an unprecedented scale, with 4 million new cases in 2017 and 110 000 deaths. Non-communicable diseases accounted for 73% of all global deaths in 2017, with over half of all deaths (28·8 million) attributable to just four risk factors: high blood pressure, smoking, high blood glucose, and high body-mass index. Obesity prevalence has risen in almost every country in the world—leading to more than a million deaths from type 2 diabetes, half a million deaths from diabetes-related chronic kidney disease, and 180 000 deaths related to non-alcoholic steatohepatitis. In 2017, depressive disorders were the third leading cause of years lived with disability after low back pain and headache disorders, and deaths from dengue fever, a disease often associated with struggling development and urbanisation, increased substantially in most tropical and subtropical countries, rising from 24 500 deaths globally in 2007 to 40 500 in 2017.
Sex-specific disagregation of the data in GBD 2017 uncovers areas where the gendered aspects of health—too often overlooked—can be acted upon. Estimates show that substantial differences in health for men and women that underlie the overall headline figures are still pervasive. Whereas deaths among adult men are stagnant in many parts of the world, and, in some areas, mortality has increased, women are living longer but with more years in poor health. Interestingly, the greatest sex differences in outcomes—substance use disorders, transport injuries, and self-harm and interpersonal violence—are socially driven, suggesting that more attention and action are needed.
For the first time in the history of the GBD, estimates of health worker density were included. These show that the global shortage and unequal distribution of health workers requires urgent attention in order not to undermine attainment of the Sustainable Development Goals (SDGs). The authors estimate that only half of all countries had the health-care workers required to deliver quality health care (estimated at 30 physicians, 100 nurses or midwives, and five pharmacists per 10 000 people). Although many European countries have highly resourced health workforces, countries across sub-Saharan Africa, southeast Asia, south Asia, and some countries in Oceania were estimated to have the greatest shortfalls.
Crucially, GBD 2017 estimates that no country is on track to meet all of WHO's health-related SDGs by 2030. Under-five mortality, neonatal mortality, maternal mortality, and malaria indicators had the most countries with at least 95% probability of success. However, for many other targets—including child malnutrition and violence reduction goals—no country in the world has attained the pace of change that is required for these goals to be met.
GBD 2017 is disturbing. Not only do the amalgamated global figures show a worrying slowdown in progress but the more granular data unearths exactly how patchy progress has been. GBD 2017 is a reminder that, without vigilance and constant effort, progress can easily be reversed. But the GBD is also an encouragement to think differently in this time of crisis. By cataloguing inequalities in health-care delivery and patterns of disease geography, this iteration of the GBD presents an opportunity to move away from the generic application of UHC and towards a more tailored precision approach to UHC. GBD 2017 should be an electric shock, galvanising national governments and international agencies not only to redouble their efforts to avoid the imminent loss of hard-won gains but also to adopt a fresh approach to growing threats.
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