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A safer world
  1. Brian D Johnston
  1. Correspondence to Dr Brian D Johnston, Department of Pediatrics, University of Washington, Harborview Medical Center, 325 Ninth Ave, Box 359774, Seattle WA 98104, USA; ipeditor{at}

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The Global Burden of Disease and Injury project (GBD) is a monumental undertaking. First commissioned by the World Bank in 1990, and more recently supported by the Bill and Melinda Gates Foundation, this study aims to quantify the global burden and distribution of mortality, morbidity and disability attributable to a comprehensive set of diseases, conditions and risk factors. Results are most commonly presented as disability adjusted life years (DALYs), a common metric that accounts for years of life lost and for years of life lived with pain, impairment or other disability. Causes are grouped into three large domains: (1) communicable, neonatal, maternal and nutritional disorders; (2) non-communicable diseases and (3) injuries.

The methods employed to generate these estimates are both state-of-the-art and daunting, involving huge human and computational resources.1 The raw data are amassed from vital registries, community and household surveys, hospital discharge abstracts and a host of other sources, including published epidemiological studies. These data are fed into sophisticated modelling programmes that generate global, regional, national and—in some cases—subnational—estimates, along with appropriate uncertainty intervals. In some cases this means extrapolating assumptions from one country or region to another. In others, it means glossing over the important—but unmeasured—differences that occur within countries and among demographic subpopulations.

These methods have been presented by the authors in multiple venues over the years and, while not without controversy, are generally seen as the best available approach to generating reasonable, meaningful and replicable estimates at a global scale.2 Updates to GBD estimates are eagerly anticipated and, in its current iteration, the project aims to provide new data on a near-continuous basis. Although typically published in peer reviewed journals, the results are also available online and accessible through interactive visualisation modules (

In this issue, Haagsma and colleagues present the first injury-focused manuscript from the GBD study.3 This study provides detail on the methods used, updates injury burden estimates with 2013 data and allows analysis of trends over the period 1990–2013. Compared with previous GBD data on injury, there is expansion of the number of E-codes and N-codes included—allowing greater nuance in estimates over populations and over time. In addition, the work encompasses new population-level outcomes of injury studies as well as short-term injury-related disability estimates.

The most welcome result is that the rate of DALYs for injury has fallen by 31% over the period 1990–2013. This is a remarkable assertion. While injury is consistently responsible for around 10% of the global burden of disease, the rate of total DALYs per 100 000 population has fallen over the last two decades and with it, the rate for injury2 (figure 1). Careful inspection suggests that both the incidence of injury and the disability associated with each event have declined. That is, success in reducing the burden of disease attributable to injury seems to have come from both primary prevention and from better medical care or rehabilitation of the injured. This is a positive and encouraging finding.

Figure 1

Rates of disability adjusted life years (DALYs) loss per 100 000 per year by major grouping of cause. Data from Institute for Health Metrics and Evaluation IHME GBD data visualisation site (, accessed November 2015.

Advocates for injury prevention will note, however, that their work is far from complete. The toll of death and human misery attributable to injury is both preventable and devastatingly high. And while the world is arguably safer than it was in 1990, there are still populations, defined by age or geography or injury mechanism, for whom little progress is evident. The beauty of the GBD data is that they allow objective exploration of those differences and the generation of hypotheses to explain them.

The GBD team presents burden data in terms of both prevalence—a summation of disability and life lost—and as rates of DALYs per 100 000 persons per year. Prevalence data can be used at a national or subnational level to plan services and allocate resources. Rate data are more helpful for comparison between regions, among countries or over time. These contrasts can be used to spark research questions.

It is also true that regional data, or even national data, will obscure important epidemiological and demographic distinctions at the local level or among specific subpopulations. Stratification in GBD results is limited to age and sex. It would be helpful to see groupings based on socioeconomic status or living conditions. In the era of sprawling megacities, there is value in monitoring and measuring the health of people living in informal settlements, such as urban slums. But traditional disease or death registries are unlikely to reflect the health of that fluid population. And it is hard to believe that data estimates derived from aggregation and extrapolation of limited primary sources can then become the basis for policy or programming at an intensely local level.

But that becomes a challenge to researchers too. Ultimately, one might like to see thousands of local epidemiological studies fielded—‘crowd sourced’, in effect—to gather data from the subregions and subpopulations unrepresented, or simply estimated, in the global aggregate. Local researchers might start with a template for data needed, quality controls for potential data sources and a reporting tool to feed results back to the GBD project. The GBD project staff, in turn, could identify gaps and data needs as they continue to refine and update their estimates. An academic publishing model for these needed studies would allow initial peer review and academic credit for authorship. Researchers would also know that their descriptive data would be immediately useful at both a local and global level.

Submissions to Injury Prevention typically start with a statement that ‘injury is a serious problem’ with, at best, a tangential reference in support. With the data now available, we can say just how serious a problem injury is, with reliable, longitudinal measures of its burden, alongside those of other major causes of human suffering. Access to these data—the comparisons they allow and the questions they raise—will have implications for policy, for research and for advocacy. We are very pleased to present these data here and hope that they will be widely and productively used.

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Following a rash of crashes involving police in one US community, a new policy was introduced that requires the department to investigate all incidents when a police vehicle exceeds 70 mph. It also creates a point system for preventable crashes. Penalties are given based on the number of points a driver receives within a five-year period.

Careless driving fines in Warwickshire

In Warwickhsire, England, 135 motorists received fines for careless driving. This coincided with an Injury Prevention Day initiated by the Association of Personal Injury Lawyers - a not-for-profit group campaigning to make tailgating socially unacceptable. The president of the group described the practice as “incredibly anti-social, … dangerous, intimidating, and entirely pointless as it's not going to get anyone to their destination any faster'.


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  • Twitter Follow Brian Johnston at @bdj8824

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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