Alexander Butchart Coordinator, Prevention of Violence and

1. Estimating global mortality due to interpersonal and collective violence Alexander Butchart Coordinator, Prevention of Violence and Colin MathersCoordinator, Mortality and Burden of Disease Global Response 2010, Copenhagen 22-25 January 2010

2. Overview • Typology of violence and global estimates of deaths due to violence • Sources of information • Measures of violence using vital registration • Interpersonal violence • Collective violence • Global Burden of Disease estimates of violence • Conclusions

3. Violence Self-directed Interpersonal Collective Typology of violence

4. Injury Unintentional Intentional Self-harm(suicide) Interpersonal(homicide) Collective(war) Firearm/Cut/Drown/Fall/Fire/Poison/Suffocation/Struck International Classification of Disease categorisation of injury deaths

5. Violent deaths by type of violence, year 2004 Collective 184,000 (13%) Self-directed 844,000 (51%) Interpersonal 600,000 (36%) N = 1.6 million

6. High income 9% Low & middle income 91% Violent deaths by country income, year 2004 N = 1.6 million

7. Top 10 causes of death, ages 5-44 years, both sexes, 2004

8. Sources of information on violence mortality and morbidity • Vital registration systems (medically certified or verbal autopsy) • Sample registration systems • Demographic surveillance systems • Population surveys and censuses with verbal autopsy • Deaths in household in last 12/24 months • Deaths of children • Deaths of siblings/parents • Self-reported injury incidence/hospitalization • Police and judicial system statistics • Media reports (conflict and natural disasters) • Hospital databases (coverage, population)

9. WHO Mortality Database • WHO Member States with vital registration systems regularly provide data on registered deaths by cause, age and sex to WHO • Most countries use the International Classification of Diseases (ICD) Revision 9 or Revision 10 (the latest version) • Some countries use earlier versions, or non-standard coding systems (short lists) • Death registration data for some countries is not complete • Available online at www.who.int/research/en • Country-years can be selected and viewed online • Full database can be downloaded in compressed form

10. Data reporting frequency varies Of the reporting countries, half of them are developed providing 75% of the number of deaths

11. Coverage in some regions is poor and reporting is sporadic

12. Measures of violence using vital registration systems:Interpersonal violence

13. Estimating homicide rates from death registration data • Coverage less than 90% complete for around 40 countries(eg. Egypt 80%, Kyrgyzstan 75%, Peru 50%, Turkey < 50%) • Cause distribution may be biased in countries with incomplete coverage (poorer, rural areas usually have less coverage) • Injury causes may be under-reported relative to other causesto avoid legal and other problems • Some countries classify higher proportions of injury deaths to a category ‘undetermined intent’

14. Vital Registration Challenges: South Africa

15. Estonia Latvia 3000 5 2500 4 2000 3 Male Male Eastern Europe – All injury deaths Thousands 1500 Female Female 2 1000 1 500 0 0 1970 1975 1980 1985 1990 1950 1990 1995 2000 1995 2000 1975 1980 1985 1950 1955 1960 1965 1955 1960 1965 1970 Lithuania Russian Federation 6 350 300 5 250 4 Male Male 200 Thousands Thousands 3 Female Female 150 2 100 1 50 0 0 1955 1960 1965 1970 1950 1960 1975 1985 2000 1950 1990 1995 2000 1970 1995 1975 1980 1985 1955 1965 1980 1990

16. Measures of violence using vital registration systems:Collective violence

17. Revolution, 1973 Chile Chile: All Injury Deaths COW: 8,000 Deaths VR Excess Injury Deaths: ~2,000 Deaths 9 8 7 6 Male 5 Thousands Female 4 3 2 1 0 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

18. Croatia: All Injury Deaths

19. Earthquake, Feb. 4, 1976 7.5 Richter Scale Peak of state violence, 1980- Guatemala Guatemala: All Injury Deaths CRED EM-DAT: 23,000 Deaths VR Excess Injury Deaths: ~12,000 Deaths AAAS: 6,000 Deaths (1980-81) VR Excess Injury Deaths: ~12,000 14 12 10 8 Thousands 6 4 Male 2 Female 0 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

20. Colombia Bosnia and Herzegovina 50 2000 40 1500 30 Male Male Thousands 1000 Female Female Missing Data - All Injury Deaths 20 500 10 0 0 1955 1975 1980 1995 2000 1950 1970 1990 1960 1965 1985 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 El Salvador • Vital registration systems usually don't function during war • Missing data and incomplete vital registration are common 12 10 8 Male Thousands 6 Female 4 2 0 1950 1970 1990 1960 1965 1985 1955 1975 1980 1995 2000

21. Global Burden of Disease (GBD) estimates of violence

22. Estimated all injury and violence deaths (000s), by region, 2004

23. Global burden of disease 2005 A complete new assessment • $11m grant from Bill and Melinda Gates Foundation • Led by Institute for Health Metrics and Evaluation (Seattle) • + WHO, Harvard University, Univ. of Queensland, Johns Hopkins • Expanded cause lists – tackling firearms injuries, intimate partner violence among many other causes and risks • Started in 2007, aim to complete by end 2010 Objectives • New disease, injury, risk factor estimates for 1990 and 2005 • For 21 regions spanning the global population • Create simplified analytical tools and training for BOD studies

24. GBD estimates of global conflict deaths Definitional issues • Include deaths due to injuries incurred years earlier and recent deaths due to explosive devices that may have been laid years earlier • Include deaths in military personnel and civilians, both on and off the battlefield • Include all organized conflicts, including cross-national, intra-national and as a result of terrorism • Exclude deaths from other causes (e.g. starvation, infectious disease) indirectly due to collective violence

25. GBD estimates of global conflict deaths Input data • Project Ploughshares • Uppsala Conflict Data Project • Centre for International Development and Conflict Management • Conflict-specific surveys and databases (e.g. Iraq, DR Congo) • Landmine Monitor • Handicap International annual reports on landmine victims • Vital registration data

26. Population surveys to measure conflict deaths • Iraq Family Health Survey, 2006-7 • Sibling survival • Afghanistan Mortality Survey, 2010 • Sibling history and parental survival • World Health Survey, 2002-3 • Sibling history

27. Conclusions • Primary approach should be to through country information systems (death registration, hospital inpatient and outpatient data systems etc) • Good coverage in Europe and Latin America, very poor coverage in Asia and Africa • Improving the coverage and quality of death registration systems (certification and coding, verbal autopsy, completeness of coverage) • Sample registration, demographic surveillance • Population surveys and censuses (deaths in household, sibling survival, verbal autopsy, issues of under-reporting and recall bias) • Cluster sample surveys of populations in crisis • Other innovative census and demographic-based methods, eg. capture-recapture studies

28. For more information http://www.who.int/healthinfo/morttables/en/index.html http://www.who.int/evidence/bod http://www.globalburden.org mathersc@who.int