The burden of atopic dermatitis and bacterial skin infections among urban-living Indigenous children and young people in high-income countries: A systematic review.

BACKGROUND: A high burden of bacterial skin infections (BSI) is well documented in remote-living Indigenous children and young people (CYP) in high-income countries (HIC). Atopic dermatitis (AD) is the most common chronic inflammatory skin condition seen in CYP and predisposes to BSI. Despite the rate of urbanization for Indigenous people increasing globally, research is lacking on the burden of AD and BSI for urban-living Indigenous CYP in HIC. Indigenous people in HIC share a history of colonization, displacement and subsequent ongoing negative impacts on health. OBJECTIVE: To provide a global background on the burden of AD and BSI in urban-living Indigenous CYP in HIC. METHODS: A systematic review of primary observational studies on AD and BSI in English containing epidemiologic data was performed. MEDLINE, EMBASE, EMCARE, Web of Science, and PubMed databases were searched for articles between January 1990 and December 2021. RESULTS: From 2278 original manuscripts, 16 were included: seven manuscripts documenting eight studies on AD; and nine manuscripts documenting nine studies on BSI. Current and severe symptoms of AD were more common in urban-living Indigenous CYP in HIC compared with their non-Indigenous peers, with children having a higher prevalence than adolescents. Urban-living Indigenous CYP in HIC had a higher incidence of all measures of BSI compared with their non-Indigenous peers, and were over-represented for all measures of BSI compared with their proportion of the background population. Limitations include incomplete representation of all Indigenous populations in HIC. CONCLUSION: A significant burden of AD and BSI exists in urban-living Indigenous CYP in HIC.

Global neonatal perioperative mortality: A systematic review and meta-analysis.

STUDY OBJECTIVE: There are large differences in health care among countries. A higher perioperative mortality rate (POMR) in neonates than in older children and adults has been recognized worldwide. The aim of this study was to provide a systematic review of published 24-h and 30-day POMRs in neonates from 2011 to 2022 in countries with different Human Development Index (HDI) levels. DESIGN AND SETTING: A systematic review with a meta-analysis of studies that reported 24-h and 30-day POMRs in neonates was performed. We searched the databases from January 2011 to July 30, 2022. MEASUREMENTS: The POMRs (per 10,000 procedures under anesthesia) were analyzed according to country HDI. The HDI levels ranged from 0 to 1, representing the lowest and highest levels, respectively (very-high-HDI: ≥ 0.800, high-HDI: 0.700-0.799, medium-HDI: 0.550-0.699, and low-HDI: < 0.550). The magnitude of the POMRs by country HDI was studied using meta-analysis. MAIN RESULTS: Eighteen studies from 45 countries were included. The 24-h (n = 96 deaths) and 30-day (n = 459 deaths) POMRs were analyzed from 33,729 anesthetic procedures. The odds ratios (ORs) of the 24-h POMR in low-HDI countries were higher than those in very-high- (OR 8.4, 95% CI 1.7-40.4; p = 0.008), high- (OR 7.3, 95% CI 2.2-24.4; p = 0.001) and medium-HDI countries (OR 7.7, 95% CI 3.1-18.7; p < 0.0001) but with no odds differences between very-high- and high-HDI countries (p = 0.879), very-high- and medium-HDI countries (p = 0.915) and high- and medium-HDI countries (p = 0.689). The odds of a 30-day POMR in low-HDI countries were higher than those in very-high-HDI countries (OR 6.9, 95% CI 1.9-24.6; p = 0.002) but not in high-HDI countries (OR 1.4, 95% CI 0.6-3.0; p = 0.396). CONCLUSIONS: The review demonstrated very high global POMRs in a surgical population of neonates independent of the country HDI level. We identified differences in 24-h and 30-day POMRs between low-HDI countries and other countries with higher HDI levels.

Prevalence of Caries and Associated Risk Factors in a Representative Group of Preschool Children from an Urban Area with High Income in Milan Province, Italy.

The present survey provides a quantitative assessment of caries prevalence, covering a group of 3-5 year-old children from an urban area generally with a high income in the province of Milan, and a comparison of the obtained results with the data presented by the W.H.O. A cross-sectional study was conducted in the period from March to September 2018 to investigate the prevalence of caries in a sample of 160 children (82 females and 78 males). The absence/presence of caries was defined as a dependent variable. Factors concerning lifestyle, diet, oral habits, oral hygiene, the presence and type of malocclusion and mouth breathing attitude were considered as risk factors. Data were analyzed by Chi-square (χ2) and regression tests using SPSS (version 25.0) software. In total, 84.38% of children (135 out of 160) showed no caries. A regression analysis demonstrated that children who had already received an early first dental visit were mostly those already affected by caries. Furthermore, children who had four meals daily or more were less exposed to the risk of developing caries compared to those who had only 1-3 meals daily. The caries prevalence of preschool children from urban areas with a high income in Milan province is relatively close to that considered acceptable by the W.H.O. in its proposed goals for the year 2020. Therefore, it can be concluded from the obtained results that there is a possibility for further improvement in preventing caries growth at its initial stage: it is necessary for the number of meals daily consumed by children to be controlled by parents, and conducting a dental visit early in childhood must not be neglected.

Copper, zinc, and magnesium content of breast milk of Indian women.

Copper, zinc, and magnesium contents were determined in samples of breast milk obtained from 412 women in a low income group, from 100 women in a high income group of an urban population, and from 22 women from a low income group living in a rural area. Paired samples of milk and serum were collected from 152 women and the concentrations of copper and zinc in these two fluids were estimated. Copper levels fell from 0.46 microgram/ml in colostrum to 0.17 microgram/ml at 7 to 12 months of lactation; zince levels fell from 5.32 to 1.12 microgram/ml by 7 months. Magnesium level in colostrum was 40 micrograms/ml and reached a stable level of around 30 micrograms/ml in mature milk samples. Concentrations of copper and zinc in serum were not correlated with those in milk. Day to day and diurnal variations in the concentrations of these elements in milk were not significant indicating thereby that analysis of one sample provides satisfactory information of the trace element content in milk. There were no differences in the levels of these elements in milk between rural and urban low income groups of women. However significant differences were noted in the copper and zinc contents of milk of women from low and high income groups of the urban population, from the 1st to 3rd month of lactation.

The prevalence, risks, and management of Chlamydia trachomatis infections in fertile and infertile patients from the high socioeconomic bracket of the South African population.

OBJECTIVE: The main objective of the study was to evaluate the prevalence of Chlamydia trachomatis endocervicitis in an infertile population. DESIGN: Forty consecutive patients were enrolled in the study group and 41 in the control group. SETTING: The study was undertaken in the Department of Obstetrics and Gynaecology of the University of the Orange Free State, Bloemfontein, Republic of South Africa. PATIENTS: Infertile white females, visiting an infertility clinic in an academic hospital and fertile white female patients visiting an antenatal clinic. INTERVENTIONS: Endocervical swabs were taken, and monoclonal direct immunofluorescence for C. Trachomatis were done on each. MAIN OUTCOME MEASURES: A difference was expected between the prevalence of C. trachomatis infection in the fertile and infertile population. RESULTS: In the study group, 14(35.9%) positive, 25(64.1%) negative, and 1 fallout were obtained. In the control group, 3 patients (7.32%) tested positive. CONCLUSION: Although no correlation was found between C. trachomatis infection of the female genital tract and the clinical history, it showed a significant correlation with infertility. This justifies routine screening tests and antibiotic treatment of positive infertile couples. Analysis of cost-effectiveness showed that empirical treatment of new infertile couples is justified in some populations.

PIP: Health workers at the Department of Obstetrics and Gynecology of the University of the Orange Free State in Bloemfontein, South Africa enrolled 40 consecutive infertile white couples 41 consecutive pregnant white females into a case control study to determine the prevalence of Chlamydia trachomatis infections in an infertile population. Both groups were from the middle to upper socioeconomic class. Laboratory personnel used the monoclonal direct immunofluorescence test to each cervical cytology smear. They had to repeat the test on 5% of the smears. Prevalence of C. trachomatis in the study group stood much higher than it did in the control group (35.9% vs. 7.3%; p.002). No association existed between clinical history and presence of C. trachomatis in the fertile group. 19.5% of the fertile patients had taken antibiotics during the 3 months prior to the study. None reported earlier episodes of salpingitis and/or pelvic inflammatory disease. The researchers proposed a possible reason for the very high rate of C. trachomatis in infertile patients. Perhaps the infertile clinic only examined unresolved infertile cases who may have had an exceptionally high rate of C. trachomatis. The infertility clinic chose to treat all new couples with lymecycline because studies showed that it is always effective against C. trachomatis. Indeed this treatment proved to be the most beneficial at the lowest cost.

Mortality from diabetes mellitus, ischemic heart disease, and cerebrovascular disease among blacks in a higher income area.

According to the 1980 census, blacks in Suffolk County on Long Island, NY, had a median family income of almost $20,000 versus $12,618 for blacks in the entire United States, or only 20 percent lower than that for whites in the county. Black-white ratios of age-specific death rates for 1979-83 in Suffolk County were elevated for all causes for men and women in age groups from 35-44 to 55-64 years (but not for those 75 years or older), for ischemic heart disease for women (but not men) for age groups from 35-44 to 55-64 years, for diabetes mellitus for most ages (especially for females), and for cerebrovascular disease for both men and women for all age groups from 35-44 to 65-74 years. The age-specific proportional mortality ratios (PMRs) for ischemic heart disease within educational level (less than 12 years and 12 or more years of school) were lower for black than for white men but more similar for black and white women. For diabetes, the PMRs were higher for black versus white women within both educational levels. PMRs for cerebrovascular disease were higher for black than white men within the group of decedents with less than 12 years of education. The findings are discussed with reference to racial differences in the prevalence of poverty as well as possible differences in risk factors (for example, obesity) or medical care independent of poverty.

PIP: The author presents age- and sex-specific death rates for black and white residents of Suffolk County, New York, for all causes of death and for diabetes mellitus, ischemic heart disease, and cerebrovascular disease. He finds that black-white ratios of age-specific death rates for the period 1979-1983 are elevated for all causes for men and women. Consideration is given to the effects of educational status, poverty, medical care, and obesity.

The challenge of world health.

PIP: 2 development specialists have expounded on the demands world health has placed on public health. Striking declines in infant and child mortality occurred with the advent of biomedical and technical interventions in developing countries after World War II. At the same time, these interventions promoted longer lives by curing and/or treating chronic diseases in developed countries. In the 1970s, however, it was apparent that the hospital based, curative approach could not meet health needs and was very costly. In developed countries, biomedical and social sciences showed that chronic diseases did not occur due to modernization but from unhealthy behaviors, diet, and lifestyle. In fact, in 1975, the US Centers for Disease Control announced that unhealthy lifestyles contributed to 50% of all deaths while the medical system was responsible for only 11%. The US and other developed countries then began to promote healthy lifestyles, and in the 1980s, considerable improvements in health occurred, especially among adults. Developing countries which depended on the Western medical model did not experience health gains in the 1970s. Yet developing countries where health systems concentrated on carrying essential services to all people and promoted basic hygiene and sound dietary practices continued to achieve considerable health gains. In 1978, WHO an UNICEF hosted the International Conference on Primary Health Care in Alma Ata, the Soviet Union to hold these developing countries with community based health systems as models of primary health care (PHC). The 1980s witnessed the spread of PHC especially in the form of child survival which focused on oral rehydration therapy and breast feeding. The biomedical and social sciences are needed to move this health policy and program strategy forward. Governments must see to policies that promote healthy people. Political will is needed to make human welfare a high priority.^ieng

Anthropometric standards of privileged neonates in Maiduguri, Nigeria.

PIP: The study had been undertaken with an objective to assess the anthropometric values of privileged neonates in Northeastern Nigeria. The subjects for the study are neonates born to physically and nutritionally normal mothers between 15-40 years of age and coming from a better socioeconomic section of various ethnic groups of Nigeria. 1530 full-term singletons, without any antenatal or natal problem have been studied for their weight, length and head circumference. The mean birth weight was observed to be 3.2 +or- 0.59 kg. with higher values in males. There was a tendency for the mean birthweight to increase with increase in parity. Ibo neonates were heavier than other ethnic groups. The overall incidence of low birthweight babies was 5.75%. Mothers 18 years of age had the highest incidence of intrauterine growth retardation. The average values for length were 49.18 +or- 2.9 cm and for head circumference 34.72 +or- 1.77 cm. Though the mean values for weight, length and head circumference are comparable to American standards, the normal range for large-for-date babies was found to be higher, particularly in Ibo neonates. The ethnic groups classified were Ibo, Kanuri, Hausa, Yoruba, Fulani, Shuwa and other.^ieng

Maternal knowledge regarding breast feeding and weaning practices.

The study assessed the knowledge of mothers of the high income group of urban Baroda, related to breast feeding and weaning. Forty mothers with children aged 4 to 18 months were studied. Knowledge and practices regarding breast feeding and weaning were assessed using pretested questionnaires. Results indicated that only half the mothers breast fed their babies on the first day. Breast feeding was stopped when the child was 3-6 months; top feeding and solid supplements were initiated at 4-6 months. Mainly commercial baby foods were used for weaning. Most mothers avoided 'dals' for the child because these were believed to be difficult to digest and produced gas in the child's stomach. Fifty percent of the mothers were not in favour of feeding the sick child with small frequent meals.

PIP: The study assessed maternal knowledge among high-income women in urban Baroda concerning breast feeding and weaning. 40 mothers with children ages 4-18 months were studied. Knowledge and practices regarding breastfeeding and weaning were assessed using pretested questionnaires. Results indicated that only 1/2 of the mothers breastfed their babies on the 1st day; breastfeeding was stopped when he child was 3-6 months, and top feeding and solid supplements were introduced at 4-6 months. Mainly commercial baby foods were used for weaning. Most mothers avoided "dals" for the child because these were believed to be difficult to digest and produced gas in the stomach. 50% of mothers were not in favor of feeding a sick child with small frequent meals.

Health care in Brazil.

Brazil has great geopolitical importance because of its size, environmental resources, and potential economic power. The organisation of its health care system reflects the schisms within Brazilian society. High technology private care is available to the rich and inadequate public care to the poor. Limited financial resources have been overconcentrated on health care in the hospital sector and health professionals are generally inappropriately trained to meet the needs of the community. However, recent changes in the organisation of health care are taking power away from federal government to state and local authorities. This should help the process of reform, but many vested interests remain to be overcome. A link programme between Britain and Brazil focusing on primary care has resulted in exchange of ideas and staff between the two countries. If primary care in Brazil can be improved it could help to narrow the health divide between rich and poor.

Influence of socioeconomic factors on attaining targets for reducing teenage pregnancies.

OBJECTIVE: To determine the rate of pregnancy and outcome in teenagers in areas of different socioeconomic conditions, and to assess the implication for achievement of government and local targets in reducing unwanted pregnancies in teenagers. DESIGN: Records of pregnancies were obtained from hospital discharge files and rates of live and still births and abortions calculated for each postcode sector. Postcodes were grouped by categories of deprivation and by local government district. SETTING: Tayside, Scotland. SUBJECTS: Teenage girls admitted to National Health Service hospitals for delivery or abortion in 1980-90. MAIN OUTCOME MEASURES: Conception in girls aged under 16 by area of residence and relative proportion leading to live births or terminations. Rate of different outcomes in girls under the age of 20 by area of residence. RESULTS: The pregnancy rate in girls aged under 16 was three times as high, and in all girls under 20 six times as high in the most deprived areas as in the most affluent areas. The proportion of teenage pregnancies ending in abortions was higher in the affluent areas, where two out of three ended in abortion compared with one out of four in the deprived areas. CONCLUSIONS: Although there was a higher pregnancy rate in teenagers in more deprived areas, the proportion ending in abortion was greater in more affluent areas, possibly due to social and parental pressure. The wide geographical variation in patterns of teenage pregnancy indicates the need for a small area rather than a regional approach to setting targets and devising measures of achieving them.

PIP: The objective was to determine the rate of pregnancy in teenagers in areas of different socioeconomic conditions to reduce unwanted pregnancies. Details of all patients admitted to Tayside, Scotland, hospitals between 1 January 1980 and 31 December 1990 were obtained and rates of live and still births and abortions were calculated for postcode sectors categorized by deprivation. Pregnancy outcomes were also evaluated in teenage girls admitted to National Health Service hospitals for delivery or abortion in 1980-90, as well as live births or terminations in girls aged under 16 by area of residence and outcomes in girls under the age of 20 by area of residence. During the 1980s the rate of conception in girls under 16 was 3 times higher in the most deprived areas than in the most affluent. In the deprived areas, however, 1 in 2 pregnancies ended in abortion compared to 2 in 3 in the most affluent areas. The annual rate in Dundee District was 11.6 conceptions/1000 girls aged 13 to 15 compared to 5.4/1000 in Perth and Kinross and 8.3/1000 in Angus. Between 1980 and 1990, 40% of the girls who conceived before their 16th birthday did not give birth or have their pregnancy terminated until after they were 16. The overall rate of teenage pregnancies increased dramatically from the most affluent to the most deprived areas. In the most deprived sectors, about 1 in 4 pregnancies ended in abortion compared with about 2 in 3 in the most affluent sectors. Between 1980 and 1990 there were 1075 girls who had had 2 pregnancies: 18% (193) were married on both occasions, and 175 had 2 live births. Among single girls at the end of both pregnancies, 32% (225) had live births (or still births) on both occasions compared with 20% (142) terminating their pregnancies on both occasions. Although there was a higher pregnancy rate in more deprived areas, the proportion ending in abortion was greater in more affluent areas, possibly occasioned by social and parental pressure.

High level manpower movements in Northwest Europe and the role of careers: an explanatory framework.

"This article works towards a theoretical explanatory framework for analyzing the geographical patterns of labor flows between the industrial countries of Western Europe. The framework proposed is based on the disaggregated nature of the modern labor market, in which specialist skills and training result in a workforce segmented into self-contained noncompeting groups. It is applied to the migration within Northwest Europe of high level manpower, especially those moving within multinational organizations."

Family strategies and the migration of women: migrants to Dagupan City, Philippines.

PIP: This study of women migrants to Dagupan, a 2ndry city in the Philippines, finds complex occupational and migration patterns with women in informal sector occupations as well as in professional/clerical ones. A large number of those in professional or clerical positions, who are also better educated, had moved away from home previously to study, whereas for a majority of those in the informal sector, including salesworkers, the move to Dagupan was the 1st in their life. While a majority of the former had moved with a definite job offer, the latter usually had come to Dagupan at the suggestion of relatives to look for work. Decision to move, usually made by the father, occurs within a cultural context which upholds strong expectations regarding the obligations of family members to 1 another, in this case, in the form of remittances. Daughters are expected to support families to a greater extent than sons, though both are encouraged to migrate to cities. 3 types of family strategies emerge in the analysis of migration pattersns: 1) rural households, usually poor and with little education, send their daughters out in the hope that remittances would help attain the basic necessities of life; 2) in an attempt to follow a strategy leading to upward mobility, some rural families educate their daughters, especially for occupations in the formal sector, whose remittances are used to educate other siblings; and 3) for those families with higher levels of education and income, encouraging daughters to migrate is done with a view to enhancing their position in society, rather than for the purpose of remittance. Women are encouraged by their families to migrate to cities with the expectation, based on strong cultural values, that such migration would help maintain the family as a unit through, among other things, financial support recieved.^ieng

[Breast feeding in different income classes in the Municipality of São Paulo]. / Aleitamento natural em diferentes classes de renda no Município de São Paulo.

PIP: The relationship between breast feeding and socioeconomic factors in children below 2 from different social classes in Sao Paulo, Brazil is analyzed. Of a total 200 children, 46 were malnourished and 31 belonged to the lower socioeconomic classes. 39% of mothers from the lower income families breastfed for 6 months, as compared to 13% of mothers from families with higher incomes 18% and 36% of mothers from the 2 classes did not breastfeed; mothers from the middle class breastfed for an average 28 days. The problem of protein-calorie malnutrition in young children is a growing one in Brazil, even in a relatively rich city such as Sao Paulo; one of the factors responsible for this problem is undoubtedly early weaning. Reasons given for early weaning in a group of 351 mothers were deficient amount of milk (49.6%), medical advice (11.1%), "bad" milk (14.3%), and only 1.4% because of occupation outside of the home. When interviewed about their opinion on the best type of milk for infants, 45% out of a group of 500 mothers indicated artificial milk, 37% maternal milk, and 16.2% cow's milk. Out of 492 mothers, 77% had 4 prenatal visits at a public health center, 11% had no prenatal visits, and 12% had 1-3 visits. Prenatal care does not influence attitude in favor of breast feeding; 45.5% of mothers who had not had any prenatal care breastfed for 6 months or more, as compared to 20% of those with 1-3 visits, and 17.5% of those with 4 visits. Those who delivered in a hospital tended to breastfeed more than those who delivered at home. It is obvious that not only mothers but health workers as well must be educated on the importance of breast feeding to fight infant malnutrition in Brazil.^ieng

[Models of feeding in the genesis of obesity in the 1st year of life]. / Pautas de alimentación en la génesis del sobrepeso durante el primer año de vida.

PIP: This work analyzes the prevalence of obesity and overweight in infants of the upper socioeconomic strata in Mexico and assesses the role of feeding practices in overweight. The study subjects were 317 healthy boys and 289 healthy girls under 1 year old seen by a group of 6 pediatricians. Obesity was defined as 120% of the standard weight for height and overweight as 110-119% of the standard. Infants were considered underweight if they weighed 80-90% of the standard weight for height. 2.8% of the children were obese, 15.7% were overweight, 75.1% were the optimal weight, and 6.4% were underweight. There were no differences by sex. The frequency of obesity and overweight were higher in the 1st half of the 1st year. There was no statistically significant difference in birth weight although the average birth weight of the currently underweight was lower. Firstborn children were significantly more likely to have a low birth weight or optimal weight. The obese and overweight children were significantly more likely to have been born between January-June. By 6 months of age, only 3.3% of the infants were exclusively breast fed and 4.9% were breast fed and given supplementary milk feedings. Over 90% of the children were bottle fed by 6 months. The obese and overweight children were weaned at earlier ages on average and were more likely to be fed cereals in the 2nd 6 months. They also were fed a more varied diet. Weight problems in infants thus appear to result in large part from exogenous factors related to feeding practices.^ieng

Feeding pattern practised by the mothers attending an under five clinic.

PIP: A random selection of 100 infants from the R.G. Kar Medical College & Hospital, Calcutta were surveyed to determine the type of feeding, monthly weight gain and mothers' opinion of feeding. The children were from upper, middle and lower classes. At 3 months of age 36% were exclusively breast fed, 19% were fed artificially, and 45% were fed mixed diets. The mean monthly weight gains were 0.91, 0.98 and 0.90 kg for the 1st, 2nd and 3rd months for breast fed babies, and 0.74, 0.71 and 0.65 kg for formula fed and supplemented babies. When surveyed, 91.5% of upper class, 86.4% of middle and 82.1% of lower class mothers were in favor of breast feeding.^ieng

Global health status.

PIP: In the paper by Kasturi Sen and Ruth Bonita, it is argued that the global rapid demographic and risk factor changes will lead to an increase in the heavy burden of noncommunicable diseases in the absence of preventive action. However, it should be emphasized that noncommunicable diseases are already well established in less developed countries. Statistical calculations using data from 1998 show that the rates of noncommunicable diseases are similar in countries with high and low or middle incomes. The rates, expressed as disease-adjusted life years per 100,000 population, take into account the fact that low-income or middle-income countries contain 85% of the world's population and account for at least 92% of the world's disease burden. It is noted that the rates for communicable conditions and injuries are 13 and 3 times higher in low-income and middle-income countries than in high-income countries, respectively. In view of this, the Global Forum for Health Research is working to help correct the imbalance in health research funding from projects benefiting few people to projects benefiting the majority.^ieng

A "world" distribution of income and of real poverty and affluence.

PIP: International comparative estimates of income distribution are formulated using data from household income and expenditure surveys for nine developing and five developed countries. The focus is on a comparison among countries concerning the percentage and number of the affluent and those living in poverty. The results show a decrease since the 1960s in the number of those living in poverty. The significance for economic development of the growth of an affluent population in the developing world is considered.^ieng

The effect of women's labor force participation on the distribution of income in the United States.

The effect of women's labor force participation on income distribution in the United States is reviewed. "Because the wives of highly paid men participate less in the labor force, the earnings of working wives make the distribution of pretax, money income more equal for families than it might otherwise be. Although there is considerable speculation that future developments in women's labor force participation may foster greater inequality, the empirical results are mixed." The factors that need to be considered in future research are outlined.

The burden of disease among the global poor.

BACKGROUND: Global and regional estimates show that non-communicable diseases in old age are rising in importance relative to other causes of ill health as populations age, and as progress continues against communicable diseases among infants and children. However, these estimates, which cover population groups at all income levels, do not accurately reflect conditions that prevail among the poor. We estimated the burden of disease among the 20% of the global population living in countries with the lowest per capita incomes, compared with the 20% of the world's people living in the richest countries. METHODS: Estimates for the global poorest and richest 20% were prepared for 1990 for deaths and disability-adjusted life years (DALYs), by a procedure used in a prominent recent study of the global disease burden. Projected mortality rates in the year 2020 were established for the world's poorest and richest 20% under various assumptions about the future rate of decline in communicable and non-communicable diseases. FINDINGS: In 1990, communicable diseases caused 59% of death and disability among the world's poorest 20%. Among the world's richest 20%, on the other hand, non-communicable diseases caused 85% of death and disability. A raised baseline rate of communicable disease decline between 1990 and 2020 would increase life-expectancy among the world's poorest 20% around ten times as much as it would the richest 20% (4.1 vs 0.4 years). However, the poorest 20% would gain only around a quarter to a third as much as the richest 20% from a similar increase in non-communicable diseases (1.4 vs 5.3 years). As a result, a faster decline in communicable diseases would decease the poor-rich gap in 2020, but under an accelerated rate of overall decline in non-communicable diseases, the poor-rich gap would widen. INTERPRETATION: Our estimates are crude, but despite their limitations, they give a more accurate picture of changes in attributable mortality among the world's poor than do the global averages in current use.

PIP: This study presents the burden of disease among the poor globally. The burden of disease among the poorest 20% of the population, was compared to that among the richest 20% using deaths and disability-adjusted life years (DALYs). Projected mortality rates for the richest and poorest were established under various assumptions about the decline in the communicable and noncommunicable disease rates. Results showed that among the poorest 20% of the world's population (1990), communicable diseases caused 59% deaths and 64% DALY loss; noncommunicable disease caused 85% of death and DALY loss. Among the world's richest 20%, communicable diseases accounted for 8% of deaths and 11% of DALY loss. A raised baseline rate of communicable disease decreases between 1990 and 2020 would increase life expectancy among the worlds poorest 20% by about 10 times the rate that it would increase life expectancy among the richest 20%. However, the poorest would gain only around quarter to a third as much as the richest 20% from a similar increase in the decline of noncommunicable diseases. Therefore, a faster overall decline in communicable diseases would decrease the poor/rich gap in 2020, but under an accelerated overall decline in noncommunicable diseases, the poor/rich gap would widen. The authors concede that the data presented are only rough estimates, but they believe that these estimates give a more accurate picture of changes in attributable mortality than do the global averages in current use.