Assessing the burden of disease and injury in Metropolitan Los Angeles

SPA 4 VIEWPOINT
ASSESSING THE BURDEN
OF DISEASE AND INJURY
IN METROPOLITAN LOS ANGELES
Los Angeles County Department of Health Services • Public Health
Metropolitan Service Planning Area Health Office (SPA 4)
Summer 2001
SPA 4 BEST PRACTICE COLLECTIONRELIABLE INFORMATION FOR EFFECTIVE COMMUNITY HEALTH PLANS, PROGRAMS AND POLICIES
M. RICARDO CALDERÓN, SERIES EDITOR

The SPA 4 Best Practice Collection fulfills the Los Angeles County
Department of Health Services (DHS) local level goal to restructure and
improve health services by“establishing and effectively disseminating
to all concerned stakeholders comprehensive data and information on
the health status, health risks, and health care utilization of Angelinos
and definable subpopulations”.1
It is a program activity of the SPA 4
Information Dissemination Initiative created with the following goals in
mind:
To highlight lessons learned regarding the design, implementation,
management and evaluation of public health programs
To serve as a brief theoretical and practical reference for program
planners and managers, community leaders, government officials,
community based organizations, health care providers, policy
makers and funding agencies regarding health promotion and
disease prevention and control
To share information and lessons learned in SPA 4 for community
health planning purposes including adaptation or replication in
other SPA’s, counties or states
To advocate a holistic and multidimensional approach to effectively
address gaps and disparities in order to improve the health and
well-being of populations
The SPA 4 Information Dissemination Initiative is an adaptation of
the Joint United Nations Program on HIV/AIDS (UNAIDS) Best Practice
Collection concept. Topics will normally include the following:
1. SPA 4 Viewpoint: An advocacy document aimed primarily at policy
and decision-makers that outlines challenges and problems and
proposes options and solutions.
2. SPA 4 Profile: A technical overview of a topic that provides
information and data needed by public, private and personal health
care providers for program development, implementation and/or
evaluation.
3. SPA 4 Case Study: A detailed real-life example of policies, strategies
or projects that provide important lessons learned in restructuring
health care delivery systems and/or improving the health and well
being of populations.
4. SPA 4 Key Materials: A range of materials designed for educational
or training purposes with up-to-date authoritative thinking and
know-how on a topic or an example of a best practice.
Assessing the Burden of Diesease and Injury in Metropolitan Los Angeles Summer 2001
At a Glance
2
METROPOLITAN SERVICE PLANNING AREA HEALTH OFFICE (SPA 4)
241 North Figueroa Street, Room 312
Los Angeles, California 90012
(213) 240-8049
The Best Practice Collection is a publication of the
Metropolitan Service Planning Area (SPA 4). The
opinions expressed herein are those of the editor
and writer(s) and do not necessarily reflect the of-
ficial position or views of the Los Angeles County
Department of Health Services. Excerpts from this
document may be freely reproduced, quoted or
translated, in part or in full, acknowledging SPA 4
as the source.
Internet: http://www.lapublichealth.org/SPA 4
LOS ANGELES COUNTY
BOARD OF SUPERVISORS
Gloria Molina, First District
Yvonne Brathwaite Burke, Second District
Zev Yaroslavsky, Third District
Don Knabe, Fourth District
Michael D. Antonovich, Fifth District
DEPARTMENT OF HEALTH SERVICES
Fred Lead, Acting Director
Jonathan E. Fielding, MD, MPH.
Director of Public Health and County Health Officer
James Haughton, MD, MPH.
Medical Director, Public Health
BEST PRACTICE COLLECTION TEAM
M. Ricardo Calderón, Series Editor
Manuscript Author SPA 4 Area Health Officer
Carina Lopez, MPH.
Project Manager, Information Dissemination Initiative
Elika Derek
Manuscript Author SPA 4 Intern

Assessing the Burden of Disease Injury in Metropolitan Los Angeles Summer 2001
I. INTRODUCTION 4

II. BACKGROUND INFORMATION 4

III. THE BURDEN OF DISEASE IN METROPOLITAN LOS ANGELES 6
IV. THE BURDEN OF DISEASE TECHNOLOGY 8
1. Cost-Effectiveness
2. Policy Development
V. ADAVANTAGES AND LIMITATIONS 12
1. Incommensurability of longevity and quality of life 13
2. Subjectivity on disability weights 14
3. Invalidity of epidemiological estimates 14
4. Exclusion of co-morbidity 14
5. Exclusion of Economic costs of illnesses 15
6. Incapability of reflecting recent disease trends 15
VI. CONCERNS AND CHALLANGES 14
1. Political
2. Technical 15
3. Financial 15
4. Managerial
5. Operational
VII. DISCUSSION 15
1. SPA 4 and Los Angeles County
2. SPA 4 and other SPAs 5
3. Future Research Needs
VIII. CONCLUSIONS 16
IX. REFERENCES 17

Table of Contents
3
ASSESSING THE BURDEN OF DISEASE AND INJURY IN METROPOLITAN LOS ANGELES

INTRODUCTION
4
“The burden of any condition can
be divided into two components:
the years of life lost due to
premature mortality and the
years of life lived with disability”.
The Global Burden of Disease
(GBD),Volume I,1996.
“There are two classes of
Disability Adjusted Life
Years (DALYs):Years of Life
Lost (YLLs) due to premature
mortality,and Years Lived
with Disability (YLDs)
adjusted for the severity of
disability.”
GBD,Volume I,1996.
I. INTRODUCTION
In the next few decades, consider-
able changes and challenges will be
experienced in global health. Condi-
tions that contributed significantly
to disability and death are being
overshadowed by other circumstanc-
es. Specifically, non-communicable
diseases, such as tobacco-related
illness and depression, are contribut-
ing more to morbidity and mortality
than the communicable diseases.
This trend is predicted to continue
and non-communicable diseases
are expected to account for 60% of
deaths in developing countries and
70% to 80% in the developed world.
A new study was undertaken in 1992
under the direction of Christopher J.
L. Murray and Alan Lopez to better
appreciate demographic disease pat-
terns. The Global Burden of Disease
and Injury Project (GBD) was a col-
laborative effort between the World
Health Organization (WHO), the
World Bank, and the Harvard School
of Public Health. The purpose of the
project was to (1) include non-fatal
disease and injuries in the analysis
of international health policy; (2)
decouple epidemiological assess-
ment from advocacy to develop more
objective disability and mortality es-
timates, and (3) quantify the burden
of disease allowing for cost-effective
analysis.1
A goal of the GBD meth-
odology was to clarify the ethical
decisions inherent in its methodol-
ogy. In this way, the authors encour-
aged informed debate and further
development of the established GBD
methodology. In 1996, the first set
of results was published under the
title The Global Burden of Disease”.
Volume I of this series described the
practical application of GDB and
the rationale for the methodology
chosen. This volume also contained
region specific estimates of the bur-
den of disease using the metrics of
Disability Adjusted LifeYears (DALYs);
that is,Years of Life Lost (YLLs) and
Years Lived with Disability (YLDs)
stratified by age group and sex in
eight different regions of the world.
A critical challenge in global health
is the allocation of scarce medical
research and medical care resources.
More specifically, the challenge is
how to improve life expectancy and
in a population. However, when this
method is applied to a culturally
diverse population like Los Angeles
County, significant inequalities in life
expectancy among different popula-
tion and ethnic groups are masked.
The reason why the Global Burden
of Disease Study became a major
landmark was the development of a
new system to assess nonfatal health
outcomes and, thus, the capacity to
measure the burden of major disease
and injuries regardless of their lethal-
ity.
This paper investigates how the
traditional measures to assess non-
fatal health outcomes compare
to the Burden of Disease as a new
method for disability assessment.
This publication utilizes the Burden of
Disease and Injury as a new tech-
nique to evaluate the health of the
SPA 4 population. Generally, crude
morbidity and mortality data do not
capture fully the impact of non-fatal
health outcomes and injuries. These
statistics have several drawbacks that
diminish their practical usefulness for
decision and policy-making. There-
fore, a discussion regarding the use
of the Burden of Disease and Injury
SPA 4 compared to crude morbidity
and mortality is warranted including
utilization implications and future
research needs.
II. BACKGROUND
INFORMATION
The mission of public health is to pro-
tect, maintain and improve the health
of the population with adequate re-
sources. The allocation of resources is
critical in meeting the health needs of
a population. In Los Angeles County,
several attributes make it a point of
interest to public health and health
policy makers, such as population
diversity, lack of access to health care,
the quality of life. Such an effort
requires the effective allocation of
resources to reduce major causes of
disease burden and health disparities
among poor and affluent popula-
tions. Estimates of life expectancy at
birth are useful to assess trends and
the distribution of life expectancy

BACKGROUND INFORMATION
5
Figure 1. Disability Adjusted LifeYears (DALY’s)
Disability Adjusted LifeYears
DALYs
Years of Life Lost Years Lived With Disability
(YLL) (YLD)
(Resulting from premature death) (Resulting from non-fatal
health outcome)
health disparities between affluent
and poor communities and increasing
trends in certain health conditions. In
January 2000, the Los Angeles County
Department of Health Services and
The UCLA Center for Health Policy
Research published The Burden
of Disease of Los Angeles County.
The study measured the burden of
disease in Los Angeles instead of the
traditional morbidity and mortal-
ity analysis. In this report, the same
methodology is used to assess the
disease burden for the Metropolitan
Los Angeles Service Planning Area
(SPA 4).
The GBD technology is different from
traditional health statistics. Generally,
health statistics have characteristics
that limit their practical value for
policymaking. Statistics are usually
fragmented. Basic mortality data
for many causes of death is unavail-
able. This data does not capture the
impact of non-fatal health outcomes
of disease and injury on the health
of a population. Some epidemiolo-
gists tend to inflate the numbers of
individuals killed or affected by a par-
ticular disease.These well-intentioned
epidemiologists become advocates
for the affected population. This is
particularly true when there is a need
to compete for scarce resources. If
these estimates were correct, some
individuals with a certain demo-
graphic composition would have
to die more than once to substanti-
ate the death numbers claimed. In
addition, traditional health statistics
cannot afford policy-makers the op-
portunity to quantify the cost-effec-
tiveness of various interventions. The
appropriate allocation of resources
is vital since the expectations of the
population regarding healthcare are
growing, as well as the regulated use
of available funding.
These issues are addressed by GBD
according to three fundamental
goals:
1. Incorporate non-fatal health
outcomes into assessments of health
status,
2. Separate epidemiology from
advocacy to reach objective, indepen-
dent and demographically plausible
assessments of disease burdens for
various diseases and conditions, and
3. Measure the burden of disease
and injury in a currency that can be
employed to evaluate the cost-ef-
fectiveness of interventions in terms
of cost per unit of disease burden
averted.
A common currency is required to
capture the impact of premature
death and disability. Researchers have
agreed that the appropriate cur-
rency is“time (in years) lost through
premature death and time (in years)
lived with a disability”. Therefore, GBD
established the Disability Adjusted
LiveYear (DALY) as the standardized
measure to express the years of life
lost to premature death and years
lived with disability --one DALY is one
year of healthy life lost.
The DALY measures the gap between
the actual health of a population and
some ideal, hypothetical norm. It
incorporates a discount rate for time
preference and an age-weighting
factor. It takes into account the higher
social value given to young adults in
most societies. Theses factors have
important implications for policymak-
ing since DALYs weigh the burden of
diseases of children less than those of
adults.
In 1996, 34.5 million DALYs were lost
in the United States. The U.S. major
causes of DALY differs significantly
from the rest of the world in that 9
out of 10 causes include injuries and
non-communicable diseases, where-
as communicable diseases are the
major cause of DALYs in the world.2
In
Los Angeles County, chronic illnesses,
drug and substance dependence, and
violence and unintentional injuries
represent a substantial burden of
disease and DALYs lost. Also, HIV/AIDS
contributes more to premature death
and disability in SPA 4 than it does to
the Los Angeles County population as
a whole.3
Its impact includes disability
and economic loss due to disability,
loss of productivity and income for
individuals and families, functional

6
DECISION FACTORSimpairment and restricted mobility,
social stigma and isolation, and psy-
chological stress and family discord.
Some of these implications are more
prominent than others depending on
the society, country or region. DALYs
allow researchers to make national,
regional and global assessments
of the burden of disease, quantify
the impact of major risk factors on
health and make projections about
future disease burdens. Therefore, the
consequences of burden of disease
in a population can be reduced given
the proper allocation and utilization
of resources.
On the other hand,“healthcare
decisions”usually follow two direc-
tions. Decisions are made based on
“evidence”or“opinion”. In addition,
decisions about patients or popula-
tions are made by combining three
factors; namely,“resources, values and
evidence”.
Presently, many healthcare decisions
are based on values and resources
that are components of“opinion-
based decision making”. Not enough
attention has been paid to evidence
obtained as a result of research and
scientific investigation. However, this
is likely to change since there is an
increasing demand and pressure on
appropriate utilization of resources.
Furthermore, healthcare decisions
must be made explicitly and publicly.
Individuals or institutions making
a decision have to describe the evi-
dence that leads them to that specific
decision.4
Steps involved in making a
decision based on evidence includes
conducting surveys, reviewing
published literature, evaluating the
evidence, and applying the evidence
to the care of the patient or popula-
tion.
One of the benefits of using the
burden of disease technology is that
policymakers can plan interventions
based on the“impact of non-fatal
health conditions”. The impact of such
conditions is assessed using evidence
currently available in the form of data
and statistics. Public health is chal-
lenged to allocate resources prioritiz-
ing diseases that require attention.
The shift to a system that incorpo-
rates evidence-based decision-mak-
ing, instead of opinion, is inevitable
as the pressure escalates for public
health sector accountability.
III. THE BURDEN OF DISEASE IN
METROPOLITAN LOS ANGELES
A GBD report for Metropolitan Los
Angeles (SPA 4) can be developed
based on the findings presented in
the Burden of Disease Report for Los
Angeles County. A comparison of
the 1997 leading cause of DALY in
Los Angeles County and SPA 4 pro-
vides a better understanding of the
specific needs of SPA 4 populations.
A comparison of DALYs in Los Ange-
les County and SPA 4 reveals that the
top three causes of premature death
prevail in both populations. However,
the fourth cause of premature death
in SPA 4 is“HIV/AIDS”while in Los
Angeles County it is“Depression”.
In fact, HIV/AIDS does not appear
among the ten leading causes of pre-
mature death in Los Angeles County
as a whole and Depression ranks
number seven in SPA 4. This indicates
that HIV/AIDS exerts a more adverse
impact in SPA 4 residents requiring
more focused attention in terms of
prevention and healthcare resources.
Planning health interventions for
SPA 4 populations must prioritize
efforts to reduce the spread of HIV/
AIDS.“Drug overdose/other intoxica-
tion”is another unique entity causing
premature death and disability in
SPA 4. Again, it is not listed as one of
the DALY for Los Angeles County as
a whole. This is consistent with the
trend that the prevalence of drug
use is higher in metropolitan set-
tings making efforts to prevent and
reduce drug use in Metropolitan Los
Angeles a priority. The third condition
affecting SPA 4 residents not found
in the first ten DALYs of Los Angeles
County is“Alzheimer’s/other demen-
tia”. Consequently, the GBD technol-
ogy highlights disease prevention
and control efforts that should be
common to all Service Planning Areas
in Los Angeles County while, at the
same time, points out premature
deaths that would go unnoticed
otherwise in SPA 4 health planning
efforts. In addition, using DALYs in

Figure 2. Typical disease course diagram in the determination of DALY.
7
FIGURE 2

8
One of the major benefits
of using the burden of
disease methodology is that
policymakers will be able to
plan interventions based on
the impact of non-fatal health
conditions.
Using the DALYs for SPA 4
allows health providers and
policymakers to compare the
cost-effectiveness of various
preventive and curative
health interventions designed
for the population.
SPA 4 also allows health providers and
policymakers to compare the cost-
effectiveness of various preventive and
curative health interventions designed
for the population.
The evaluation of the leading causes
of death by sex and race provides
insight into how these factors contrib-
ute to health disparities among SPA
4 populations. Sex and race explain
huge variations in adult mortality. They
account for complex causation factors
within social, community and eco-
nomic environments, such as income,
education, employment, social capital,
income inequality, proximal behavioral
and environmental factors. Table 2
lists the 20 leading causes of disease
burden by sex in SPA 4.“Acute Lower
Respiratory Illness (ALRI)”is the lead-
ing cause of disease burden in men
and women. This finding is supported
by reports indicating tobacco-related
conditions as the leading cause of
premature death and disability in
the United States. This also correlates
with Los Angeles County and SPA 4
data listing“coronary heart disease”
as the leading cause of DALY. Further
examination of the data reveals HIV
cases to be significantly higher in
males than females. Public health
practitioners must address the be-
havioral factors contributing to this
health disparity. These factors may
include homosexual and bisexual
relationships and type of safe sex
practices. Hence, it is crucial to con-
sider behavioral differences prior to
developing interventions, especially
to address health conditions accord-
ing gender.
IV. THE BURDEN OF DISEASE
TECHNOLOGY
Health assessment based on this new
approach can be used as follows:
(a) to highlight variations in disease
patterns among different geographic
places to conduct a cross sectional
assessment. This assessment could
be done in Los Angeles County where
each SPA has disease patterns that
may vary in magnitude and severity.
(b) GBD could also provide predic-
tions of future changes in disease
burden taking into account demo-
graphic changes and disease trends.
This application would be especially
important in Los Angeles County
since the ethic composition of the
population is continuously changing.
For example, an influx of immigrants
into Metropolitan Los Angeles could
significantly alter disease trends
requiring redirection of services or
resources. (c) The burden of disease
technology could also be used as a
tool to assess the outcome of inter-
ventions aimed at changing disease
patterns and assist in the evaluation
of such interventions.
If the future burden of disease and
injury in SPA can be projected, county
and state policymakers could deter-
mine whether interventions imple-
mented today would help decrease
the burden of disease in the future.
This would be a crucial endeavor,
particularly when evaluating the cost
effectiveness of interventions. This
would assist policymakers and public
health institutions to answer ques-
tions such as:“Did we allocate the
proper resources?”,“Did we avoid loss
of years of healthy life?”,“Were we
able to decrease the disease burden
for the population?”, etc. Therefore,
cost-effectiveness becomes an
important consideration through the
application of the burden of disease
technology.
1. Cost-Effectiveness
What the burden of disease estimates
at any moment reflects the amount
of health care that is already being
provided to the population, in addi-
tion to other actions that protect or
damage health. Where treatment is
possible, whether preventive, cura-
tive or palliative, the effectiveness
of the intervention is defined as a
“reduction”in the disease burden that
the treatment produces.7
Although
existing treatments have contrib-
uted to reduce disease burdens, this
does not mean that all remaining
disease burden can be eliminated. An
intervention that reduces the disease
burden can make the condition or
disease less probable, less severe,
of shorter duration, or less likely to
result in death. Also, its effectiveness
can be measured in the same units
(DALYs) allowing for comparison
across interventions that treat differ-
ent problems and produce different
outcomes. This comparison illustrates
how interventions differ signifi-
cantly in how much they can improve

LEADING CAUSES OF DEATH DISABILITY IN THE US AND LOS ANGELES COUNTY
9
Table 1. The ten (10) leading causes of death and disability in the US, Los Angeles
County and SPA 4 based on disability-adjusted life years (DALY) in 1997. 5

SEX-SPECIFIC DISEASE BURDEN IN SPA 4
10
Table 2. Sex-specific disease burden for 20 leading causes of death for SPA 4 in 1998. 6

Graph 1. Leading cause of death in males in SPA 4
SEX-SPECIFIC CAUSES OF DEATH IN SPA 4
11
Graph 2. Leading cause of dealth in females in SPA 4

THE BURDEN OF DISEASE TECHNOLOGY
“Disease burden (numbers
of death by cause) can be
partitioned in three separate
ways for different age,sex and
regional groupings (Murray
et al 1994).One partition
is by risk factor –genetic,
behavioral,environmental
and physiological.The second
is by disease.The third is by
consequence –premature
mortality at different ages and
different types of disability
(e.g.sensory,cognitive
functioning,pain,affective
state,etc.)’.
GBD,Volume I,1996.
12
health. For example, curing a case of
tuberculosis saves the patient and
disrupts transmission to others also.
Consequently, the total health gain
measured in years can exceed an indi-
vidual's life expectancy. On the other
hand, various types of health care
provide the equivalent of less than one
full day of additional healthy life.8
The healthcare sector and its policy-
making aims to ensure the best health
status possible for the population
according to limited resources. This is
equivalent to saying that it is possible
to measure the gains in health that are
attributable to different actions, and in
some way to“add them up”. Taking into
account the total health of a popula-
tion, this“adding-up”must include
individuals, health problems and treat-
ments or interventions. Without these
comparisons, health fails to be a global
concept making the burden of disease
limited to separate diseases of particu-
lar individuals. In essence, the concept
of effectiveness follows automatically
from the concept of“best-attainable
health”after factors such as financial
constraints and resource limitations
are introduced”. Hence, it is appropri-
ate to consider cost-effectiveness as a
criterion for maximizing health gains.
Cost-effectiveness can also be used to
compare different treatments for the
same condition, decide if one inter-
vention is better than another, and
determine if it the same outcome is
achieved at lower cost, or a better out-
come at the same cost.9
However, since
the outcome can be disease-specific,
it is not necessary to compare differ-
ent health problems. In addition, there
is no need to compare individuals as
long as it is assumed that for every out-
come, every individual receives some
type of intervention.
2. Policy Development
The burden of disease approach aids
is useful in health decision-making,
program development and policy re-
view. A more comprehensive view of
the current and future health needs
positions is conducive to better poli-
cymaking, good health and more ef-
fective programs and services. These
programs and interventions would
actually target relevant diseases and
decrease their burden in the popula-
tion. DALYs can be used as reliable
and promising measures of health
assessment. The DALY could become
the official feature of disease surveil-
lance within the next few years.10
It
could replace morbidity and mortal-
ity measures as the principal indica-
tor for reporting health needs and
selecting new priorities at local, state
and national level. The DALY is more
indicative of future disease patterns
and, thus, can support public health
efforts to decrease the disease bur-
den by developing interventions to-
day. The use of the burden of disease
identifies elements that will improve
current methodology, particularly,
the exploration of risk factors, the
sorting out of inter-related diseases,
and future work on the descriptive
epidemiology of disease categories.
V. ADVANTAGES AND
LIMITATIONS
As with any new approach to provid-
ing appropriate healthcare,“pros
and cons”must be evaluated before
implementation begins. The burden
of disease offers advantages over
the exclusive use of mortality data. It
gives weight to the future of fitness
in physical, social or occupational
terms. Programs can be more effec-
tive when they consider future health
issues. Projections of the future
disease burden and risk factors are
useful to inform policymaking. The
DALYs can be projected on the basis
of continuing secular trends to allow
a prediction of the burden of disease
at any future time. This characteristic
of the DALY is of crucial importance
making it a powerful approach. It is
also imperative for program planning
and policy development. Policymak-
ers have to be assured that what they
are putting into action today will
indeed be beneficial in decreasing
the disease burden in the future for a
specific population.
The advantage of the DALY is that it
can help health planners to identify
the most pressing health concerns in
their areas. When it is combined with
financial information, it can give an
indication of whether appropriate

ADVANTAGES AND LIMITATIONS
“Disaggregation of disease
burden by risk factor helps guide
policy concerning primary and
secondary prevention,including
development of new preventive
measures.Disaggregation
by disease helps guide policy
concerning cure,secondary
prevention and palliation;and
disaggregation by consequence
helps guide policies for
rehabilitation”
GBD,Volume I,1996.
13
amounts of money are being spent
on the“right”conditions affecting
a population. Therefore, one of the
central themes of using the burden
of disease method is whether it is
cost-effective. Resources must be al-
located giving more attention to the
most prominent health issues. Public
health advocates need to know when
overspending is justified and which
resources are most relevant. Funding
research studies may also serve to be
beneficial. They provide results that
allow further refinement of current
methodologies and evaluation of
future objectives. Research is needed
to understand the complex interre-
lated web of socioeconomic factors
like education, employment, income,
social capita, and distal and proximal
behavioral and environmental factors
such as diet, physical activity, tobacco
use and health care, along with
physiological factors such as blood
pressure, cholesterol levels and the
genetic component of disability and
mortality.11
Nevertheless, there are several draw-
backs with the use of this technology.
Limitations can be divided into the
following six categories:
1. Incommensurability of Longevity
and Quality of Life
A criterion is needed to compare
longevity with the quality of life of an
individual. Even if an individual’s life
expectancy is high, the years lived
healthy or with disability is the critical
issue. Disability decreases quality of
life despite longevity. The burden of
disease must allow for comparisons
to determine how each year lived
contributes to the overall well being
and quality of an individual’s life.
2. Subjectivity of Disability Weights
Another problem that arises is the
actual use of concept of“burden”.
Should it be limited to disability?
Should it be broadened to handicap?
Or should it look beyond individuals
and careers? Whose values should
be used to assign burden weights to
non-fatal illnesses? A decision needs
to be made on what the ideal health
status should be. In order to make
this decision, value choices must be
made including how long people
“should”live and whether years of
healthy life are worth more in young
adulthood than in early or late life. If
a year of life now is worth more than
a year 20 years from now, it should
be determined if all individuals are
equal, and how we should compare
years of life lost with life lived with
disabilities of differing severities.
Establishing a population’s consensus
on what the value choices should be
is imperative in determining disability
weights.
3. Invalidity of Epidemiological Esti-
mates
Epidemiological estimates tend
to overestimate the actual disease
burden taking place in a popula-
tion. Erroneous estimations could
result in the improper classification
of a disease or condition leading to
an incorrect allocation of resources.
It could also prevent appropriate
interventions to be implemented and
worsen the disease burden. Hence
the lack of validity of some epide-
miological estimates could initiate
a causal chain of events that could
potentially halt progress towards
achieving good health. Additionally,
limitations exist on the DALY measure
and itsYLD component.12
They have
a tendency to be under or overstate
certain health conditions.
4. Exclusion of Co-Morbidity
Consideration must be given regard-
ing how two conditions can have
a synergistic effect to increase the
burden of disease. Generally, disabil-
ity, in terms ofYLL orYLD, is attrib-
uted to a specific condition although
each condition possesses a different
disability weight. However, how can
disability weights be assigned in a co-
morbidity scenario? The problem is
that almost all disability and disease
burden analyses exclude the co-mor-
bidity status. For example, some dis-
eases are themselves a risk factor for
other conditions. This would make
the total disease burden the result
of interrelated factors that make the
process of averting a disease burden
extremely difficult.
5. Exclusion of the Economic Costs of
Illnesses
Treating disability in the United
States is a multi-million dollar
expenditure every year. There are

14
“While improving the people’s
health may not be the sole,or
even dominant,basis on which
priorities are established,
information on the magnitude
of different health problems
(diseases,injuries or risk factors)
and understanding of the cost-
effectiveness of different options
for intervention can have a
powerful influence on health
sector priorities”.
GBD,Volume I,1996.
two major economic costs associated
with illness: (a) the cost of medical care
used to diagnose and treat the illness,
and (b) the loss of income associated
with decreased productivity and labor
supply.13
Some people cannot cover
the cost of major illness, although they
can accommodate the costs of small
health concerns. The burden of dis-
ease fails to account for the costs tied
to an illness. It is crucial to address the
economic costs associated with illness.
This could serve as a better indica-
tion of what measures are needed to
reduce the disease burden along with
its associated fiscal implications.
6. Incapability to Reflect Recent Dis-
ease Trends
DALY estimates do not account for
recent trends in terms of incidence or
disease patterns. There is also a possi-
bility for gender and race bias, par-
ticularly accurate measures of disease
incidence and prevalence for men,
women and ethnic populations. Other
biases that could occur are related to
socioeconomic status, age and level
of education. These are questions that
must be answered and their responses
considered prior to the burden of
disease assessing in a population.
Lastly, using the burden of disease
approach tends to focus on individual
outcomes and health interventions.
Consideration must be given to the
“processes”that generate ill health and
influence access to health care. It also
needs to address the behaviors that
profoundly influence and affect health.
For example, tobacco use is presently
one of the leading causes of death and
disability worldwide. By the year 2020,
tobacco will be the number one cause
of morbidity and mortality in the world
surpassing the disease burden caused
by HIV/AIDS.14
This highlights an
important point. The trend is that more
deaths are being caused by noncom-
municable diseases than communi-
cable ones. This trend emphasizes the
importance of addressing behavioral
factors that underlie certain health
conditions. Therefore, it is important
to incorporate behavioral element into
health assessments and make projec-
tions of the impact of non-fatal health
outcomes.

VI. CONCERNS AND
CHALLENGES
Acceptance of the use of the burden of
disease technology depends upon the
confidence in its success. Various sec-
tors and/or stakeholders in SPA 4 may
find difficulties with different aspects
of this methodology as follows:
1. Political: As previously described,
the burden of disease methodology
can serve as a useful tool to inform and
influence policymaking. However, the
extent to which findings of burden of
disease studies influence health poli-
cies depends on the practices of fund-
ing and allocation of resources. Areas
of concern are the amount of money,
time and resources invested and the
reliability of study outcomes. The use
of this novel technology will become
more commonplace as it proves to be
more reliable, produces better results,
and assesses more effectively health
outcomes.
2. Technical: There is a need to explore
the methodology and test its reliability
and validity. It is important to avoid
refinement to a point that denies
access to those who are involved in
epidemiology and medical statistics
health service organizations. Some
terms and concepts --such as the DALY
andYLD- are exclusively used for the
burden of disease technology. Ad-
ditionally, methodological issues must
be strengthened making GBD more
sensitive to gender and health issues.
Such efforts would increase its value
as a tool for health assessment and
analysis.
3. Financial: There is a significant imbal-
ance between investments in health
research and the burden of disease. In
the past, health research has focused
on morbidity and mortality data and
risk factors are associated with each
cause of death. Now with the Burden
of Disease and Injury, the focus has
shifted to“future projections”of a
population’s health status. Future cost
considerations arise with GBD utiliza-
tion. This can result in a reorientation
and direction of available funds to new
areas of health research.
4. Managerial: Acceptance of the
burden of disease approach will grow
if (a) it becomes useful to policymak-
ers, (b) local public health practitioners
learn to use it in local settings, (c) its
results become a necessary prelude
to cost-effectiveness studies, and (d)
if it is incorporated into health sector
resource allocation methods.15
This will
CONCERNS AND CHALLENGES

“The DALYs have the following
six major uses to underpin health
policy.
The first five relate to
measurement of burden of disease;
the final one values the relative
priority of interventions in terms
of cost-effectiveness:
-Assessing performance
-Generating a forum for
informed debated of values and
priorities
-identifying national control
priorities
-allocating training time
for clinical and public health
practitioners
-allocating research and
development resources
-allocating resources across health
interventions”
GBD,Volume I,1996.
15
DISCUSSION
be a considerable challenge to over-
come in order to play a prominent role
within the health community and be
managed effectively and efficiently.
5. Operational: The implementation
of the burden of disease technology
must take into account socioeconomic
data, standardization of definitions,
ethnic variations, and the evaluation
of disability. If these factors are indeed
considered, operational challenges will
be minimized, if not eliminated.
VII. DISCUSSION
SPA 4 is able to research the burden
of disease and incorporate non-fatal
health outcomes into assessments of
health status for the first time. Compar-
isons with other SPAs is also possible
using their burden of disease data to
determine which conditions cause
greater disease burdens to Los Angeles
County populations. The utilization of
DALYs into SPA assessments provides
a better appreciation of health status.
More importantly, the disease burden
in SPA 4 can be used as a“currency”or
tool to evaluate current strategies and
programs, as well as the cost-effective-
ness of future programs and interven-
tions still at a development phase. The
cost would be in terms of cost per unit
of disease averted.
1. SPA 4 and Los Angeles County
The purpose to utilize Global Burden of
Disease and Injury Technology in SPA
4 is to inform health decision-making,
program development and policy-
making in a way that addresses more
effectively the needs of the popula-
tion. According to DALYs, SPA 4 has
a slightly higher rate than the rest of
the county. The higher rates may be
attributable to factors such as socio-
economic status, race, ethnicity, access
to health care and other demographic
factors amongst other reasons. Alco-
hol dependence is the second cause
of DALY after coronary health disease
in SPA 4. Alcohol dependence is also a
burden of mental illness and its impact
has been grossly underestimated by
traditional approaches that account for
death and not disability. The data also
indicates that communicable diseases
such as HIV/AIDS are a significant
cause of DALY in Metropolitan Los
Angeles. HIV/AIDS is the 13th cause of
DALY in Los Angeles County but 4th in
SPA 4.16
Therefore, the traditional use
of morbidity and mortality is impor-
tant but non-traditional approaches
such as the burden of disease technol-
ogy is also vital to properly plan for the
health needs of SPA 4 residents and
be relevant to demographic patters of
disease and disability.
2. SPA 4 and other SPAs
“The Burden of Disease Report for Los
Angeles County”lists the top ten lead-
ing causes of DALY for all eight Service
Planning Areas in Los Angeles. Most
SPAs have coronary heart disease as
the leading cause of DALY except SPA 1
and SPA 6 where alcohol dependence
and homicide/violence top the DALY
list, respectively. Homicide/violence
is ranked third in SPA 4. The higher
DALYs in these two SPAs could well
be attributed to their unique demo-
graphic structure. SPA 4 is also the only
SPA that had HIV/AIDS on its DALY top
ten list. This unique characteristic has
important programmatic and financial
implications. It also requires research
on healthcare seeking behavior,
behavior change communication, and
individual or group risk behaviors.
However, evaluating individual health
outcomes and health interventions
will not suffice. In order to address HIV/
AIDS in SPA 4, health decision-makers
and policymakers will need a better
understanding of social, economic,
cultural and educational factors that
influence risky behaviors.
3. Future Research Needs
Information on the leading causes of
DALY by race/ethnicity for SPA 4 is not
yet available for analysis. It could be a
valuable tool to assess the burden of
disease for each sub-population group.
Metropolitan Los Angeles has a diverse
racial and ethnic makeup and insights
regarding how DALYs are different
between racial/ethnic groups could ex-
plain existing health disparities. Race/
ethnicity could also be a risk factor for
a given disease burden. For example,

16
”In most decision making
arenas,priorities are
determined by many factors
such as budgetary inertia
(where programs this year
are those funded last year),
vocal political constituencies,
the effects of past investment
decisions in hospitals or other
infrastructure,funding
agency agendas,perceived
public health crises and
maximizing health gain
for the population given the
available resources”.
GBD,Volume I,1996.
CONCLUSIONS
more attention could be given to
particular disease burdens among
Hispanics since they comprise a larger
percentage of the SPA 4 population.
Future studies might also want to dis-
entangle connected to health actions
that“treat”versus health actions that
“promote”health. Research should also
be sensitive to differences in health
consequences in different settings.
The Global Burden of Disease and
Injury method could also be a valuable
tool for women health advocates. As
described earlier, there are differences
in disease burden for men and women
in SPA 4. Resource mobilization could
increase the allocation of resources for
women’s health. Research is, therefore,
the commodity needed to improve the
overall healthcare delivery system in-
cluding health promotion and disease
prevention and control. Additional
research would enable SPA 4 to assess
the cost-effectiveness of current pro-
grams, policies and services and, more
importantly, to evaluate the (a) attain-
ment of good health, (b) responsive-
ness of the system to the legitimate
expectations of SPA 4 population, and
(c) fairness in financial contribution
among different stakeholders and
populations.
VIII. CONCLUSIONS
The purpose of this report was to
provide an analysis of the application
of the Global Burden of Disease and
Injury technology in Metropolitan Los
Angeles (SPA 4). Accordingly,
• Information included in this publica-
tion could serve as the basis for health
priority setting and decision-making
in SPA 4. The integration of burden
of disease concepts into existing and
future program development could
shape and redirect strategic thinking
and funding including organization
and deployment of resources.
• A comparison of traditional ap-
proaches to assess risk factors and
health outcomes (morbidity and mor-
tality) with the Burden of Disease and
Injury approach demonstrates that
the new technology provides a better
appreciation of the health status and
wellbeing of the SPA 4 population,
particularly the years of life lost due
to premature death and disability.
• The Burden of Disease and
Injury technology is useful to (a)
evaluate the outcomes programs
and interventions specific to SPA 4
demographic patterns of disease, (b)
predict future changes in the burden
of disease in the SPA, and (c) high-
light variations in disease patterns
compared to Los Angeles County and
the United States.
• The burden of disease and injury in
SPA 4 is caused by both communica-
ble and non-communicable diseases.
“HIV/AIDS, Drug Overdose/Other
Intoxications and Alzheimer’s/Other
Dementia”represent health issues
among the first ten causes of DALY
in SPA 4 that are not found in the Los
Angeles County nor the U.S. top ten
DALY list. This information is vital for
strategic health planning purposes
to ensure that programs, policies and
services are relevant to the needs of
the population.
• Alcohol Dependence is a signifi-
cant contributor to SPA 4’s disease
burden and Los Angeles County as a
whole. This also highlights the critical
importance of mental illness as a
cause of death and disability and the
need to develop strategic alliances
and partnerships with mental health
providers.
• The conventional understand-
ing is that the three main killers in
the United States are heart disease,
cancer and stroke. Accordingly,
interventions targeting four modifi-
able behaviors ---tobacco use, lack of
physical activity, poor nutrition and
alcohol consumption--- could have
an enormous impact on the health
status and wellbeing of American
populations. While this continues to
be true, the Global Burden of Disease
and Injury provides additional infor-
mation to properly guide“specific”
health decision and policymaking
for“specific”target populations and
geographical locations.
• The Global Burden of Disease and
Injury provides a new methodology
for health planers, policymakers,
program developers and the medi-
cal and public health community as
a whole, to better assess and plan
to protect, maintain and improve
the health status and wellbeing of
invidual, families and communities.

17
IX. REFERENCES
1. Murray CJL, Lopez AD. The Global
Burden of Disease: A Comprehensive
Assessment of Mortality and Disability
from Diseases, Injuries, and Risk Factors
in 1990 Projected to 2020. Cambridge,
Mass: Harvard School of Public Health;
1996.
2. Michaud CM, Murray CLJ, Bloom BR.
Burden of Disease-Implications of Future
Research. JAMA, Vol. 285 No. 5; 2001.
3. The Burden of Disease in Los Angeles
County: A Study of the Patterns of
Morbidity and Mortality in the County
Population. Los Angeles County
Department of Health Services and The
UCLA Center for Health Policy Research;
2000.
4. Evidence Based Decision Making;
An Evidence Based reference site for
healthcare decision makers: www.
evidencebased.net
5. The Burden of Disease in Los Angeles
County: A Study of the Patterns of
Morbidity and Mortality in the County
Population. Los Angeles County
2000.
6. Los Angeles County Department of
Health Services. SPA4 Health Statistics,
1998.
7. Haddix A, Teutsch S, Shaffer P, Dunet
D. A Practical Guide to Prevention
Effectiveness: Decision and Economic
Analyses. NewYork: Oxford University
Press, 1996.
8. Musgrove P. Cost-Effectiveness and
Health Sector Reform. Seminar on Health
Sector Reform in Latin America, Buenos
Aires, Argentina, March 14-16 1994.
9. Musgrove P. Cost-Effectiveness and
Health Sector Reform. Seminar on Health
Sector Reform in Latin America, Buenos
Aires, Argentina, March 14-16 1994.
10. International Burden of Disease
Network: Atlanta Report. www.ibdn.net.
11. Michaud CM, Murray CLJ, Bloom BR.
Burden of Disease-Implications of Future
Research. JAMA, Vol. 285 No. 5; 2001.
12. The Burden of Disease in Los
Angeles County: A Study of the Patterns
of Morbidity and Mortality in the
County Population. Los Angeles County
2000.
13. Gertler P, Gruber J. Insuring
Consumption Against Illness. NBER
Working Paper No.W6035, 1997.
14. Murray CJL, Lopez AD. The Global
Burden of Disease: A Comprehensive
Assessment of Mortality and Disability
from Diseases, Injuries, and Risk Factors
in 1990 Projected to 2020. Cambridge,
Mass: Harvard School of Public Health;
1996.
15. International Burden of Disease
Network: Atlanta Report. www.ibdn.net.
16. The Burden of Disease in Los
Angeles County: A Study of the Patterns
of Morbidity and Mortality in the
County Population. Los Angeles County
2000.
REFERENCES

Metropolitan Service Planning Area (SPA 4)
241 North Figueroa Street, Room 312
Los Angeles, California 90012
Tel: (213) 240-8049
Fax: (213) 202-6096
www.lapublichealth.org
© 2001 SPA 4

Assessing the burden of disease and injury in Metropolitan Los Angeles

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