From the front lines of population health – a clinician’s perspective on the Global Burden of Disease

Over the past few years, the Global Burden of Disease (GBD) collaborator network has seen incredible growth – from the roughly 500 experts who contributed to GBD 2010, to the almost 2,000 collaborators from about 125 countries who worked on GBD 2015. This consortium of experts represents an array of experience, competencies, and disciplines, and it is this diversity of perspective that makes GBD the most comprehensive view of global health burden in the world.

One of these experts, Dr. Sudha Jayaraman, is an Assistant Professor of acute care surgical services at Virginia Commonwealth University (VCU) and a practicing surgeon. As a clinician, Dr. Jayaraman is on the front lines of population health – responding to the burden of injury and disease in real time. She discussed this unique vantage point in October during the GBD 2015 launch event, “Development is not Destiny,” and we had the opportunity to learn more about Dr. Jayaraman’s experiences after the event.

How did you first learn about the Global Burden of Disease study?

I heard about the Global Burden of Disease study nearly 10 years ago when there was a call for collaborators – an opportunity to submit data to create a large and comprehensive attempt at studying diseases from around the world.

Why did you decide to become a GBD collaborator?

I thought it would be a great idea to become a collaborator for two reasons. First, I thought it was important to submit the best quality data that I and my colleagues had on our work in Uganda to an effort that would lead to better understanding across a larger and more comprehensive setting. If it was not a cooperative effort including all researchers, or as many of them as possible, it would be an effort that would be doomed to fail.

Second, I also thought it was really important as a clinician to participate in the GBD. This effort requires expert statisticians and epidemiologists to gather and analyze data from all over the world, but clinicians add a whole different level of contextual relevance by participating in the study. 

What was your first contribution to the GBD study? How has your involvement evolved since then?  

My first contribution to the study involved data on injury mortality from Uganda. My colleagues and I had investigated injury mortality from the capital city of Kampala. This involved going to every mortuary in the city, the main public hospital, the police department, the government forensics office, and more. 

We spent a lot of time looking through handwritten log books, taking pictures and then transcribing them into Excel spreadsheets, using statistical software for analysis. It was an exhaustive process. But because we were being as careful as possible in collecting all of the mortality data in a city and country that did not have any vital registration systems in place, we could offer the best quality of data to the GBD study compared to what existed. 

Since then I have participated by contributing to many of the papers coming out of the GBD group that are specifically related to injury, surgery, and emergencies, as well as the East African setting and the US setting. This is in part because I am familiar with these topics and geographies, as a clinician and as a researcher.

Why is accurate health measurement important from a clinical perspective?

This is a really critical question that is underestimated by clinicians and researchers throughout the world, in my opinion. No matter the development status of the setting, clinicians need to have a sense of the magnitude of disease burden. Clinicians often engage the local community through outreach efforts and directly educate patients and families by sharing educational materials and providing counseling during clinical visits. So clinicians, if well-informed, can be huge advocates at the level of the community. 

This offers a chance to create solutions that are “bottom-up” as opposed to hierarchical “top-down.” In some ways, the end users of the GBD data are clinicians who are on the front lines of health care. Engaging them offers the opportunity to modify clinical care and to turn the tide on the burden of disease.

Can you recall a specific scenario or instance while working in countries outside the US that was influenced or could be influenced by GBD findings?

My work in East Africa has largely been around surgery, trauma systems, access to emergency services, and pre-hospital care, where I function both as a surgeon and as a public health professional. One recent instance that could be influenced by the GBD study findings is an experience I had taking care of a newborn baby who had a congenital abnormality in Rwanda. He was born without a food pipe (esophagus), and couldn’t eat. Therefore, he would not survive without an operation to insert a feeding tube, a procedure that would at least give him a chance to grow large enough to then have a more complex operation to be able to eat normally. Unfortunately, there was no trained pediatric surgeon on staff at the hospital (which is one of the main public hospitals in the country), and there was only one ventilator for neonatal patients. I was able to do this operation, and the baby was well enough that he didn’t need the neonatal ventilator, which was already in use for another baby. This child got lucky, but others are not so fortunate.

In Rwanda, roughly 14% of neonatal deaths are due to congenital abnormalities, 18% are due to lower respiratory infections, and 25% are due to sepsis (systemic illness due to infection), per the GBD study. Many of these babies will need care by a trained pediatric surgeon or will need to use a neonatal ventilator to survive. Their deaths can be prevented by distilling the results of the GBD down to the fundamental building blocks of a health system that overlaps across diseases and conditions – staff and equipment. By hiring one pediatrician or buying one additional ventilator, deaths from diverse conditions such as sepsis, pneumonia, empyema, bowel perforation, and a variety of operable congenital anomalies may be limited.

Could you explain this idea of locally driven solutions, and provide a short example of how this could be done?

The above story is an example of this. While statisticians and epidemiologists can identify the different causes of neonatal mortality in Rwanda, clinicians can help identify solutions that may cut across seemingly dissimilar diseases and conditions. The GBD results, although typically used in a disease-specific approach to health system capacity building, can also be used to pinpoint high-impact, cross-cutting interventions that address a variety of diseases and conditions. How and where these interventions can have the most impact on burden of disease can be determined within every country by identifying those that have the best return on investment.  

Click here to learn more about becoming a GBD collaborator.