University of California Davis Department of Surgery, Sacramento, California, United States of America.
Al Mustansiriya University, College of Medicine, Baghdad, Iraq.
PLoS Med. 2021 Aug 5;18(8):e1003673. doi: 10.1371/journal.pmed.1003673. eCollection 2021 Aug.
Previous research has focused on the mortality associated with armed conflict as the primary measure of the population health effects of war. However, mortality only demonstrates part of the burden placed on a population by conflict. Injuries and resultant disabilities also have long-term effects on a population and are not accounted for in estimates that focus solely on mortality. Our aim was to demonstrate a new method to describe the effects of both lives lost, and years of disability generated by a given conflict, with data from the US-led 2003 invasion and subsequent occupation of Iraq.
Our data come from interviews conducted in 2014 in 900 Baghdad households containing 5,148 persons. The average household size was 5.72 persons. The majority of the population (55.8%) were between the ages of 19 and 60. Household composition was evenly divided between males and females. Household sample collection was based on methodology previously designed for surveying households in war zones. Survey questions were answered by the head of household or senior adult present. The questions included year the injury occurred, the mechanism of injury, the body parts injured, whether injury resulted in disability and, if so, the length of disability. We present this modeling study to offer an innovative methodology for measuring "years lived with disability" (YLDs) and "years of life lost" (YLLs) attributable to conflict-related intentional injuries, using the Global Burden of Disease (GBD) approach. YLDs were calculated with disability weights, and YLLs were calculated by comparing the age at death to the GBD standard life table to calculate remaining life expectancy. Calculations were also performed using Iraq-specific life expectancy for comparison. We calculated a burden of injury of 5.6 million disability-adjusted life years (DALYs) lost due to conflict-related injuries in Baghdad from 2003 to 2014. The majority of DALYs lost were attributable to YLLs, rather than YLDs, 4.99 million YLLs lost (95% uncertainty interval (UI) 3.87 million to 6.13 million) versus 616,000 YLDs lost (95% UI 399,000 to 894,000). Cause-based analysis demonstrated that more DALYs were lost to due to gunshot wounds (57%) than any other cause. Our study has several limitations. Recall bias regarding the reporting and attribution of injuries is possible. Second, we have no data past the time of the interview, so we assumed individuals with ongoing disability at the end of data collection would not recover, possibly counting more disability for injuries occurring later. Additionally, incomplete data could have led to misclassification of deaths, resulting in an underestimation of the total burden of injury.
In this study, we propose a methodology to perform burden of disease calculations for conflict-related injuries (expressed in DALYs) in Baghdad from 2003 to 2014. We go beyond previous reports of simple mortality to assess long-term population health effects of conflict-related intentional injuries. Ongoing disability is, in cross section, a relatively small 10% of the total burden. Yet, this small proportion creates years of demands on the health system, persistent limitations in earning capacity, and continuing burdens of care provision on family members.
之前的研究主要关注与武装冲突相关的死亡率，将其作为评估战争对人口健康影响的主要指标。然而，死亡率仅展示了冲突给人群带来的部分负担。受伤和由此产生的残疾也会对人群产生长期影响，但在仅关注死亡率的估计中并未考虑到这些因素。我们的目的是展示一种新方法，利用来自美国领导的 2003 年入侵和随后占领伊拉克的数据，描述特定冲突导致的生命损失和产生的残疾年数。
我们的数据来自于 2014 年在 900 户巴格达家庭中进行的 5148 人的访谈。每个家庭的平均人口规模为 5.72 人。大多数人口（55.8%）年龄在 19 至 60 岁之间。家庭组成男女各占一半。家庭样本的收集基于先前为战区家庭调查设计的方法。由家庭户主或在场的成年家庭成员回答调查问题。问题包括受伤发生的年份、受伤机制、受伤部位、受伤是否导致残疾，如果导致残疾，则残疾持续的时间。我们提出这个建模研究，提供了一种创新的方法，使用全球疾病负担（GBD）方法来衡量与冲突相关的故意伤害导致的“残疾年数”（YLDs）和“生命损失年数”（YLLs）。使用残疾权重计算 YLDs，通过将死亡年龄与 GBD 标准生命表进行比较来计算剩余预期寿命，计算 YLLs。还使用伊拉克特定的预期寿命进行了计算，以便进行比较。我们计算出，2003 年至 2014 年期间，与冲突相关的伤害导致巴格达地区损失了 560 万残疾调整生命年（DALYs）。损失的 DALYs 主要归因于 YLLs，而不是 YLDs，损失了 499 万个 YLLs（95%不确定区间 387 万至 613 万），而损失了 61.6 万个 YLDs（95%不确定区间 39.9 万至 89.4 万）。基于原因的分析表明，由于枪伤导致的 DALYs 损失比任何其他原因都多（57%）。我们的研究有几个局限性。可能存在对受伤的报告和归因的回忆偏倚。其次，我们没有超过访谈时间的数据，因此我们假设在数据收集结束时持续残疾的人不会康复，这可能会对后来发生的伤害造成更多的残疾。此外，数据不完整可能导致死亡的错误分类，从而低估总伤害负担。
在这项研究中，我们提出了一种方法，用于计算 2003 年至 2014 年期间与冲突相关的伤害（以 DALYs 表示）在巴格达的疾病负担。我们超越了简单死亡率的报告，评估了与冲突相关的故意伤害对人口长期健康的影响。当前的残疾相对较小，仅占总负担的 10%。然而，这一小部分人群会对卫生系统产生长期需求，持续限制他们的工作能力，并继续给家庭成员带来护理负担。
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