• Ali H Mokdad, Mohammad Hossein Forouzanfar, Farah Daoud, Charbel El Bcheraoui, Maziar Moradi-Lakeh, Ibrahim Khalil, Ashkan Afshin, Marwa Tuffaha, Raghid Charara, Ryan M Barber, Joseph Wagner, Kelly Cercy, Hannah Kravitz, Matthew M Coates, Margaret Robinson, Kara Estep, Caitlyn Steiner, Sara Jaber, Ali A Mokdad, Kevin F O'Rourke, Adrienne Chew, Pauline Kim, El Razek Mohamed Magdy Abd MM Aswan University Hospital, Aswan Faculty of Medicine, Aswan, Egypt., Safa Abdalla, Foad Abd-Allah, Jerry P Abraham, Laith J Abu-Raddad, Niveen M E Abu-Rmeileh, Abdulwahab A Al-Nehmi, Ali S Akanda, Hanan Al Ahmadi, Mazin J Al Khabouri, Faris H Al Lami, Zulfa A Al Rayess, Deena Alasfoor, Fadia S AlBuhairan, Saleh F Aldhahri, Suliman Alghnam, Samia Alhabib, Nawal Al-Hamad, Raghib Ali, Syed Danish Ali, Mohammad Alkhateeb, Mohammad A AlMazroa, Mahmoud A Alomari, Rajaa Al-Raddadi, Ubai Alsharif, Nihaya Al-Sheyab, Shirina Alsowaidi, Mohamed Al-Thani, Khalid A Altirkawi, Azmeraw T Amare, Heresh Amini, Walid Ammar, Palwasha Anwari, Hamid Asayesh, Rana Asghar, Ali M Assabri, Reza Assadi, Umar Bacha, Alaa Badawi, Talal Bakfalouni, Mohammed O Basulaiman, Shahrzad Bazargan-Hejazi, Neeraj Bedi, Amit R Bhakta, Zulfiqar A Bhutta, Aref A Bin Abdulhak, Soufiane Boufous, Rupert R A Bourne, Hadi Danawi, Jai Das, Amare Deribew, Eric L Ding, Adnan M Durrani, Yousef Elshrek, Mohamed E Ibrahim, Babak Eshrati, Alireza Esteghamati, Imad A D Faghmous, Farshad Farzadfar, Andrea B Feigl, Seyed-Mohammad Fereshtehnejad, Irina Filip, Florian Fischer, Fortuné G Gankpé, Ibrahim Ginawi, Melkamu Dedefo Gishu, Rahul Gupta, Rami M Habash, Nima Hafezi-Nejad, Randah R Hamadeh, Hayet Hamdouni, Samer Hamidi, Hilda L Harb, Mohammad Sadegh Hassanvand, Mohammad T Hedayati, Pouria Heydarpour, Mohamed Hsairi, Abdullatif Husseini, Nader Jahanmehr, Vivekanand Jha, Jost B Jonas, Nadim E Karam, Amir Kasaeian, Nega Assefa Kassa, Anil Kaul, Yousef Khader, Shams Eldin A Khalifa, Ejaz A Khan, Gulfaraz Khan, Tawfik Khoja, Ardeshir Khosravi, Yohannes Kinfu, Barthelemy Kuate Defo, Arjun Lakshmana Balaji, Raimundas Lunevicius, Carla Makhlouf Obermeyer, Reza Malekzadeh, Morteza Mansourian, Wagner Marcenes, Habibolah Masoudi Farid, Alem Mehari, Abla Mehio-Sibai, Ziad A Memish, George A Mensah, Karzan A Mohammad, Ziad Nahas, Jamal T Nasher, Haseeb Nawaz, Chakib Nejjari, Muhammad Imran Nisar, Saad B Omer, Mahboubeh Parsaeian, Emmanuel K Peprah, Aslam Pervaiz, Farshad Pourmalek, Dima M Qato, Mostafa Qorbani, Amir Radfar, Anwar Rafay, Kazem Rahimi, Vafa Rahimi-Movaghar, Rahman Sajjad Ur SU Hamad Medical Corporation, Doha, Qatar., Rajesh K Rai, Saleem M Rana, Sowmya R Rao, Amany H Refaat, Serge Resnikoff, Gholamreza Roshandel, Georges Saade, Mohammad Y Saeedi, Mohammad Ali Sahraian, Shadi Saleh, Lidia Sanchez-Riera, Maheswar Satpathy, Sadaf G Sepanlou, Tesfaye Setegn, Amira Shaheen, Saeid Shahraz, Sara Sheikhbahaei, Kawkab Shishani, Karen Sliwa, Mohammad Tavakkoli, Abdullah S Terkawi, Olalekan A Uthman, Ronny Westerman, Mustafa Z Younis, Maysaa El Sayed Zaki, Faiez Zannad, Gregory A Roth, Haidong Wang, Mohsen Naghavi, Theo Vos, Abdullah A Al Rabeeah, Alan D Lopez, and Christopher J L Murray.
• Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. Electronic address: mokdaa@uw.edu.
• Lancet Glob Health. 2016 Oct 1; 4 (10): e704-13.

BackgroundThe eastern Mediterranean region is comprised of 22 countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, and Yemen. Since our Global Burden of Disease Study 2010 (GBD 2010), the region has faced unrest as a result of revolutions, wars, and the so-called Arab uprisings. The objective of this study was to present the burden of diseases, injuries, and risk factors in the eastern Mediterranean region as of 2013.MethodsGBD 2013 includes an annual assessment covering 188 countries from 1990 to 2013. The study covers 306 diseases and injuries, 1233 sequelae, and 79 risk factors. Our GBD 2013 analyses included the addition of new data through updated systematic reviews and through the contribution of unpublished data sources from collaborators, an updated version of modelling software, and several improvements in our methods. In this systematic analysis, we use data from GBD 2013 to analyse the burden of disease and injuries in the eastern Mediterranean region specifically.FindingsThe leading cause of death in the region in 2013 was ischaemic heart disease (90·3 deaths per 100 000 people), which increased by 17·2% since 1990. However, diarrhoeal diseases were the leading cause of death in Somalia (186·7 deaths per 100 000 people) in 2013, which decreased by 26·9% since 1990. The leading cause of disability-adjusted life-years (DALYs) was ischaemic heart disease for males and lower respiratory infection for females. High blood pressure was the leading risk factor for DALYs in 2013, with an increase of 83·3% since 1990. Risk factors for DALYs varied by country. In low-income countries, childhood wasting was the leading cause of DALYs in Afghanistan, Somalia, and Yemen, whereas unsafe sex was the leading cause in Djibouti. Non-communicable risk factors were the leading cause of DALYs in high-income and middle-income countries in the region. DALY risk factors varied by age, with child and maternal malnutrition affecting the younger age groups (aged 28 days to 4 years), whereas high bodyweight and systolic blood pressure affected older people (aged 60-80 years). The proportion of DALYs attributed to high body-mass index increased from 3·7% to 7·5% between 1990 and 2013. Burden of mental health problems and drug use increased. Most increases in DALYs, especially from non-communicable diseases, were due to population growth. The crises in Egypt, Yemen, Libya, and Syria have resulted in a reduction in life expectancy; life expectancy in Syria would have been 5 years higher than that recorded for females and 6 years higher for males had the crisis not occurred.InterpretationOur study shows that the eastern Mediterranean region is going through a crucial health phase. The Arab uprisings and the wars that followed, coupled with ageing and population growth, will have a major impact on the region's health and resources. The region has historically seen improvements in life expectancy and other health indicators, even under stress. However, the current situation will cause deteriorating health conditions for many countries and for many years and will have an impact on the region and the rest of the world. Based on our findings, we call for increased investment in health in the region in addition to reducing the conflicts.FundingBill & Melinda Gates Foundation.Copyright © 2016 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license. Published by Elsevier Ltd.. All rights reserved.

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