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Population and Health
Lecture 16. Divergences/convergences
in mortality.
A new approach to health transition
Jacques Vallin
INED
Moscow, New Economic School,14th January - 1st February 2013
MPIDR-NES Training Programme
Health for all!
• Social security systems
• WHO target of the 1970s
• UN Population Division scheme of converging life expectancies towards the highest levels
• Far from having been realised, today such objectives seems to be hopeless
Increasing disparities in life expectancy
Will life expectancy increase indefinitely ?
Oeppen-Vaupel straight line
Oeppen Jim and Vaupel James W., 2002. – Broken limits to life expectancy, Science, vol. 296, n° 10 May 2002, p. 1029-1031.
Year
Life
exp
ecta
ncy in
ye
ars
1840 1860 1880 1900 1920 1940 1960 1980 2000
45
50
55
60
65
70
75
80
85
90
AustraliaIcelandJapanThe NetherlandsNew Zealand non-MaoriNorwaySwedenSwitzerland
Will life expectancy increase indefinitely ?
A broken line
Is there any theory that can explain contradictory facts observed to-day?
The 3 ages of the epidemiologic transition theory according to Abdel Omran (1971)
• Age of pestilence and famine, when mortality
was very high and fluctuating, with life
expectancy less than 30 years,
• Age of pandemics receding, during which life
expectancy has stedily increased, from about 30
years to close to 60,
• Age of degenerative diseases and man made
diseases, when, after some additional reduction,
mortality tends to stabilise at a low level.
The main failures of the theory
• When life expectancy climes up again in western
industrialized countries (the cardiovascular
revolution)
• When Eastern Europe misses this new step
• When AIDS spread in Africa
Is it enough to expand the theory?
Or necessary to put its bases in question?
Extending the epidemiologic transition theory ?
• Interpretation of the cardiovascular
revolution: a 4th age?
– « Age of delayed degenerative diseases », Jay
Olshansky et Brian Ault (1986)
– « the hybristic stage » (the age of diseases
related to behaviour and lifetstyle), Richard
Rogers and Robert Hackenberg (1987)
Extending the epidemiologic transition theory ?
• Interpretation of AIDS: a 5th age?
– The age of reemergence of infectious and parasitic diseases, Jay Olshansky et al. (1998)
– The age of aspired quality of life with paradoxical longevity and persistent inequities. Abdel Omran (1998)
• «and beyond»: a 6th age?
– «Health for all» towards equity and quality Abdel Omran 1998
Considering Omran’s epidemiologic transition
as only a first step of the health transition
• The health transition (Frenk et al., 1991)
• Several successive epidemiologic transitions
(Horiuchi, 1999)
• A succession of phases of divergence-convergence
(Vallin et Meslé, 2004, 2005)
The concept of health transition
• Julio Frenk, José-Luis Bodabilla, Claudio Stern, Thomas Frejka et Rafael Lozano « Elements for a theory of the health transition » Health Transition Review, vol 1 n° 1, 1991
• A concept from M. Lerner (1973), wider than that of epidemilogic transitions since it includes social and behavioural changes
• Combine different levels: « systemic », « societal » « institutional » and « individual »
• However their description is purely theoretical without precise reference to facts
Successive epidemiological transitions
in the History of Mankind
• Shiro Horiuchi Epidemiological transition in human history in: Joe Chamie et Robert Cliquet Health and mortality issues of global concern, NU, 1999
• A link between the type of society and the main causes of death: « hunting and picking » « agriculture » « industry » « high technology » « future » / « violence » « infection » « Cardiovascular diseases » « cancers » « aging »
• Close to the concept of pathocenosis (Mirko Grmek, 1969) but far from the complexity of current situations
A succession of divergence/ convergence processes (Vallin et Meslé, 2004, 2005)
• Any major factor of improvement in life expectancy results in a phase of divergence
• After some time those that were late catch up the pioneers in a convergence phase
• New improvements cause new processes of divergence/convergence
• One on-going process can be interrupted or even contradicted by negative new facts, any time
• A new process can start even if the previous one has not ended
• Sub-national trends may follow the same rule
Three large historical examples
First stage :
Omran’s epidemiologic
transition
Long-term trends in female life expectancy for selected
industrialized countries until the mid-60s
England & Wales
France
Denmark
New Zealand
Netherlands
Italy
Russia
Japan
25
30
35
40
45
50
55
60
65
70
75
80
1740 1765 1790 1815 1840 1865 1890 1915 1940 1965
Life expectancy at birth
Contribution of
mortality decline
by age groups to
gains in life
expectancy in
Sweden and
Austria:
1829-1880 and
1880-1960
Contribution of mortality decline by age and causes
to gains in life expectancy in France 1925-1960
Major improvement involved
• New medical tools (Pasteur revolution:
aseptic, immunization, antibiotics, etc.)
• Education
• Social security and welfare state
Long-term trends in female life expectancy for developing countries
except Sub-Saharan Africa and countries affected by war
20
30
40
50
60
70
80
1950 1960 1970 1980 1990 2000
Life expectancy
Yemen
Puerto Rico
Mexico
Indonesia
Hong Kong
A
Long-term trends in female life expectancy for developing countries
except Sub-Saharan Africa and countries affected by war
20
30
40
50
60
70
80
1950 1960 1970 1980 1990 2000
Norway
Puerto Rico
Mexico
Indonesia
Yemen
Life expectancy
B1900
1900
1950
1950
A longer perspective for some countries
20
30
40
50
60
70
80
1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010
Sweden
Puerto
Rico
Egypt
Yemen
Life expectancy
Argentina
Chile
MDC
pioneers
MDC
latecomers
India
Afghanistan
Year
Contribution of mortality decline by age groups to gains in life expectancy
in Argentina, India and Afghanistan before and after WW-2
20
25
30
35
40
45
50
55
60
65
70
1950 1960 1970 1980 1990 2000 2010
D. Countries hit by war
RwandaSomalia
Cambodia
Life expectancy (years)
Year
20
25
30
35
40
45
50
55
60
65
70
1950 1960 1970 1980 1990 2000 2010
C. Countries hit by AIDS South Africa
ZimbabweZambia
Life expectancy (years)
Year
20
25
30
35
40
45
50
55
60
65
70
1950 1960 1970 1980 1990 2000 2010
B. Countries slowed down
by 1980 world economic crisis
Congo, DR
Nigeria
Angola
Life expectancy (years)
Year
20
25
30
35
40
45
50
55
60
65
70
1950 1960 1970 1980 1990 2000 2010
A. Countries with regular but slow progress
Sudan
Niger
Life expectancy (years)
Mali
Egypt
Year
Second stage:
the cardiovascular revolution
Trends in life expectancy (both sexes) since 1965
in industrialized countries
Japan
Russia
Eng.-Wales
Czech Rep.
64
66
68
70
72
74
76
78
80
82
84
1965 1970 1975 1980 1985 1990 1995 2000 2005
Life expectancy
Trends in life expectancy (both sexes) since 1965
in industrialized countries
Russia
Eng.-Wales
Czech Rep.
64
66
68
70
72
74
76
78
80
82
84
1965 1970 1975 1980 1985 1990 1995 2000 2005
Life expectancy
SwedenFrance
PolandRomania
Ukraine
USA
Denmark
Hungary
Japan
Contribution
of trends in
age-specific
mortality for
seven main
groupes of
causes to
changes in
male life
expectancy
betwen 1965
and 2005
-1.0
-0.5
0.0
0.5
1.0
1.5
0 5-9 15-
19
25-
29
35-
39
45-
49
55-
59
65-
69
75-
79
85+
FRANCE FEMALES
Gains or losses
-1.0
-0.5
0.0
0.5
1.0
1.5
0 5-9 15-
19
25-
29
35-
39
45-
49
55-
59
65-
69
75-
79
85+
FRANCE MALES
Gains or losses
-1.0
-0.5
0.0
0.5
1.0
1.5
0 5 15 25 35 45 55 65 75 85
RUSSIA FEMALES
Gains or losses
-1.0
-0.5
0.0
0.5
1.0
1.5
0 5 15 25 35 45 55 65 75 85
RUSSIA MALES
Gains or losses
Infection Cancer Cardiovascular diseases
Respiratory diseases Digestive diseases Other diseases
Injury and poisoning
Trends in
male
standardized
mortality rate
from
cardiovascular
diseases since
1965 in 6
industrialized
countries
Major improvement involved
• New medical tools (heart surgery and drugs, emergency services, etc.)
• Behavioural changes (diet, stop smoking, exercise)
• Economical and financial aspects
Third stage:
the fight against ageing
Trends in life expectancy since 1980 in some
Western industrialized countries
70
72
74
76
78
80
82
84
86
1980 1985 1990 1995 2000 2005
Japan
France
Italy
USA
Sweden
Netherlands
England & Wales
Denmark
Life expectancy
Females
70
72
74
76
78
80
82
84
86
1980 1985 1990 1995 2000 2005
Japan
France
Italy
USA
Sweden
Netherlands
England-Wales
Denmark
Life expectancy
Males
Trends in
female life
expectancy
at age 65,
since 1980
17
18
19
20
21
22
23
24
1980 1985 1990 1995 2000 2005
Life expectancy at 65
Netherlands
USA
France
Japan
Age and
cause
components
of life
expectancy
changes
1984-2005:
increasing
weight of
lung cancers
and mental
disorders in
the USA and
the
Netherlands
-0.3
-0.1
0.1
0.3
0.5
0.7
0.9
1.1
65
-69
70
-74
75
-79
80
-84
85
-89
90
-94
95
+
USA
Gains or losses
-0.3
-0.1
0.1
0.3
0.5
0.7
0.9
1.1
65
-69
70
-74
75
-79
80
-84
85
-89
90
-94
95
+
Netherlands
Gains or losses
-0.3
-0.1
0.1
0.3
0.5
0.7
0.9
1.1
65
-69
70
-74
75
-79
80
-84
85
-89
90
-94
95
+
Japan
Gains or losses
-0.3
-0.1
0.1
0.3
0.5
0.7
0.9
1.1
65
-69
70
-74
75
-79
80
-84
85
-89
90
-94
95
+
France
Gains or losses
Cardio-vascular diseases Cerebrovascular diseases
Inf. + Resp. dis. Cancer
Mental disorders+ Alzheimer Other diseases
Violent deaths Senility
Lung cancer Diabetes mellitus
Major improvement involved
• The way to take care of elderly
The improbable generalised convergence
• Each major improvement induces new divergence
• No hope for general convergence except if no
more progress can be done…
What about sub-national differences ?
Trends in
female life
expectancy by
French
Départements
as compared to
the upper and
lower limits of
national trends
in
industrialized
countries 20
30
40
50
60
70
80
90
1805 1825 1845 1865 1885 1905 1925 1945 1965 1985
Life expectancy at birth
Morbihan
Hautes-Pyrénées
Upper limit
Lower limit
Historical
trends in
maximum,
minimum,
mean and
standard
déviation of
female life
expectancy by
French
Départements
20
30
40
50
60
70
80
90
1800 1850 1900 1950 2000
Maximum
MinimumMean
Life expectancy
0
2
4
6
8
1800 1850 1900 1950 2000
Standard deviation
Geographical variations in life expectancy
in France and Japan since le 1920s
35
40
45
50
55
60
65
70
75
80
85
1920 1930 1940 1950 1960 1970 1980 1990 2000
Males
Females
* Bouches-du-Rhône
* IndreIlle-et-Vilaine
Landes
Life expectancy
*
*
FRANCE
35
40
45
50
55
60
65
70
75
80
85
1920 1930 1940 1950 1960 1970 1980 1990 2000
Females
Males
Life expectancy
* Ishikawa
Toyama
Okinawa
* Miyazaki
*
*
JAPANOkinawa
Trends in sex differences in life expectancy
0
1
2
3
4
5
6
7
8
1750 1800 1850 1900 1950 2000
DenmarkNetherlands
Norway
Sweden
Difference
Nordic countries
0
1
2
3
4
5
6
7
8
1750 1800 1850 1900 1950 2000
US
E&W
New ZealandCanada
Australia
Difference
Anglo-Saxon
countries
Trends in life expectancy at birth in
England and Wales by social classes
66
68
70
72
74
76
78
1970 1975 1980 1985 1990 1995
Professionnal
Mangerial & tech.
Skilled, non manual
Skilled, manualPartly skilled, manual
Unskilled, manual
Conclusion
• Health transition is not running smoothly
• Successions of diverging/converging moves: an
explanatory theory which
– helps understanding the diversity of cases
existing to-day in the world
– but makes quite pessimistic about a possible
future reduction of inequalities
The end
Long-term trends in female life expectancy
for Sub-Saharan Africa
25
35
45
55
65
75
85
1950 1960 1970 1980 1990 2000
Indonesia
Yemen
Life expectancy
Countries with slow progress
Niger
Ghana
25
35
45
55
65
75
85
1950 1960 1970 1980 1990 2000
Indonesia
Yemen
Life expectancy
African countries with AIDS
Zimbabwe
Uganda
1900
