Cardiovascular and Tuberculosis Mortality: The Contrasting Effects of Changes in Two Causes of Death

Tuberculosis was the largest source of deaths among younger adults, and cardiovascular disease among older adults, in the America of 1900. Decreases in deaths from tuberculosis since 1900 and cardiovascular disease since 1940 explain most of the mortality drops in those age groups over the century. This article, building on previous work by White and Preston, shows the results of increased survival from these two causes on the US population structure. Standard demographic cause-specific mortality calculations are used to generate life tables without deaths from cardiovascular disease or tuberculosis. Then fixed rates for these diseases from early in the century are assumed while all other causes of death are allowed to change as they did historically. Improvements in cardiovascular mortality and tuberculosis produce some seemingly illogical contrasts. More people are alive today because of the decrease in tuberculosis. Yet more deaths from cardiovascular disease have been prevented, and cardiovascular improvements have raised life expectancy more. Lower tuberculosis mortality had virtually no effect on the average age of the population. Lower cardiovascular mortality alone has raised that average more than all twentieth-century causes of improved mortality combined.     

A Comparison of US and Canadian Mortality in 1998

On average, Americans die earlier than Canadians. An estimate based on comparing the number of actual US deaths with the number that would have obtained had Canadian age‐ and sex‐specific death rates applied to the US population shows an excess number of US deaths in 1998 amounting approximately to 253,000. Excess US deaths were especially numerous among older women, middle‐aged men, and nonwhites. Circulatory diseases were the major cause of excess deaths. Prevalences of two of the major risk factors for circulatory deaths—smoking and hypertension—were higher in Canada than in the US. But obesity was higher in the US, suggesting a likely important role that obesity plays in higher mortality in the US relative to Canada. Comparisons of the level, age pattern, and causes of US and Canadian mortality, however, raise more questions than currently available data can answer.     

Mortality in England and Wales from 1848 to 1947

This is a survey of the changing causes of death in England and Wales during the past 100 years. Based on the published mortality statistics of the General Register Office the framework of the survey is a series of specially prepared tables of death rates by sex, age and cause of death for the periods 1848–72, 1901–10, 1921, 1931, 1939 and 1947. Adjustments were made wherever necessary to compensate for changes in medical nomenclature and in the statistical classification of disease.

After allowance has been made for the changing age structure of the population, the male death rate at all ages in 1947 was 42% of the rate in 1846–50, and the female rate 35 %. Maximum improvement was among girls aged 5–9 years, whose death rate in 1947 was 9% of the rate 100 years before.

In 1848–72 the group to which were allocated the largest proportion of the deaths at all ages were the infectious diseases with one-third of the total; and these were followed by the respiratory, nervous and digestive diseases. In 1947, on the other hand, diseases of the circulatory system came first with rather more than one-third of the total at all ages, and these were followed by cancer.

Changes in proportionate mortality rates from various causes have been examined at successive ages from infancy to old age. There was a decline in proportionate mortality from the infectious diseases other than tuberculosis, but increased mortality from tuberculosis in the younger age groups and from violence, circulatory diseases and cancer.

The trends of absolute mortality from the various causes were also studied. The reduction in total mortality was such that whereas there were half a million deaths of civilians registered in England and Wales in 1947, the total would have been over a million had the death rates of 1848–72 still prevailed.

The article concludes with a brief review of the factors responsible for the changes that have taken place.     

Cigarette Use and the Narrowing Sex Differential in Mortality

What explains the recent reversal in many countries of century‐long trends toward a growing female advantage in mortality? And might the reversal indicate that new roles and statuses of women have begun to harm their health relative to men? Using data on 21 high‐income countries that separate smoking deaths from other deaths, this study answers the first question by showing that the reversal in the direction of change in the sex differential results from increased levels of smoking among women relative to men. Using additional cross‐national data on cigarette consumption and indicators of gender equality, this article answers the second question in the negative by showing that the declining female advantage in smoking mortality results from patterns of the diffusion of cigarette use rather than from improvements in women's status. Evidence of continued improvement in the female mortality advantage net of smoking deaths, and the likely decline of smoking among women in the future, imply that the recent narrowing of the differential will reverse.     

Mortality of American Troops in the Iraq War

We estimate the death rate of United States troops deployed to Iraq from the beginning of the US invasion through 30 September 2006. Eighty percent of the deaths in Iraq were combat‐related. The death rate in Iraq is lower than that of the civilian population of the United States but substantially higher than that of young adults. It is much lower than the death rate of US troops in Vietnam, in part because a much smaller fraction die among those wounded in Iraq. We also estimate relative mortality levels for US troops according to numerous demographic variables through 30 November 2006. The risk of death in Iraq per deployment is shown to be highest for Marines; Naval and Air Force personnel in Iraq have lower death rates than the civilian population of comparable age. Other categories with above‐average mortality in Iraq are enlisted troops, males, younger persons, and Hispanics.     

Causes of death contributing to changes in life expectancy in New York City between 1983 and 1992

Recent changes in life expectancy among race and sex groups in New York City were evaluated by analyzing the relative effects of different causes of death in 1983 and 1992, a period in which life expectancy at birth declined by 1.1 years among white males, remained unchanged among black males, and increased 1.2 years among white and black females. Heart disease was found to be the leading cause of death making positive contributions to changes in life expectancy regardless of race or sex, and HIV/AIDS was the leading negative contributor. Overall, deaths from infectious diseases and external causes are becoming more important compared to degenerative conditions in explaining trends in life expectancy in New York City. Past improvements in survival due to reductions in infant deaths are being reversed due to an increase in deaths from preventable causes such as violence and AIDS. Future gains in longevity may require a greater emphasis on policies and programs emphasizing conflict resolution and HIV prevention.     

Trends in Causes of Death in Low‐Mortality Countries: Implications for Mortality Projections

This study examines the potential role that information about trends in causes of death could have in improving projections of mortality in low‐mortality countries. The article first summarizes overall trends in mortality by cause since the middle of the twentieth century. Special attention is given to the crucial impact of the smoking epidemic on mortality and on cause‐of‐death patterns. The article then discusses the implications for projections and reaches two conclusions. First, mortality projections can be improved by taking into account the distorting effects of smoking. Mortality attributable to smoking has risen in the past but has now leveled off or declined, thus boosting improvements in life expectancy. Second, making cause‐specific projections is not likely to be helpful. Trends in specific medical causes of death have exhibited discontinuities in the past, and future trends are therefore difficult to predict.     

The impact of childhood mortality on Fertility in six rural Thanas of Bangladesh

In this article, we examine the relationship between child mortality and subsequent fertility using prospective longitudinal data on births and childhood deaths occurring to nearly 8000 Bangladeshi mothers observed over the 1982-1993 period, a time of rapid fertility decline. Generalized hazard-regression analyses are employed to assess the effect of infant and child mortality on the hazard of conception, with controls for birth order and maternal age and educational attainment. Results show that childhood mortality reduces the time to subsequent conception if the death occurs within a given interval, representing the combined effect of biological and volitional replacement. The time to conception is also reduced if a childhood death occurs during a prior birth interval, a finding that signifies an effect of volitional replacement of the child that died. Moreover, mortality effects in prior birth intervals are consistent with hypothesized insurance (or hoarding) effects. Interaction of replacement with elapsed time suggests that the volitional impact of child mortality increases as the demographic transition progresses. This volitional effect interacts with sex of index child. Investigation of higher-order interactions suggests that this gender-replacement effect has not changed over time.     

The cocos-keeling islands: A demographic laboratory

The Cocos Islands, which are situated in the Indian Ocean approximately halfway between Colombo and Fremantle, were first peopled early in the nineteenth century and were gradually developed as a very isolated coconut plantation with a labour force consisting partly of persons of Malay stock descended from the original group of settlers and partly of Bantamese contract labourers from Java. As the Cocos-born population increased in size, the dependence on contract labour decreased and, before the end of the century, all immigration ceased. The 1947 Malay population of the islands was about 1,800.

The islands are fascinating from a demographer's point of view because there was a virtually complete registration of live births, deaths and marriages and a partial registration of stillbirths. With these registration records it was possible to construct the life history of every individual from birth, through infancy and childhood to marriage, and thence through fatherhood or motherhood to death.

The picture revealed by an analysis of these records is that of a population with very high fertility and with mortality at a high level before the first World war and at a medium level after that war. Crude birth rates varied between 50 and 60 per thousand population during the period 1888 to 1947. Crude death rates were between 30 and 40 per thousand population until 1912 but under 2.0 per thousand population after 1918.

Most Cocos girls married before reaching the age of 20 and there were an average of between eight and nine live births per woman living through the childbearing period. There was a steady decline in the average number of live births with advancing age at marriage from age 16 onwards. A significantly high proportion of those dying in the middle of the childbearing period had never married, but the fertility of those marrying at an early age (14, 15 and 16) and dying before reaching the age of 36 was slightly higher than that of those who married at a similar age and survived. Women who survived to the age of 55 were of higher fertility than those who died between the ages of 40 and 55. An analysis of birth intervals revealed significant differences (a) between birth intervals after a stillbirth or after a live birth in which the child died in early infancy, and birth intervals after a live birth in which the offspring survived for longer than 0.4 years, and (b) between the interval from first to second birth and the subsequent birth intervals. There was a difference of almost exactly a year between the average birth interval after a stillbirth or live birth ending in a neo-natal death and the average birth interval after the birth of a child surviving to age 2; there was a similar difference of a year between corresponding median birth intervals.

From 1888 to 1912 infant mortality was well above 300 per thousand. After 1918 infant mortality averaged rather under 100 infant deaths per 1,000 live births. The reduction in infant mortality rates was accompanied by an increase in the mortality of children aged 1 to 4, and the heavy incidence of mortality at these ages after 1918 is the most striking feature of the analysis of mortality by age. Whilst mortality in infancy fell much more heavily on males than on females, early childhood mortality was much higher in Cocos for girls than for boys. The life table computed for the period 1918 to 1947 indicated a life expectancy of about 50 years for males and 47 years for females.     

The Epidemiologic Transition Revisited: Compositional Models for Causes of Death by Age and Sex

For decades, researchers have noted systematic shifts in cause‐of‐death patterns as mortality levels change. The notion of the “epidemiologic transition” has influenced thinking about the evolution of health in different societies and the response of the health system to these changes. This article re‐examines the epidemiologic transition in terms of empirical regularities in the cause composition of mortality by age and sex since 1950, and considers whether the theory of epidemiologic transition presents a durable framework for understanding more recent patterns. Age‐sex‐specific mortality rates from three broad cause groups are analyzed: Group 1 (communicable diseases, maternal and perinatal causes, and nutritional deficiencies); Group 2 (noncommunicable diseases); and Group 3 (injuries), using the most extensive international database on mortality by cause, including 1,576 country‐years of observation, and new statistical models for compositional data. The analyses relate changes in cause‐of‐death patterns to changing levels of all‐cause mortality and income per capita. The results confirm that declines in overall mortality are accompanied by systematic changes in the composition of causes in many age groups. These changes are most pronounced among children, for whom Group 1 causes decline as overall mortality falls, and in younger adults, where strikingly different patterns are found for men (shift from Group 3 to Group 2) compared to women (shift toward Group 2 then Group 3). The underlying patterns that emerge from this analysis offer insights into the epidemiologic transition from high‐mortality to low‐mortality settings.     

A note on suicide in Russia, 1965–1993

Recently, theCentre for Demography and Human Ecology in Moscow in collaboration with theInstitut National d’études Démographiques in Paris undertook a reconstruction of registered deaths in individual republics of the former Soviet Union. The first set of such data, tabulated by sex, age and cause of death, covers the deaths registered in Russia between 1965 and 1993. The present article extracts from the data set information on registered suicide mortality and reviews its trends and age and sex patterns. The link between alcoholism and suicide is strongly suggested.     

Mortality From the Influenza Pandemic of 1918–1919: The Case of India

Estimates of worldwide mortality from the influenza pandemic of 1918-1919 vary widely, from 15 million to 100 million. In terms of loss of life, India was the focal point of this profound demographic event. In this article, we calculate mortality from the influenza pandemic in India using panel data models and data from the Census of India. The new estimates suggest that for the districts included in the sample, mortality was at most 13.88 million, compared with 17.21 million when calculated using the assumptions of Davis (1951). We conclude that Davis' influential estimate of mortality from influenza in British India is overstated by at least 24%. Future analyses of the effects of the pandemic on demographic change in India and worldwide will need to account for this significant downward revision.     

The peculiar pattern of mortality of Jews in Moscow, 1993-95

Russian Jews, particularly men, have a large mortality advantage compared with the general Russian population. We consider possible explanations for this advantage using data on 445,000 deaths in Moscow, 1993-95. Log-linear analysis of the distribution of deaths by sex, age, ethnic group, and cause of death reveals a relatively high concentration of endogenous causes and a relatively low concentration of exogenous and behaviourally induced causes among Jews. There is also a significant concentration of deaths from breast cancer among Jewish women. Mortality estimates using the 1994 micro-census population as the denominator reveal an 11-year Russian-Jewish gap in the life expectancy of males at age 20, but only a 2-year life-expectancy gap for women. Only 40 per cent of the Russian-Jewish difference for men, but the entire difference for women, can be eliminated by adjustment for educational differences between the two ethnic groups. Similarities with other Jewish populations and possible explanations are discussed.     

Mortality in Poland in the period 1950-1990

"In this paper, crude, specific [mortality] rates as well as nonstandardized and standardized indices of regional mortality differentials are analysed [for Poland] for the period 1950-1990, in order to show mortality differentiation, its increase by age, sex, and place of residence. Taking into account cause specific death rates, the pattern of causes of deaths was found to be similar to that existing in the western countries, although the level of standardized mortality is higher in Poland. Values of calculated indices of regional mortality differentials point to significant differences in mortality by voivodship."     

Mortality,past and future

The study of mortality in previous centuries and of the trends in recent decades helps to elucidate some present-day medical problems and to contribute to their solution. The author considers, from a historical and socio-economic point of view, the factors which, during the last 200 years, have influenced the trends of mortality. This analysis indicates the lines along which present research, aimed at reducing mortality and extending expectation of life, should be directed.

Infancy (0–1 year): In backward countries, the whole of infancy is a period of high mortality. In progressive countries, on the other hand, the main reproductive wastage is in the ‘perinatal’ period, that is to say, covering stillbirths and deaths during the first week of life. For example, even in New Zealand, the death risk per day is more than eighty times as high during the first week of life than in the following 358 days.

Historical studies and social class comparisons suggest that further reduction of perinatal mortality is likely to depend on socio-economic, housing and cultural factors rather than on improvements in obstetric skill. Evidence cited by the author indicates that a crucial factor may be to provide expectant mothers with adequate rest during the weeks immediately prior to delivery. In general, research into mortality in infancy is too much bounded by a purely medical point of view whereas a socio-medical approach is needed.

Childhood (1–14 years): There has been an immense reduction in childhood mortality during the last 200 years. Less than 200 years ago the mortality among children aged 1–4 and 5–9 years was thirty-three times, and among those aged 10–14 years twelve times, that of the present day. Future reduction of mortality among children will be primarily a function of social factors and trends.

Adolescence and maturity (15–49 years): One of the outstanding trends of the last 200 years has been a relative increase in tuberculosis mortality among those aged 15–49 years, whereas among children tuberculosis has become relatively less important

as a cause of death. Recently, however, there has been a decline in the relative importance of tuberculosis as a cause of death among the adolescent and mature and, among New York males, it now takes second place to the cardiovascular

diseases. The total mortality of people in this age group has fallen, since the sixteenth century, by 77% for men and 81% for women. No spectacular discoveries are needed to reduce the mortality of this group by a further third; in doing this, control of environment will be the important factor.

Later maturity and old age (50 years and over): In the four centuries since the Renaissance the mortality of people over 50 years of age has been reduced by half. Among the factors contributing to this reduction is a fall in mortality due to tuberculosis. But even cancer, which is popularly supposed to have increased, used to be more common in the eighteenth century than it is now and to appear at an earlier. age. Moreover, there has been a change in the organs most commonly affected. The distribution of the greater proportion of cancer in a given population is a function of living conditions in the broadest sense of the term. Studies of groups exposed to carcinorelevant factors suggest that a high incidence of cancer in one organ is associated with a low incidence in other organs. But on many other causes of death at the older ages far more research is required, especially on the cardio-vascular-renal complex, and on the degenerative joint and bone diseases.     

Structure and change in causes of death: An international summary

Abstract Model patterns of the cause structure of mortality at different levels were established for males and females, based on data for 165 national populations. These patterns suggest that the cause of death most responsible for mortality variation is influenza/bronchitis, followed by 'other infectious and parasitic diseases', respiratory tuberculosis, and diarrhoeal disease. Together, these causes typically account for about 60 per cent of the change in level of mortality from all causes combined. Their respective contributions have not depended in an important way on the initial level of mortality. These results - especially tbe importance of the respiratory and diarrhoeal diseases - imply that past accounts may have over-emphasized the role in mortality decline of specific and well-defined infectious diseases and their corresponding methods of control. There is strong statistical support for the suggestion that most of the remainder of mortality variation should be ascribed to changes in cardio-vascular diseases, but that methods of cause-of-death assignment in high-mortality populations have often obscured the importance of these diseases. When death rates from 'other and unknown' causes are held constant, changes in cardio-vascular disease account for about one-quarter of the decline in mortality from 'all causes'.Although the causal factors are poorly established, corroborative results have been demonstrated cross-sectionally in the United States. The composition of the group of populations most deviant from the structural norms is apparently dominated by differentials in the mode of assigning deaths to cardio-vascular disease. However, when broad groups of regions or periods are distinguished, more subtle differences emerge. Controlling mortality level for all causes combined, diarrhoeal diseases are significantly higher in non-Western populations and southern/eastern Europe than in overseas Europe or northern/western Europe. These differences are probably related to standards of nutrition and personal hygiene, but may also reflect climatic factors. Much higher cardio-vascular mortality in overseas European populations than in non-Western populations at similar overall levels probably reflects variation in habits of life. Regional differences in death rates from violence, maternal mortality, respiratory tuberculosis and influenza/pneumonia/bronchitis are briefly noted and commented upon. Cause-of-death structures at a particular level of mortality display some important changes over time. Respiratory tuberculosis and 'other infectious and parasitic diseases' have tended to contribute less and less to a certain level of mortality. They have in part been 'replaced' by diarrhoeal disease, specifically in non-Western populations. These developments reflect an accelerating rate of medical and public health progress against the specific infectious diseases, and a disappointing rate of progress against diarrhoeal disease. Western and non-western populations have shared to approximately the same extent in the accelerating progress against infectious diseases, and developments during the post-war period are more appropriately viewed as an extension of prior trends rather than as radical departures therefrom. For males, cardio-vascular disease and cancer have significantly increased their contribution to a particular level of mortality, while no such tendency is apparent for females. These developments may be related to changes in personal behaviour and in environmental influences whose differential impact on the sexes has been demonstrated in epidemiological studies. Although we have avoided an explicit treatment of age by having recourse at the outset to standardization, certain of the results are apparently reflected in studies of age patterns of mortality. The joint occurrence in non-Western populations and Southern/Eastern populations of exceptionally high death rates from diarrhoeal disease may explain why the 'South' age-pattern, with it high death rates between ages one and five, is often the most accurate referent for use in Latin America and Asia. The fact that the list of populations with the least deviation cause structure is almost exclusively confined to members of the 'West' group of Coale and Demeny may account for the lack of persistent deviation in this group's age patterns. Finally, tbe increasing importance of cardio-vascular disease and neoplasms in cause-of-death structures for males but not females is probably associated with the changing age patterns of male mortality noted by Coale and Demeny.     

Annual Variations in Deaths by Age,Deaths by Cause,Prices, and Weather in London 1670 to 1830

The impact of annual variations in prices, temperature, and rainfall on annual fluctuations in age-specific and disease-specific mortality is examined for London from 1670 to 1830. The analysis reveals that deaths in London in the middle and older age groups tended to increase when grain prices were high. Increases in deaths among the elderly are associated with unusually cold winters and unusually warm summers. High grain prices tend to increase the incidence of epidemic diseases, while endemic diseases appear to increase with colder winters and warmer summers. The role of migration is discussed in the light of the results and the implications for long-term mortality decline are considered.     

Mortality of the chronically impaired

An analysis of the effects of diabetes and generalized atherosclerosis on death due to ischemic heart disease or stroke was conducted using multiple cause mortality statistics. Specifically, all U.S. deaths in 1969 were classified into two groups on the basis of whether diabetes or generalized atherosclerosis was mentioned anywhere on the death certificate. Then race and sex specific analyses were made of ischemic heart disease deaths (or alternately of stroke deaths) using modified life table techniques for each group (one with the specified chronic disease and one without). Comparisons were made of mortality due to the acute circulatory events (ischemic heart disease or stroke) in the two groups to determine the implications of the chronic disease for the progression of the circulatory disease events. It was found, according to expectations, that diabetes and generalized atherosclerosis play very different roles in deaths due to stroke and ischemic heart disease.     

Recent trends in mortality in Australia—an analysis of the causes of death through the application of life table techniques

The paper examines the post-1971 reduction in Australian mortality in light of data on causes of death. Multiple-decrement life tables for eleven leading causes of death by sex are calculated and the incidence of each cause of death is presented in terms of the values of the life table functions. The study found that in the overall decline in mortality over the last 20 years significant changes occurred in the contribution of the various causes to total mortality. Among the three leading causes of death, heart disease, malignant neoplasms (cancer), and cerebrovascular disease (stroke), mortality rates due to neoplasms increased and those of the other two causes decreased. The sex-age-cause-specific incidence of mortality changed and the median age at death increased for all causes except for deaths due to motor-vehicle accidents for both sexes and suicide for males. The paper also deciphers the gains in the expectation of life at birth over various time periods and the sex-differentials in the expectation of life at birth at a point in time in terms of the contributions made by the various sex-age-cause-specific mortality rates.