Deadly Cities? Spatial Inequalities in Mortality in sub‐Saharan Africa

We investigate whether sub‐Saharan African countries are affected by an “urban mortality penalty” repeating the history of industrialized countries during the nineteenth century. We analyze Demographic and Health Surveys from several sub‐Saharan African countries for differences in child and adult mortality between rural and urban areas. For the first decade of the 2000s, our findings indicate that child mortality is higher in rural than in urban areas for all countries. On average, child mortality rates are 13.6 percent in rural areas and 10.8 percent in urban areas. In contrast, average urban adult mortality rates (14.1 percent) have exceeded rural adult mortality rates (12.4 percent). Child mortality rates are on average 65 percent higher in urban slums than in formal settlements. Child mortality rates in slum areas are, however, still lower than or equal to those in rural areas for most countries in our sample.     

Losses of Expected Lifetime in the United States and Other Developed Countries: Methods and Empirical Analyses

Patterns of diversity in age at death are examined using e ^†, a dispersion measure that equals the average expected lifetime lost at death. We apply two methods for decomposing differences in e ^†. The first method estimates the contributions of average levels of mortality and mortality age structures. The second (and newly developed) method returns components produced by differences between age- and cause-specific mortality rates. The United States is close to England and Wales in mean life expectancy but has higher life expectancy losses and lacks mortality compression. The difference is determined by mortality age structures, whereas the role of mortality levels is minor. This is related to excess mortality at ages under 65 from various causes in the United States. Regression on 17 country-series suggests that e ^† correlates with income inequality across countries but not across time. This result can be attributed to dissimilarity between the age- and cause-of-death structures of temporal mortality reduction and intercountry mortality variation. It also suggests that factors affecting overall mortality decrease differ from those responsible for excess lifetime losses in the United States compared with other countries. The latter can be related to weaknesses of health system and other factors resulting in premature death from heart diseases, amenable causes, accidents and violence.     

Divergence in Age Patterns of Mortality Change Drives International Divergence in Lifespan Inequality

In the past six decades, lifespan inequality has varied greatly within and among countries even while life expectancy has continued to increase. How and why does mortality change generate this diversity? We derive a precise link between changes in age-specific mortality and lifespan inequality, measured as the variance of age at death. Key to this relationship is a young–old threshold age, below and above which mortality decline respectively decreases and increases lifespan inequality. First, we show for Sweden that shifts in the threshold’s location have modified the correlation between changes in life expectancy and lifespan inequality over the last two centuries. Second, we analyze the post–World War II (WWII) trajectories of lifespan inequality in a set of developed countries—Japan, Canada, and the United States—where thresholds centered on retirement age. Our method reveals how divergence in the age pattern of mortality change drives international divergence in lifespan inequality. Most strikingly, early in the 1980s, mortality increases in young U.S. males led to a continuation of high lifespan inequality in the United States; in Canada, however, the decline of inequality continued. In general, our wider international comparisons show that mortality change varied most at young working ages after WWII, particularly for males. We conclude that if mortality continues to stagnate at young ages yet declines steadily at old ages, increases in lifespan inequality will become a common feature of future demographic change.     

The Trend in International Health Inequality

Estimates of average life expectancy for 169 countries are used to compute the trend in between‐country health inequality from 1980 to 2000. Results show that inequality in the distribution of life expectancy across countries declined in the 1980s, but then increased through the 1990s. The recent turnaround in between‐country health inequality is significant because it reverses a long‐term trend of declining inequality across countries that began in the first half of the twentieth century. The primary cause of rising inequality across countries is declining life expectancy in sub‐Saharan Africa, largely owing to HIV/AIDS. Life expectancy in sub‐Saharan Africa holds the key to the future trend in between‐country inequality.     

A Cross-National Analysis of Lifespan Inequality, 1950–2015: Examining the Distribution of Mortality Within Countries

Cross-national health research devotes considerable attention to lifespan and survival rate disparities that are found between countries. However, the distribution of mortality across the world is shaped mostly by what happens within countries. We address this striking gap in the literature by modeling length-of-life inequality for individual nation-states. We use life tables from the United Nation’s (2015) World Population Prospects to estimate inequality levels for 200 countries across 13 waves between 1950 and 2015. We find that lifespan inequality is steadily declining across the world, but that each country’s level of inequality, and the rate at which it declines, vary considerably. Our models account for more than 90% of the longitudinal and cross-sectional variation in country-level lifespan inequality during the 1990–2015 period. Maternal mortality is the strongest predictor in our model, while disease prevalence, access to safe water, and health interventions figure prominently, as well. Gross domestic product per capita shows the expected curvilinear association with lifespan inequality, while primary education (both overall enrollment and gender equity in enrollment), external debt, and migration also play critical roles in shaping health outcomes. By contrast, the distribution of political and economic resources (i.e., democracy and income inequality) is less important.

     

Life Course Changes in Smoking by Gender and Education: A Cohort Comparison Across France and the United States

Widening of educational disparities and a narrowing female advantage in mortality stem in good part from disparities in smoking. The changes in smoking and mortality disparities across cohorts and countries have been explained by an epidemic model of cigarette use but are also related to life course changes. To better describe and understand changing disparities over the life course, we compare age patterns of smoking in three cohorts and two nations (France and the US) using smoking history measures from the 2010 French health barometer (N = 20,940) and the 2010 US National Health Interview Survey Sample Adult File (N = 20,444). The results demonstrate statistically significant widening of gender and educational differences from adolescence to early and middle adulthood, thus accentuating the disparities already emerging during adolescence. In addition, the widening disparities over the life course have been changing across cohorts: age differences in educational disparities have grown in recent cohorts (especially in France), while age differences in gender disparities have narrowed. The findings highlight the multiple sources of inequality in smoking and health in high-income nations.     

Inequality in Human Development: An Empirical Assessment of 32 Countries

One of the most frequent critiques of the HDI is that is does not take into account inequality within countries in its three dimensions. In this paper, we apply a simply approach to compute the three components and the overall HDI for quintiles of the income distribution. This allows a comparison of the level in human development of the poor with the level of the non-poor within countries, but also across countries. This is an application of the method presented in Grimm et al. (World Development 36(12):2527–2546, 2008) to a sample of 21 low and middle income countries and 11 industrialized countries. In particular the inclusion of the industrialized countries, which were not included in the previous work, implies to deal with a number of additional challenges, which we outline in this paper. Our results show that inequality in human development within countries is high, both in developed and industrialized countries. In fact, the HDI of the lowest quintiles in industrialized countries is often below the HDI of the richest quintile in many middle income countries. We also find, however, a strong overall negative correlation between the level of human development and inequality in human development.     

Survival Convergence and the Preceding Mortality Crossover for Two Population Subgroups

In this paper, we present and develop the argument that if the survival functions for two population subgroups converge in later life, a mortality crossover must precede the occurrence of this convergence. Specifically, two survival curves, S ₁(x) and S ₂(x), associated with two distinct population subgroups, G₁ and G₂, tend to converge before all members die out, as often observed and anticipated. This convergence leads to an increased mortality acceleration for the “advantaged” group, and eventually fosters the occurrence of a mortality crossover. We present a mathematical proof for this relationship and offer several explanations for the mechanisms involved in the process of survival convergence and the preceding mortality crossover. This new presentation demonstrates that mortality crossover is a highly observable demographic event given the trend of survival convergence in later life.     

Falling Short of Highest Life Expectancy: How Many Americans Might Have Been Alive in the Twentieth Century?

Life expectancy at birth in the United States during the twentieth century was lower than in many other highly developed countries. We investigate how this mortality disadvantage in the last 100 years translates into the number of hypothetical lives lost and their sex and age structure. We estimate the hypothetical US population if it had experienced in each decade since 1900 the mortality level of the country with the then highest life expectancy and compare the results to the actual figures in 2000. By 2000, the number of additional people who could have been alive had the mortality levels in the United States been as low as those in countries with the highest life expectancy was 66 million. This number is distributed equally between males and females. Suboptimal mortality at reproductive ages is crucial for the cumulative effect of potential lives lost, resulting from premature deaths of women who could still become first‐time mothers or bear additional children. Out of the 66 million additional persons who could have been alive in 2000, 45 million are attributable to those indirect deaths. Although the differences in the composition of the population by sex and age under the two mortality regimes are minor, the majority of people who might have been alive—54 million—were of working age or younger.     

On the Determinants of Mortality Reductions in the Developing World

This article presents and critically discusses evidence on the determinants of mortality reductions in developing countries. It argues that increases in life expectancy between 1960 and 2000 were largely independent of improvements in income. The author characterizes the age and cause‐of‐death profile of changes in mortality and assesses what can be learned about the determinants of these changes from the international evidence and from country‐specific studies. Public health infrastructure, immunization, targeted programs, and the spread of less palpable forms of knowledge all seem to have been important factors. Finally, the article suggests that the evolution of health inequality across and within countries is intrinsically related to the process of diffusion of new technologies and to the nature of these new technologies, public or private.     

A note of correction with reference to parameters of the menstrual cycle and the efficiency of rhythm methods of contraception

It is known that further mortality reductions in industrialized countries depend heavily on trends in mortality rates at the oldest ages. In this article, a model proposed by Coale and Kisker is used to investigate mortality trends at the extreme old age of 110 years. The most important conclusions are that (1) the form of the model proposed by Coale and Kisker fits observed mortality schedules very well indeed, and (2) the trend in mortality rates at extremely high ages has apparently been flat for men, but may have declined slightly for women during this century.     

Statistical modeling of selected aspects of the childbearing process with application to world fertility survey countries∗

The childbearing process should be monitored in developing countries experiencing high population growth rates and high levels of maternal and infant mortality. A mathematical model for estimation of certain aspects of the childbearing process, which requires only data on age‐specific fertility rates, is developed. Synthetic maternal childbearing indices, namely, mean ages at first and last birth, length of reproductive life span, inter‐birth spacing, and proportion of childless women, in addition to the well‐known mean age at childbearing, for the WFS countries are obtained using the proposed model. The indices are free from age truncation effects, and, under certain assumptions, provide information about a cohort's completed fertility before the women stop reproducing. The effects of women's residence and education on fertility are also examined.     

Mixed estimation of old‐age mortality

The estimation of the mortality of the “oldest old”; is subject to considerable random error, but important prior information exists that can be used to make the estimates more robust. Mixed estimation is a method of incorporating auxiliary information into the statistical estimation of linear models. We extend the method to cover general maximum likelihood estimation, and show that the mixed estimator can be represented approximately as a weighted average of the purely data based estimator and the auxiliary estimator. The methods can be applied to the analysis of the old‐age mortality via logistic and Poisson regression. A major advantage of the mixed estimator is the simplicity with which it can incorporate partial prior information. Moreover, no special software is needed in the fitting. We show how the targeting methods of Coale and Kisker can be represented as mixed estimation in a natural way that is more flexible than the original proposal. We also derive empirical estimates of the target information based on pooled data from several countries with high quality data. We consider the mortality of Finland at ages 80 +, study the reliability of the evidence of mortality crossover, and derive estimates of life expectancy at age 100.     

Age-Specific Variation in Adult Mortality Rates in Developed Countries

This paper investigates historical changes in both single-year-of-age adult mortality rates and variation of the single-year mortality rates around expected values within age intervals over the past two centuries in 15 developed countries. We apply an integrated hierarchical age-period-cohort—variance function regression model to data from the human mortality database. We find increasing variation of the single-year rates within broader age intervals over the life course for all countries, but the increasing variation slows down at age 90 and then increases again after age 100 for some countries; the variation significantly declined across cohorts born after the early 20th century; and the variation continuously declined over much of the last two centuries but has substantially increased since 1980. Our further analysis finds the recent increases in mortality variation are not due to increasing proportions of older adults in the population, trends in mortality rates, or disproportionate delays in deaths from degenerative and man-made diseases, but rather due to increasing variations in young and middle-age adults.     

Future life expectancy in Australia,Europe, Japan and North America

Human life expectancy has risen in most developed countries over the last century, causing the observed demographic shifts. Babel, Bomsdorf and Schmidt (forthcoming) introduce a stochastic mortality model using panel data procedures which distinguishes between a common time effect and a common age effect of mortality evolvement. Using this mortality model, the present paper provides forecasts of future life expectancy for 17 countries divided into 12 regions: Australia, Alps, Bene, Canada, England and Wales, France, Germany, Italy, Japan, Spain, Scandinavia and the United States of America. We consider (traditional) period life expectancies as well as cohort life expectancies, the latter being a more realistic approach but less common. It turns out that a continuing increase of life expectancy is expected in all considered countries. Further, we show that the probabilistic uncertainty of forecast life expectancies is different if either period life expectancies or cohort life expectancies are considered and, moreover, the uncertainty increases substantially if the error of parameter estimation is included.     

How We Fall Apart: Similarities of Human Aging in 10 European Countries

We analyze human aging—understood as health deficit accumulation—for a panel of European individuals, using four waves of the Survey of Health, Aging and Retirement in Europe (SHARE data set) and constructing a health deficit index. Results from log-linear regressions suggest that, on average, elderly European men and women develop approximately 2.5 % more health deficits from one birthday to the next. In nonlinear regressions (akin to the Gompertz-Makeham model), however, we find much greater rates of aging and large differences between men and women as well as between countries. Interestingly, these differences follow a particular regularity (akin to the compensation effect of mortality) and suggest an age at which average health deficits converge for men and women and across countries. This age, which may be associated with human life span, is estimated as 102 ± 2.6 years.     

Inequality in Human Development across the Globe

The Human Development Index is the world's most famous indicator of the level of development of societies. A disadvantage of this index is however that only national values are available, whereas within many countries huge subnational variation in development exists. We therefore have developed the Subnational Human Development Index (SHDI), which shows within-country variation in human development across the globe. Covering more than 1,600 regions within 161 countries, the SHDI and its underlying dimension indices provide a 10 times higher resolution picture of human development than previously available. The newly observed within-country variation is particularly strong in low- and middle-developed countries. Education disparities explain most SHDI inequality within low-developed countries, and standard of living differences are most important within the more highly developed ones. Strong convergence forces operating both across and within countries have compensated the inequality enhancing force of population growth. These changes will shape the twenty-first century agenda of scientists and policy-makers concerned with global distributive justice.     

Changes in world inequality in length of life: 1970–2000

Previous research has revealed much global convergence over the past several decades in life expectancy at birth and in infant mortality, which are closely linked. But trends in the variance of length of life, and in the variance of length of adult life in particular, are less well understood. I examine life-span inequality in a comprehensive panel of 180 countries observed in 1970 and 2000. Convergence in infant mortality has unambiguously reduced world inequality in total length of life starting from birth, but world inequality in length of adult life has remained largely unchanged. Underlying both of these observations is a growing share of total inequality attributable to between-country variation. Especially among developed countries, the absolute level of between-country inequality has risen over time. The sources of widening inequality in length of life between countries remain unclear, but signs point away from changes in income, leaving patterns of knowledge diffusion as a likely candidate.     

European Perspectives on Healthy Aging in Women

SUMMARY

Using data from the 1994 European Community Household Panel, we compare active life expectancy differentials at age 65 years between women and men in 12 European countries. We seek to explain the extent to which differences are a reflection of gender differentials in life expectancy at 65 years or reflect differences in active life expectancy earlier in life. Considerable variation in the gender differentials in both total and active life expectancies at age 65 years exist within Europe, with some countries experiencing 20% lower life expectancy at age 65 years for men compared to women. Some evidence was found to suggest that gender differentials in active life expectancy may continue from younger ages through to later life.     

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.