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.     

Three measures of longevity: Time trends and record values

This article examines the trend over time in the measures of “typical” longevity experienced by members of a population: life expectancy at birth, and the median and modal ages at death. The article also analyzes trends in record values observed for all three measures. The record life expectancy at birth increased from a level of 44 years in Sweden in 1840 to 82 years in Japan in 2005. The record median age at death shows increasing patterns similar to those observed in life expectancy at birth. However, the record modal age at death changes very little until the second half of the twentieth century: it moved from a plateau level, around age 80, to having a similar pace of increase as that observed for the mean and the median in most recent years. These findings explain the previously observed uninterrupted increase in the record life expectancy. The cause of this increase has changed over time from a dominance of child mortality reductions to a dominance of adult mortality reductions, which became evident by studying trends in the record modal age at death.     

Diverging Trends in Female Old‐Age Mortality: The United States and the Netherlands versus France and Japan

In the most advanced countries, child mortality and adult mortality under age 65 years have fallen so low that further improvement in life expectancy relies almost completely on the decline of mortality at older ages. This phenomenon is particularly pronounced among women, who are far ahead of men in survival rates. Thus, to project the future of life expectancy, this study focuses on trends in female life expectancy at ages 65 and older. Four countries are selected for this analysis: the United States, Netherlands, France, and Japan. It is particularly interesting to understand why American and Dutch trends in female old‐age mortality have been diverging from those in France and Japan for two decades. It is shown here that most of the divergence derives from the fact that decline in cardiovascular mortality is more and more offset by increases in other causes of death in the United States and the Netherlands, while the other two countries are more successful in reducing mortality from all causes at increasingly older ages. This latter phenomenon could represent a new stage of the health transition.     

Trends in senescent life expectancy

The distinction between senescent and non-senescent mortality proves to be very valuable for describing and analysing age patterns of death rates. Unfortunately, standard methods for estimating these mortality components are lacking. The first part of this paper discusses alternative methods for estimating background and senescent mortality among adults and proposes a simple approach based on death rates by causes of death. The second part examines trends in senescent life expectancy (i.e., the life expectancy implied by senescent mortality) and compares them with trends in conventional longevity indicators between 1960 and 2000 in a group of 17 developed countries with low mortality. Senescent life expectancy for females rises at an average rate of 1.54 years per decade between 1960 and 2000 in these countries. The shape of the distribution of senescent deaths by age remains relatively invariant while the entire distribution shifts over time to higher ages as longevity rises.     

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.     

Modeling Quality-Adjusted Life Expectancy Loss Resulting from Tobacco use in the United States

Purpose  To describe the development of a model for estimating the effects of tobacco use upon Quality Adjusted Life Years (QALYs) and to estimate the impact of tobacco use on health outcomes for the United States (US) population using the model. Method  We obtained estimates of tobacco consumption from 6 years of the National Health Interview Survey (NHIS). In addition, NHIS data were used to impute the Quality of Well-Being (QWB) Scale using a new methodology known as QWBX1. The QWB places health status on a continuum ranging from death (0.0) to full functioning without symptoms (1.0). The method allows the adjustment of life expectancy for reduced quality of life associated with health conditions. NHIS data were matched to the National Death Index for 14,464 deaths occurring by December 31, 1997. The analysis is limited to adults between the ages of 18 and 70 years. Results  Quality of Well-Being scores were broken down by age and for six smoking categories: (1) non-smokers, (2) those who smoke 1–10 cigarettes per day, (3) 11–20 cigarettes per day, (4) 21–30 cigarettes per day, and (5) 31–40 cigarettes per day, and (6) 40 or greater cigarettes per day. There was a systematic relationship between current tobacco use and health-related quality of life at each point along the age spectrum and there was a clear and systematic separation of quality-adjusted life expectancy by number of cigarettes smoked per day. Teenagers who continue to smoke loose 3.5 QALYs between ages 18 and 70 in comparison to non-smokers. A greater portion in the loss in QALE is attributable to quality of life than to shorten life expectancy. Conclusions  The overall goal of Healthy People 2010 is to increase Years of Healthy Life (or QALE) in the United States. Each year, tobacco use results in hundreds of thousands of quality-adjusted life years lost. Combined models of morbidity and mortality incorporating a range of tobacco consumption levels are required to best represent the impact of tobacco use. Supported by a Grant 11RT-0243 from the Californian Tobacco Related Disease Research Program (TRDRP)     

Follow-up surveys for census estimates of maternal mortality: experiences from Bolivia and Mozambique

Maternal mortality measurement through special census questions will be a common practice in the 2010 census round. To check this information or make it cause-specific, some countries have experimented with follow-up surveys containing verbal autopsies or triangulation with administrative data. However, follow-up studies can be costly and not without complications. In order to assess the benefits, two such experiences are discussed in detail (Bolivia, 2002; and Mozambique 2007–2008) and two others mentioned more briefly (Islamic Republic of Iran, 1996; and Democratic People’s Republic of Korea, 2008). In the former, several problems were apparent. In Mozambique, the follow-up survey used a cluster sample of 4.5% of deaths, from all causes. This design was adequate for the more common causes, but not for maternal mortality. Another problem was the large proportion of invalid cases (35.1%, plus 16% not verifiable) and the likelihood that there was a similar proportion of omitted deaths. The Bolivian census generated many invalid cases and missing ages, due in part to the flawed design of the questionnaire. This overburdened the follow-up, so that only 15% of the census deaths of women of reproductive age unrelated to pregnancy could be investigated. Once the false positives were eliminated, the results seem consistent with Growth Balance analyses, but the many classification errors compromise confidence in the results. Despite this mixed record of outcomes, it is believed that carrying out a limited number of similar studies in the current census round may be valuable, if appropriate lessons are learned from these experiences.     

Maternal mortality in South Africa: an update from the 2007 Community Survey

The 2007 Community Survey conducted in South Africa included questions on maternal deaths in the previous 12 months (pregnancy-related deaths). The Maternal Mortality Ratio (MMR) was estimated at 702 per 100,000 live births, some 30% more than at the 2001 census. This high level occurred despite a low proportion of maternal deaths (4.3%) among deaths of women aged 15–49 years, which is even lower than the proportion of time spent in the maternal risk period (7.6%). The high level of MMR was due to the astonishingly high level of adult mortality, which increased by 46% since 2001. The main reasons for these excessive levels were HIV/AIDS and external causes of death (accidents and violence). Differentials in MMR were very marked, and similar to those found in 2001 with respect to urban residence, race, province, education, income, and wealth. Provincial levels of MMR correlated primarily with HIV/AIDS prevalence. Maternal mortality defined as ‘pregnancy-related death’ appears no longer as a proper indicator of ‘safe motherhood’ in this situation.     

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.     

Predicting adult health and mortality from adolescent facial characteristics in yearbook photographs

Several important longitudinal studies in the social sciences have omitted biomarkers that are routinely recorded today, including height and weight. To account for this shortcoming in the Wisconsin Longitudinal Study (WLS), an 11-point scale was developed to code high school senior class yearbook photographs of WLS participants for relative body mass (RBM). Our analyses show that although imperfect, the RBM scale is reliable (α = .91) and meets several criteria of validity as a measure of body mass. Measured at ages 17–18, the standardized relative body mass index (SRBMI) was moderately correlated (r = .31) with body mass index (BMI) at ages 53–54 and with maximum BMI reported between ages 16 and 30 (r = .48). Overweight adolescents (≥ 90th percentile of SRBMI) were about three times more likely than healthy-weight adolescents (10th–80th percentile of SRBMI) to be obese in adulthood and, as a likely consequence, significantly more likely to report health problems such as chest pain and diabetes. Overweight adolescents also suffered a twofold risk of premature death from all nonaccidental causes as well as a fourfold risk of heart disease mortality. The RBM scale has removed a serious obstacle to obesity research and lifelong analyses of health in the WLS. We suggest that other longitudinal studies may also be able to obtain photos of participants at younger ages and thus gain a prospectively useful substitute for direct measures of body mass.     

Infant Mortality and Socioeconomic Status: New Bottle,Same Old Wine

This paper presents the results of an ecological analysis of the relationship between infant mortality and economic status in metropolitan Ohio for the period 1960–2000. The data examined are centered on the five censuses undertaken during this 40-year period. The basic unit of analysis is the census tract of mother’s usual residence, with economic status being determined by the percentage of low income families living in each tract. For each of the five periods covered, census tracts were aggregated into broad income areas and three-year average infant mortality rates were computed for each area, by age, sex, race and exogenous-endogenous causes of death. The most important conclusion to be drawn from the data is that in spite of some very remarkable declines in infant mortality at all class levels since 1960, there continues to be a very clear and pronounced inverse association between income status and infant mortality. Indeed, the evidence indicates that the relationship has become stronger over the years. These observations are applicable for both sexes, for whites and nonwhites, for neonatal and postneonatal deaths, and for both major cause of death groups. It is concluded that while public health programs are important, any progress in narrowing this long-standing differential is unlikely unless ways can be found to enhance the economic well-being of the lower socioeconomic groups.     

A method for deriving mortality estimates from incomplete vital Statistics

Summary Although they are available in many developing countries vital registration records are very little used for mortality estimation which is still mainly based on census returns. However, defective death records may yield accurate estimations of mortality. This procedure requires few data only; a sex-age distribution of the population (preferably at the middle of a period) and a sexage distribution of deaths, either derived from vital records or from census returns to questions relating to deaths during the preceding twelve months. This method is based on the observation that for a fixed age structure of the population, there is a one-one relation between the age structure of deaths (measured by the proportion of deaths at older ages) and the level of mortality (measured by the death rate above a certain minimum age). It is assumed that at ages above this minimum the rate of underregistration of deaths does not vary significantly with age. Therefore, the age distribution of registered deaths makes it possible to estimate the true proportion of deaths at older ages. This in its turn will permit the estimation of the true level of mortality, because of the relation which exists between age structure of deaths and level of mortality. The true level is then compared with the observed, to estimate the rate of underregistration, and observed age-specific death rates can be adjusted in the light of this knowledge.     

African-american mortality at older ages: Results of a matching study

In this paper we investigate the quality of age reporting on death certificates of elderly African-Americans. We link a sample of death certificates of persons age 65+ in 1985 to records for the same individuals in U.S. censuses of 1900, 1910, and 1920 and to records of the Social Security Administration. The ages at death reported on death certificates are too young on average. Errors are greater for women than for men. Despite systematic underreporting of age at death, too many deaths are registered at ages 95+. This excess reflects an age distribution of deaths that declines steeply with age, so that the base for upward transfers into an age category is much larger than the base for transfers downward and out. When corrected ages at death are used to estimate age-specific death rates, African-American mortality rates increase substantially above age 85 and the racial “crossover” in mortality disappears. Uncertainty about white rates at ages 95+, however, prevents a decisive racial comparison at the very oldest ages.     

Rising Mortality in Hungary

Although Hungary is not alone in Eastern Europe in experiencing a rising death rate during recent years, this adverse development would seem to have progressed further there than in neighbouring socialist countries, with the possible exception of the Soviet Union. The Hungarian death rate has been rising since the mid-1960s in part because the population was ageing but, more significantly from the health point of view, because of a real increase in mortality among certain sections of the population. The age-specific death rates of males aged 15 and over were all higher in 1980 than in the mid-1960s, the increase being particularly marked for the age group 30–59; moreover, women aged 30–59 are also now beginning to display the same characteristic. In the paper the individual contributions of the various causes of death to these trends are examined and some of the factors that are thought to have enhanced the risk of dying are outlined.     

The Contribution of Smoking to Black-White Differences in U.S. Mortality

Smoking has significantly impacted American mortality and remains a major cause of morbidity and mortality. No previous study has systematically examined the contribution of smoking-attributable deaths to mortality trends among blacks or to black-white mortality differences at older ages over time in the United States. In this article, we employ multiple methods and data sources to provide a comprehensive assessment of this contribution. We find that smoking has contributed to the black-white gap in life expectancy at age 50 for males, accounting for 20 % to 48 % of the gap between 1980 and 2005, but not for females. The fraction of deaths attributable to smoking at ages above 50 is greater for black males than for white males; and among men, current smoking status explains about 20 % of the black excess relative risk in all-cause mortality at ages above 50 without adjustment for socioeconomic characteristics. These findings advance our understanding of the contribution of smoking to contemporary mortality trends and differences and reinforce the need for interventions that better address the needs of all groups.     

Continued Reductions in Mortality at Advanced Ages

Mortality data for 30 mostly developed countries available in the Kannisto–Thatcher Database on Old‐Age Mortality (KTDB) are drawn on to assess the pace of decline in death rates at ages 80 years and above. As of 2004 this database recorded 37 million persons at these ages, including 130,000 centenarians (more than double the number in 1990). For men, the probability of surviving from age 80 to age 90 has risen from 12 percent in 1950 to 26 percent in 2002; for women, the increase has been from 16 percent to 38 percent. In the lowest‐mortality country, Japan, life expectancy at age 80 in 2006 is estimated to be 6.5 years for men and 11.3 years for women. For selected countries, average annual percent declines in age‐specific death rates over the preceding ten years are calculated for single‐year age groups 80 to 99 and the years 1970 to 2004. The results are presented in Lexis maps showing the patterns of change in old‐age mortality by cohort and period, and separately for men and women. The trends are not favorable in all countries: for example, old‐age mortality in the United States has stagnated since 1980. But countries with exceptionally low mortality, like Japan and France, do not show a deceleration in death rate declines. It is argued that life expectancy at advanced ages may continue to increase at the same pace as in the past.     

Demographic crisis: The impact of the Bangladesh civil war (1971) on births and deaths in a rural area of Bangladesh

Summary In Matlab Bazaar Thana the Cholera Research Laboratory has registered the births, deaths and migrations in a population of approximately 125,000 since 1966. Although this rural area was not the scene of any significant armed encounters, striking changes in birth and death rates were registered during and after the conflict. Birth rates did not change during the relatively brief period of the civil war, but a small decline was registered for one year after the war. Fertility rates which had been declining slightly and irregularly in the pre-war baseline period may have increased slightly during the war and fell substantially in all age groups in the year following the war. The crude death rate, which rose by 37 per cent during the war, was a very sensitive reflection of the administrative and economic problems. Overall infant mortality rose by only 15 per cent over pre-war levels because all of the increase was observed in the post-neo-natal component, which traditionally accounts for less than one-third of the total infant mortality in Bangladesh. Children and older adults accounted for the majority of excess deaths which were largely attributed to acute diarrhoeas and other gastro-intestinal causes. The death rate at ages 1-4 rose by 43 per cent and at ages 5-9 soared to 208 per cent above pre-war baseline rates. All increases in age-specific mortality rates fell to baseline levels during the year following the war, except the 5-9-year age group, in which rates continued to be high largely because of deaths due to dysentery.     

Period‐Based Mortality Change: Turning Points in Trends since 1950

We investigate a major turning point in mortality trends at adult ages that occurred for many low‐mortality countries in the late 1960s or early 1970s. We analyze patterns of total and cause‐specific mortality over the past 60 years using data from the Human Mortality Database and the World Health Organization. We focus on four broad categories of causes of death: heart diseases, cerebrovascular diseases, smoking‐related cancers, and all other cancers. We use a two‐slope regression model to assess the timing and magnitude of turning points in mortality trends over this era, making separate analyses by sex, age, and cause of death. The age pattern of temporal changes is given particular attention. Our results demonstrate convincingly that period‐based factors were very significant in the onset of the “cardiovascular revolution” in the years around 1970. In general, although cohort processes cannot be ruled out as a driver of mortality change in recent decades (especially for mortality due to smoking‐related cancers), the evidence reviewed here suggests that period factors have been the dominant force behind the mortality trends of high‐income countries during this era.     

‘Incorrect,loose and coarse terms’: classifying nineteenth-century English-language causes of death for modern use. An example using Tasmanian data

This paper outlines a cause-of-death classification system applicable to nineteenth-century English-language death data. Consisting of 32 categories, this system combines aspects of William Farr’s nosology, developed in nineteenth-century Britain, and the modern International Classification of Diseases. It is sufficiently broad for meaningful categories to be created for analytical purposes, but specific enough for particular cause-of-death trends and patterns to be traced. Individual-level death registration data from the British colony of Tasmania, 1838–1899, are used to demonstrate the application of this classification system. The paper describes the history of recording causes of death in nineteenth-century Tasmania and discusses several problems particular to nineteenth-century cause-of-death data. The benefits and disadvantages of three existing nosologies, Farr’s, Preston’s and the International Classification of Diseases, are considered with reference to nineteenth-century data. The final sections outline the data and method, and discuss an application of the classification system developed for cause-specific child mortality in nineteenth-century Tasmania.     

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.