Factors responsible for mortality decline

- The role of medicine

- Major changes in life expectancy prior to 1920 occurred largely in the absence of germ theory

- Throughout the 1800s, miasma was the more accepted theory of disease causation; rotten smells in the air cause disease

        - One exception was smallpox vaccine (developed in 1760)

Macro-level and micro-level changes leading to the decrease in infectious disease

Changes in exposure, resistance, and recovery all contribute

Exposure

- Macro Changes: Sanitation, pollution, population density, pasteurization, labor conditions

- Micro Changes: Refrigeration, acceptance of public health initiatives, quarantine, hand washing, boiling milk

Resistance

- Macro Changes: Vaccination, food availability

- Micro Changes: Better diet

Recovery

- Macro Changes: Drugs, medical care

- Micro Changes: Access to and use of health care

            - Levels of mortality in US by occupation

- Preston looks at levels of mortality among US children by fathers’ occupation in 1895, 1905, and 1922/4

- In 1895, farmers and manufacturing managers’ kids have lowest mortality

- Farm and manufacturing laborers’ kids have highest

- In 1922/4, doctors and teachers’ kids have lowest

- Overall in 1922/4, higher educated classes have lower mortality than lower educated classes

           - Shows differential dissemination of information

            - More educated ppl can read and adopt public health info

- Segregation of population along class lines also probably contributed to differential death rates

Levels of mortality by age

- Vallin created graph of mortality in France by age 1720-1914

- Finds that decrease in mortality happened at pretty much all ages

- Main exception: death rates among young adults higher in 1877-1881 than in 1820-1829

            - Most likely due to migrating to cities

“Socioeconomic status and health: The challenge of the gradient.” American Psychologist, 49(1), 15-24.

- Health differentials by socioeconomic status are not just about material deprivation; they occur at all levels of the SES hierarchy

- This article reviews evidence for the existence of an SES-health gradient and considers factors that might account for it, paying particular attention to psychosocial variables

Evidence for the gradient

- Whitehall studies (Matmot et al. 1984) find evidence of an occupational gradient in the UK

- Kitagawa and Hauser (1973) find evidence of an educational gradient in the US

- Furthermore, it appears as though the SES-health gradient has gotten steeper over time

3 possible explanations of this association are

1) it’s spurious (various factors related to both SES and health),

2) health causes SES,

3) SES causes health

- Authors consider various mechanisms by which SES might affect health

- Health risk behaviors such as smoking, physical inactivity, poor diet, and substance abuse

- Despite the close ties of these factors to both SES and health, the association between SES and health is reduced but not eliminated when these variables are controlled

- Psychological factors such as depression, hostility, and stress, all of which are more common among low SES and have been linked to poor health outcomes

- SES may be linked to stress in 2 ways:

1) higher SES may diminish chances of encountering negative events and

2) high SES may afford people more social and psychological resources with which to cope with stressful events

- One relative position in the social hierarchy may also explain link between SES and health

- These effects may be moderated by the amount of mobility in a society; studies on animals suggest that living in closed society may negatively affect people with low SES whereas living in an open society may negatively affect people with high SES

- Past research on SES and health has been limited by failure to consider the full range of the SES hierarchy (too much emphasis on low levels of SES), examining only one variable as a proxy for SES (ex: education or income or occupation), and failing to consider the context  in which people live (having low income in a low income area might be better/worse for health than having low income in a high income area)

“Low levels of maternal education and the proximate determinants of childhood mortality: A little learning is not a dangerous thing.” Social Science and Medicine, 60, 2011-2023.

- Previous research suggests almost perfect inverse linear relationship between maternal education and child mortality

- Authors want to examine whether children of slightly educated mothers are significantly better-off than children of uneducated mothers

- Examine “low levels” of maternal education (some primary school and/or completed primary school) on actual levels and proximate determinants of child mortality

- Use 1992/3 Indian National Family Health Survey

- Find that mothers with low levels of education have a reduced risk of child mortality at 1-24 months compared to illiterate women

- No differences in neonatal mortality

- Low levels of education also leads to better illness management, service utilization, and some health behaviors

- More education has even more beneficial effects, but it appears as though even a little education makes a difference when it comes to child health

Some possible mechanisms

- Research hypothesize that even with only a little schooling, girls learn to respect and obey authority and to follow a routinized program of behavior, which makes them more likely to follow the dictates of health care providers later in life

- Such low levels of education probably not greatly increasing female autonomy

“Where and why are 10 million children dying every year?” The Lancet, 361, 2226-2234.

Most child deaths are neonatal, then caused by diarrhea and phenmonia

About half (53%) of deaths from all casues are due to being underweight

underwight children are more susceptible to infectious diseases.

88% of child mortality from diarrhea is due to lack of clean water.

- 6 countries account for 50% of all child deaths under 5 years old; 42 countries account for 90%

(India is the highest with 2.4 million childern dying each year)

(Sierra Leone has highest rate of U5MR)

Highest rates in countries with increasing population and decreasing GDP, in Africa, and in places with political instablity.

- Most child deaths occur in sub-Saharan African and South Asia

- Different death rates and causes in different countries mean that different policies should be implemented at the local/national level

- However, lack of data on causes of death in low-income regions can make planning interventions difficult

- Risk factors for child mortality include ingestion of unsafe water, lack of access to sanitation, birth spacing, not being breastfed

- In 42 countries studies, proportions of deaths caused by diarrhea and pneumonia were consistent

- Proportions caused by malaria, AIDS, and deaths in the neonatal period varied greatly

- Diarrhea and pneumonia are leading causes of death in high death rate regimes

- As death rates fall, the proportion of deaths in the neonatal period increases

- Comorbidity of health disorders -> synergistic effect on mortality rates that are higher than the sum of individual rates

 - Ex: being underweight and contracting an infectious disease

“Population aging and the rising cost of public pensions.” Population and Development Review, 30(1), 1-23.

Objective of study was the demonstrate that current trends in public pension expenditures are unsustainable and to calculate sensitivities to policy options

- Uses the pensioner-worker ratio (PWR) and the pensioner-expenditure ratio (PER) to assess dependency burden

- The pensioner-expenditure ratio is a function of the benefit ratio (average public pension divided by average earnings), the old-age dependency ratio (number of ppl aged 65+ divided by population aged 15-64), the pensioner-ratio (population receiving pension divided by population aged 65+), and the employment-ratio (number employed divided by population aged 15-64)

- The pensioner-expenditure ratio reflects the total amount of annual spending on public pensions divided by the total pre-tax earnings of workers

- Projections indicate that the pensioner-worker ratio will increase substantially in most Western countries by 2050

- Italy projected to have a ratio of 1.55

Bongaarts proposes 4 potential policy options to reduce public pension expenditures

1. Counteract population aging through increased fertility/immigration

2. Increase labor force participation among those aged 15-64

3. Raise the age of retirement

4. Reduce public pension benefits

 “Trends in senescent life expectancy.” Population Studies, 63(3), 203-213.

 Mortality can be divided into two components

Senescent mortality is the result of biological aging; reflects the types of death that generally increase with age; it can be postponed through medical interventions and lifestyle adjustments, but it cannot be avoided

 Non-senescent mortality is unrelated to aging; involves things like accidents and many infections; also called background mortality

Makeham was the first to distinguish between these two types of mortality in the 1860s

- Bongaarts first estimates trends in senescent and background mortality

- Senescent life expectancy rose at an average rate of 1.54 years per decade between 1960 and 2000

- Overall life expectancy has been converging on senescent life expectancy due to large declines in non-senescent mortality

- Future improvements in life expectancy at birth will come largely from continuing declines in senescent mortality, as declines in non-senescent mortality appear to have largely run their course

“Routes to low mortality in poor countries.” Population and Development Review, 12(2), 171-220.

- Is economic development a prerequisite for mortality decline?

           - Caldwell says no

Examines 3 countries that have much lower levels of mortality than would be predicted based on SES: Kerala, Sri Lanka, and Costa Rica

- All three of the countries examined went through a “breakthrough” period in the mid 20^th century in which mortality, especially child mortality, declined quickly

- Argues that the provision of health care services can markedly reduce mortality, but that certain prerequisites must be met before good and efficient health care can be achieved

1. Public must demand education

     - Religious background of these three countries place value on  achieving enlightenment

    - Furthermore, in these countries girls’ education is valued as much as boys’, which increases the demand for good schooling

    - Educated population → ability to make informed decisions, later marriage, protection of indigenous cultures

2. Female autonomy

- Women must have ability to do as they please and to play a key role in decision-making

- This allows mothers to better care for their child’s health

- Furthermore, women who are better educated are able to make more informed decisions regarding their child’s health

- Ex: In Sri Lanka, British government instituted universal suffrage in 1928 with the express purpose of lowering child mortality

- Increased female autonomy also leads to higher levels of participation in labor force and delayed age of marriage

- Furthermore, when women’s position in society is good, so usually is that of children

- Sons and daughters more likely to be treated equally

- Parents more willing to send children to school rather than have them work

3. Political activity

- Political participation leads to increased social reform

- In all 3 of these countries, grass-roots social movements paved the way for social change, especially in the areas of health and education

- These three laid the groundwork for each country’s mortality breakthrough

- Sri Lanka’s breakthrough occurred 1946-53, Kerala’s breakthrough occurred 1956-71, and Costa Rica’s breakthrough 1970-1980

- During these periods, Sri Lanka’s life expectancy increased 12 years, Kerala’s increased 12 years, and Costa Rica’s increased 7 years

- These breakthroughs corresponded with dramatic improvements in health care

- All countries developed a greater density of health care clinics

- Improved efficiency of health care

- Increase in household health visits (esp. in antenatal period)

- Developed “nutritional floors” for all people (Ex: via school lunch programs)

- These developments allowed new medical technology to move seamlessly through entire population

- Caldwell emphasizes that the interaction of better health care and an educated population is what allowed for these health breakthroughs Having only one or the other doesn’t afford nearly the same benefits

- In sum, unusually low mortality can be achieved if the following inputs hold:

 - Female autonomy

 - Government inputs into health services and education for males and females

 - Health services available to all

 - Health services work efficiently

 - Basic nutrition provided to all

 - Universal immunization

 - Concentration of health care on periods right before and after birth

- Caldwell advocates that investing in education (particularly female education) and health is the route to lower mortality for all

  - Low mortality will not come as a spinoff from economic growth

“Sex differences in morbidity and mortality.” Demography, 42(2), 189-214.

- The gender paradox in health refers to the fact that women have worse self-rated health and more hospitalization episodes than men in early and middle age, but are less likely to die at each age

-Researchers examine whether or not this paradox is true, and if so, why

Some possible explanations

1. Sex differences in the distribution of chronic conditions;

-women may be more likely to suffer from conditions, such as headaches and arthritis, that result in poorer self-rated health but contribute relatively little to mortality,

-whereas men may be more likely to have conditions such as cardiovascular disease that have relatively large effects on the probability of death

2. Women may simply report worse health than men on surveys

Findings

Use data from the National Health Interview Survey (1986-1994; 1997-2001)

- Women do indeed report worse self-rated health than men but are less likely to die

- Men and women with the same health conditions report similar self-rated health

- This suggests that differences in self-reports are due to differing distributions of disease, rather than reporting differences

- Women are more likely to get chronic but not fatal conditions (headaches, arthritis, depression) whereas men more likely to get fatal conditions

- Men are also more likely to die from smoking-related diseases than women with the same diseases

- Specifically, 50% of sex difference in mortality explained by 14 chronic health conditions,

with 25% of this difference explained by men being more likely than women to have conditions that have larger effects on mortality and

75% of it explained by men having greater probability of dying than women with same chronic conditions

Determinants of reduction in maternal mortality in Bangledesh - 30 yr cohort study

Found a decrease in maternal moraltiy in a 30 yr periods with international and gov't interventions.

Better health care, midwives, safer abortions helped

But women's education and financial assitance for the poor and poverty reduction are essential.

“Mortality crossovers: Reality or bad data?” Population Studies, 40(3), 389-401.

- The mortality crossover refers to the fact that countries with relatively high death rates in the early and middle years of life sometimes report very low death rates in the later years of life, causing the mortality schedule of these countries to cross that of countries with low death rates in the early and middle years of life

- For instance, the proportion surviving from ages 5 to 70 in the Soviet life table of 1926 was only about 50%, compared to 80% in recent life tables for Sweden and Japan, yet the expectation of life at the 70^th birthday in the U.S.S.R. was greater than that of present day Japan or Sweden

2 possible explanations for this pattern

1. Adverse conditions experienced at younger ages in certain populations eliminate the least resistant (most frail) members of these populations resulting in very low mortality among the highly selected survivors to older ages.

2. Data from which mortality rates are calculated in certain populations are biased in a way that causes a severe understatement of death rates at older ages.

Authors use cross-national data to examine each of these hypotheses

- Find that in populations for which data on deaths are highly reliable (such as Japan, Sweden, Norway, and the Netherlands), there actually exists a close positive relationship between mortality at younger and older ages

- In countries where age misreporting is common, low mortality at older ages is often accompanied by high mortality at younger ages

- Age misreporting often involves age heaping and age overstatement among the elderly

            - Summary of how we as a species got to where we are today

- We can really only estimate the size of the global population with any degree of accuracy beginning in the mid 18^th century

- Prior to that, the next earliest time for which data are available was the early Christian era when Rome enumerated its population

- The population was approximately 8 million at the end of the hunter-gatherer era in 8000 BC

- The population grew somewhat with the establishment of agriculture to approximately 300 million by AD 1

            - By 1750 the population was about 800 million

- The history of the human population can be divided into two eras: long era of slow growth prior to 1750 and short era of fast growth after 1750

- In a stationary population, life expectancy equals the reciprocal of the birth rate

- This relation allows us to determine the most extreme fertility and mortality rates possible in a stationary population

- If each woman has 2.1 births (birth rate 13.3 per 1000) life expectancy will be about 75 years in a stationary pop

- If life expectancy is about 15 years, women who live to childbearing age must have an average of 8.6 children to maintain population size

- Differences in fertility can be attributed to 2 factors: differential exposure of women of childbearing age to risk of childbirth through marriage/cohabitation and differences in rates of conception and live birth among women who are married/cohabiting

- Henry defined natural fertility as the fertility of couples who do not modify their behavior according to the number of kids already born

            - Natural fertility still affected by custom, health, and nutrition

- For the period of long, slow growth in human history, it is probable that short-term variations in population size occurred frequently (likely not a uniform upward trend)

- Coale suspects that the small uptick in the size of the human population following the establishment of agriculture was due to fertility rates increasing more than death rates

            - Death rates likely increased due to more infectious diseases

- The demographic transition describes changes in fertility and mortality that accompany a nation’s progression from a largely rural, agrarian, and illiterate society to a primarily urban, industrial, and literate one

            - Mortality falling before fertility explains population boom

- In the premodern era the birth rate was relatively constant while the death rate fluctuated from year to year; in the postmodern era the death rate is relatively constant while the birth rate fluctuates

- Birth rates fell because couples wanted to have fewer children, not because new contraceptive technologies became available

- Less developed countries have been growing dramatically since WWII

- The present global population growth is due to moderate rates of increase in the developed world and very large rates of increase in the developing world

- Coale believes that at some point in the future the human population will inevitably return to a growth rate near zero

- What is undetermined is what combination of fertility and mortality will sustain this level of growth

 “Child mortality differences, personal health care practices, and medical technology.”

- Purpose of paper is to examine the role of behavioral factors (as opposed to economic development and public health measures) in changes in child mortality

- Begin with finding that French-Canadians had highest rates of child mortality and Jews had the lowest; why?

- Most likely attributable to differences in childcare, cleanliness, and medical knowledge

            - Diarrheal diseases were the most common cause of child mortality

- In the early 1900s health officials began educating mothers on taking proper care of kids

- Medical experts were unsure about exactly what caused young children and infants to contract diarrhea (was it a direct effect of heat or something caused by heat?)

- Debate over whether or not germs caused disease

- Nevertheless, many of the treatments and precautions recommended to mothers were effective at reducing kids exposure to bacteria, even though medical experts were unaware that this is what was happening

- Areas of advice given to mothers included 1) advice on feeding infants, especially the promotion of hygiene among those who were not breastfeeding, 2) Advice on isolating children from sick family members, 3) advice on handwashing and general hygiene, and 4) advice on when to consult a physician

- Authors conclude that decrease in child mortality was primarily due to advances in disease prevention rather than disease treatment

Danish infants born in June and months around it are more likely to die both as infants and 50+ than those born in other months.

As kids, this makes sense, bad milk -> illness but this is a crictal period that effects whole life.

Black - white crossover (@ 82 for women)

Frality effect

The "frailer blacks die earlier and at older ages the most robust are still alive

“Inequality in life spans and a new perspective on mortality convergence across industrialized countries.” Population and Development Review, 31(4), 645-674.

- Authors want to know whether the age pattern of mortality has converged across industrialized countries as life expectancy has

- Examine the standard deviation of ages at death past age 10 (S₁₀)

- Also examine within-group versus between group variation

- Analysis of 7 industrialized countries reveals only a slight decrease in the variation of death rates since 1960

  - The US has the highest S₁₀ of the countries examined

- What accounts for high S₁₀ in the US?

- Increasing differentials in life expectancy for males and females

- In addition, males have greater variation in mortality rates than females

- Race doesn’t seem to be driving high US S₁₀

- However, blacks have greater variation than whites

- SES (measured by dichotomized education and income) doesn’t account for higher US S₁₀

- However, disadvantaged groups have higher variance than advantaged ones

- Although authors did not find clear patterns of what’s driving S₁₀, they argue that it remains a useful measure for revealing life-span inequality (which may be the most fundamental form of inequality in the human population), as well as for forecasting future mortality, planning for work, saving, and investing, and for determining Old Age Support policies

Longevity by County in the US

From 1983-199

LE droped significantly in 11 counties for men and 180 for women

why?

consistent with

smoking

high blood pressure

obesity

 “Cumulative disadvantage and health: Long-term consequences of obesity?” American Sociological Review, 68, 707-729.

Paper investigates the long-term risks of obesity on health inequality in adulthood, drawing on cumulative disadvantage theory

Cumulative disadvantage theory proposes that early advantages or disadvantages are critical to how individuals within cohorts become differentiated over time

- A theoretical consideration that has typically been overlooked is that health disadvantages are potentially reversible

- Are there compensatory mechanisms that can reduce the effects of previous disadvantages?

- A second limitation of empirical work is the issue of selective survival

4 research questions addressed in paper:

1) Is obesity associated with physical disability?

2) If obesity is related to disability, is the effect of obesity more substantial during certain periods of the life course?

3) Does the timing of obesity influence health inequality?

4) Can compensatory mechanisms reduce or eliminate the effects of obesity on health decline?

Findings

- Evidence for both lagged and immediate effects of obesity on lower body disability

- Only modest effects of obesity on upper body disability

- Transitioning from the obese to the non-obese state between waves 1 and 2 did not reduce the risk of lower body disability compared to those who did not transfer

- No evidence for exiting risk on health

- However, regular exercise did reduce the effect of obesity on disability

- Evidence for compensatory mechanism that occurs via exercise but not via weight loss

- Effects of obesity reduces the independent effects of socioeconomic status on health measures

  “Economic growth, population theory, and physiology: The bearing of long-term processes on the making of economic policy.” American Economic Review, 84(3), 369-395.

Fogel argues that nutrition is the key mechanism via which income influences health

- Purpose of paper is to develop a theory to account for the secular decline in morbidity and mortality that takes account of changes induced in physiological functioning since 1700

- Decline in mortality in Britain and France took place in 2 waves

- First wave began during second half of 18^th century and lasted until beginning of 19^th century

- 2^nd wave began in the late 19^th century and continued until the present day

- Fogel argues that high prevalence of disease can cause malnutrition even if food supply is adequate by impeding the uptake of nutrients from food

- Caloric intake estimates from 1790 in Britain and France suggest that the population must have been pretty short and slim

- Even accounting for small stature, low calorie intakes also suggest that a substantial proportion of the population would not have been very productive in the labor market

- Fogel uses 2 indices—height and BMI—as proxies for malnutrition and health to predict risk of death at middle and late ages

- Height reflects health throughout life whereas BMI reflects more current nutritional intake

- Height and weight are likely predictive of mortality because they are associated with nutritional factors that affect the chemical composition of organ tissues, electrical transmission across membranes, the fxning of vital organ systems, etc.

- Finds that gains in BMI accounted for most of the reduction in mortality prior to 1870 and that gains in height accounted for most of the reduction after 1870

- Nutritional state not only affects risk of death due to infectious diseases but also affects risk due to chronic diseases

- This study suggests that childhood malnutrition may affect health throughout life (both vulnerability to infectious diseases and risk of chronic diseases)

- Increased caloric intake affects labor productivity both directly (more energy) and indirectly (disease)

            - Implications for economic growth

Looked at height of veteran of war and modern norwegians.

The taller have lower mortality.

“Chronic conditions and the decline in late-life disability.” Demography, 44(3), 459-477.

- Recent evidence suggests that the prevalence of late-life disability has been declining

- Objective of paper is to determine the extent to which declines in late-life disability are due to declines in the prevalence of chronic conditions that cause disability versus declines in the risk of disability among those that have these conditions

- Measured disability by looking at the Activities of Daily Living (ADLs) and the Instrumental Activities of Daily Living (IADLs)

General trends

- Find that between 1997 and 2004, the percentage of Americans living with disability declined by about 11%

- Prevalence of many of the potentially debilitating conditions increased significantly

- Cancer, heart and circulatory conditions, diabetes, obesity, and arthritis all increased

- Only severe mental distress and visual impairments decreased

- The probability of disability given a chronic condition was lower in 2004 than in 1997

Decomposition of these trends

- Declines in heart and circulatory conditions as causes of disability were the largest contributors to the disability decline

- Expanding medical and rehabilitative treatments have limited the amount of disability resulting from these conditions

- Declines in overall prevalence of sensory impairments were next

- Increases in the prevalence of obesity contributed to increases in reported disability

- The gender gap in disability declined over this period; women were experiencing less disability relative to men

 - This could perhaps reflect increases in women’s ses relative to men’s

- Education had a mixed effect on disability

- Increased proportion of elderly with more than a high school education contributed to decreased disability

- However, the disadvantage of having less than a high school education increased over this period, which caused overall shifts in education to push disability upward over this period

“Is poverty or wealth driving HIV transmission?” AIDS, Supplement 7, S5-S16.

Literature review of recent findings on the relationship between wealth and HIV infection in sub-Saharan Africa

- Some researchers theorize that in the early stages of the HIV epidemic, the wealthy were more likely to contract the disease due to higher rates of partner change stemming from greater personal autonomy and spatial mobility

- In later stages of the epidemic it has been argued that the poor are more likely to contract the disease due to increased sexual risk taking and decreased immune function (less resistant to the disease in the event of an unprotected sexual encounter)

Some key patterns from recent literature

- At the national level, income inequality is associated with HIV prevalence, but poverty rates are not

- Poor women and wealthy men are particularly likely to engage in transactional sex and to have more sexual partners

- In fact, gender inequality at the population level may lead to riskier sexual behaviors

Two key problems with cross-sectional studies

- Cannot determine whether poverty causes HIV infection or vice versa

- Unable to control for the fact that individuals from richer households may survive longer with HIV, and are thus more likely to be in the population

- Education has a strong negative relationship with HIV infection

- This association changed over time; at the early stage of the epidemic there was little association between education and HIV, but later in the epidemic education was significantly negatively correlated with HIV (similar to association between wealth and infectious diseases over time as discussed by Preston)

- Individuals with more education tend not to engage in risky behaviors, which reduces their chance of HIV infection

- The urban poor appear to have higher rates of HIV than the rural poor

- Authors speculate that this may be due to reduced privacy in urban slums, which allows children to view sexual activity and thus become sexually active at a much earlier age

- In sum, income and gender inequality are particularly predictive of HIV at the national level

- Educational attainment predictive at the individual level

“Trajectories of functional health: The ‘long arm’ of childhood health and socioeconomic factors.” Social Science and Medicine, 66, 849-861.

examines how circumstances associated with early life may shape the level and progression of functional limitations among older adults

- 2 theories suggest how events earlier in the life course affect later life health

1. Critical period approach (Kuh and Ben-Shlomo 1997) suggests that negative events during developmentally salient periods may alter later life health trajectory

2. Cumulative insult approach suggests that exposures accumulate over the life course and alter an individual’s risk of disease

- Present study uses a combination of prospective and retrospective data between 1994 and 2002 (5 waves) waves of the HRS to study the effects of childhood health and SES on adult health trajectories

- Find that poor health in childhood and disadvantaged social background are associated with both increased baseline limitation and steeper trajectories over time, net of adult chronic conditions and SES

- More proximate health and SES partially mediate childhood impacts on functional health

- This suggests that upward social mobility may partially counteract the effects of poor childhood circumstances on adult health

- Currents SES is only associated with baseline level of limitation (not with trajectories over time); this may be because the effect of SES on health plays out over a longer period of time

Haas’s proposed model

- Childhood SES impacts childhood health, adult SES, and adult health

- Childhood health impacts adult SES and adult health

- Adult SES impacts adult health

posit that better educated mothers may seek medical care more actively, may be more aware of sanitary precautions, nutritional info, and health services, and may be better able to recognize serious health conditions

ASDR in 1890-1910

Lowest for forestry, fisherman, and agriculture professionsal

Increased for labourers and servicemen

Next highest in transportation and communication.

“The significance of socioeconomic status in explaining the racial gap in chronic health conditions.” American Sociological Review, 65(6), 910-930.

- According the 1996 estimates, life expectancy of Black men in the US was 66 years compared to 74 years for white men

- Although evidence suggests that the black-white mortality gap converges at older ages (beyond age 65), blacks still remain disadvantaged (Elo and Preston 1994)

2 main questions addressed in paper

1. Are blacks consistently disadvantaged relative to whites across all major chronic diseases and disabling conditions?

2. How do fundamental social conditions affect the racial gap in health?

- Association between race and prevalence is assumed to reflect the historical relationship between SES and health conditions by the time of middle age

- Whereas association between race and incidence is assumed to reflect the occurrence of health problems during middle age

- Include a wide array of covariates in their models because race is assumed to represent the confluences of biological factors, geographic origins, cultural, economic, political, and legal factors, and racism

- For any particular disease, race differences are likely to be the result of differences in combinations of experiences over the life cycle

- Use 1992 and 1994 waves of HRS (respondents 51-61 years old) to assess 1992 prevalence and 1992-1994 incidence of diseases and conditions

- Dependent variables include major fatal chronic diseases (heart disease, hypertension, stroke, diabetes, COPD, and cancer), arthritis and mental diseases, and disability at work and home

- Independent variables include race, gender, educations, mid-life ses, life stressors, social support, health behaviors, and health insurance

Results

- Greater prevalence of all health problems in blacks

- Also higher incidence, but not as substantial

- The greater prevalence of health problems among blacks at middle age is likely to result of cumulative disadvantage over the life cycle, rather than simply the result of the simple bifurcation of health at middle age

- Particularly bad health among black women

- Education and social structure, rather than risk behaviors, explain most of the racial disparities in health (lends support to Link and Phelan’s “fundamental causes of disease” argument)

- It is also important to recognize that health disparities may increase ses disparities between blacks and whites

- Prior to this research, health differences by race were believed to be biological

- This study suggests that health is a product of social variables

- Health results from economic inequality, educational inequality, lifestyle differences, etc.

“The uneven tides of the health transition.” Social Science and Medicine, 55, 313-322.

- Uses the Global Burden of disease data to compare mortality patterns of the 20% of the world population living in the poorest countries, provinces, and states and the 20% of the world’s population living in the richest countries

- Find that poorest populations experience higher mortality in each of the three main groups of mortality, but that the excess mortality of the poorest populations is mostly due to their higher incidence of communicable diseases (77% of excess deaths)

- These diseases only account for 34.2% of deaths in the world but still dominate mortality among the poorest 20% of the world’s population (58.6% of deaths)

- Although developing countries have, to a certain extent, undergone an epidemiological transition, poorest populations still suffer from Group I diseases (in a sense they have been left behind by the epidemiological transition)

- This is partially due to the young age structure of poorer populations, but finding persists even with age standardization

- Most likely this trend has only gotten worse with the increase of AIDS

 “Epidemiological transitions in human history.” In Health and Mortality Issues of Global Concern. Proceedings of the Symposium on Health and Mortality. Pp. 54-71.

- Epidemiological Transition: long-term change in the overall distribution of diseases, injuries, and their risk factors

5 epidemiological transitions

1. External injuries to infectious diseases

- External injuries were the most common cause of death in hunter-gatherer societies

- Infectious diseases common among agricultural societies

- Some characteristics of farming societies that made it easier for pathogens to infect more people include greater population size of communities, higher population density, longer periods of residence at the same location, storage of foods, domestication of animals, and extended contact with other communities

- Also important are the rise of urbanization and decreased dietary diversity

- Common infectious diseases included tuberculosis, smallpox, cholera, etc.

2. Infectious diseases to degenerative diseases

- 2 phases of this transition

- First, crisis mortality due to epidemics reduced

- Second, mortality declines even in normal mortality years

- Many reasons for the decline in infectious diseases, such as improved nutrition, public health, and personal hygiene

- Increased proportion of deaths due to degenerative diseases occurred in the mid-1900s

- Common degenerative diseases include heart disease, stroke, cancers, diabetes, chronic liver disease, and chronic kidney disease

3. Decline of cardiovascular disease mortality

- This shift primarily affected old-age mortality, whereas previous shift contributed to gains in life expectancy by primarily reducing mortality at young and middle ages

- In some countries the periods of the second and third transitions are very distinguishable and in other countries they’re not

4. Decline of cancer mortality

- Expected to occur in the future

- Deaths due to some types of cancer (ex: lung cancer) have been declining in recent years, but whether this is the beginning of a long-term decline remains to be seen

5. Slowing of senescence

- Expected to occur in the future

- Senescence refers to a state of non-specific vulnerability; essentially old-age frailty

- 3 factors that may lead to delays in senescence are

1. maintain a healthier life style,

2. increased use of medical technologies, and

3. gerontological research on the fundamental biological mechanisms of senescence

- Demographic patterns associated with epidemiological transitions

- Drastic increase in life expectancy occurred between the 2^nd and 3^rd transitions

- In the early stages of the 2^nd transition mortality reduction was large for infants and young children, in the later stages of the 2^nd transition mortality decreased at reproductive ages (due to decrease TB), and in the 3^rd transition mortality decline was mainly seen among the elderly

- Sex differentials in life expectancy are relatively recent, and seem to have occurred due to unhealthier lifestyles among men

 - 5 reverse transitions (periods of increased mortality)

          1. Early stages of the industrial revolution

             - Industrialization -> urban poor -> diseases such as TB

          2. Unhealthy lifestyles among wealthy

              - High-fat diets, smoking, drinking, sedentary

          3. Re-emergence of infectious diseases

              - Reasons for this include

1) the emergence of new drug-resistant strains of old diseases,

2) technological advances that have allowed for increased global contact à faster spread,

3) only rapidly diffusing diseases can be deadly and continue to evolve at the same time, and

4) ecological advancement à contact with new diseases

           4. Pollution

               - Likely to increase mortality in the future

           5. Social alienation

               - Likely to increase mortality in the future

- Alienation may lead to mortality due to

1) lack of self-control and long-term plans increasing homicides, suicides, and accidents,

2) low concerns about health care,

3) unhealthy life styles during pregnancy and inadequate care of young kids, and

4) reduction of positive health effects stemming from positive attitudes

In most African Countries, mothers will even limited eduation have lower infant mortality

Mom's eduation as a proxy for household SES

shows variation in HIV burden.

“Sociodemographic differentials in adult mortality: A review of analytic approaches.” Population and Development Review, 24(3), 553-578.

Some trends in adult mortality differentials

- SES differentials have gotten steeper since 1960 (Pappas et al. 1993)

- Kitagawa and Hauser (1973) paved the way for studies of SES differences in mortality by estimating cause-specific mortality differences by education, income, occupation, marital status, etc.

- Since then, there has been much debate over which SES indicator(s) to use in studies of health and mortality (income vs. education vs. occupation vs. wealth)

- Unmarried versus married men’s risk has widened since 1960 (Smith 1996)

- Racial and gender differentials have at least persisted, and may have gotten stronger, since 1960

- Two repeatedly documented patterns of racial differences in mortality are the

epidemiological paradox (Hispanic populations tend to have lower mortality than non-Hispanic whites despite their lower SES; Markides and Coreil 1986), and the

racial mortality crossover (blacks tend to have lower mortality than whites at oldest ages; Nam 1995)

One major shortcoming of the demographic literature on mortality differentials is that it fails to explain why such differences exist

- Human agency doesn’t play the same role in studies of mortality as it does in studies of migration or fertility, because it is assumed that all people are motivated to avoid death

- One explanatory finding has been that gender differences in mortality are largely due to differences in heart disease

- Biodemographers are paving the way for a theory of human mortality by studying the limits to human life expectancy

- One fundamental assumption of studies of differences in mortality across subgroups is that such differences are social, rather than biological, in origin

A second shortcoming of this work is that without understanding the proximate determinants of mortality differentials, policy questions remain unanswerable

A third shortcoming is that even when proximate determinants have been studies, point in time estimates of risk factors limits their explanatory power

 - Researchers must find a way to incorporate time into studies of the proximate determinants of health and mortality, either by cohort studies, longitudinal studies, or retrospective questions

Some further challenges to this line of work

 - Different causes of death likely have different proximate determinants

- People often die of more than one thing, even though only one cause is listed on death certificate

- Macro-level factors often play a role (e.g. access to health care, dangerous inner-city neighborhoods, etc.)

- However, it is difficult to quantify what role macro-level factors might play on individual health due to processes like selection into certain neighborhoods, variation in utilization of services etc.

“Global aging: The challenge of success.” Population Bulletin, 60(1).

Overview of the social and economic implications of the world’s aging population

Some key facts

- People usually associated the growth of older populations with developed countries; however 60% of the world’s older population now live in less developed countries

- In 2004, Italy had the largest percentage of people 65+ (19.1%) followed by Japan (19.0%), Greece (18.6%), and Germany (18.3%); US ranks 38^th, with 12.4% of its population age 65+

- The elderly support ratio is not necessarily a good measure of those who need financial assistance, because it doesn’t reflect only economically active people in the denominator or exclude economically active people from the numerator

-If these factors were taken into account, the alternative elderly support ratios would be even higher in most industrialized nations (Japan is one exception)

- Declines in fertility is number one reason for population aging

- Declines in fertility have been incredibly rapid in developing countries (aging proceeded much more gradually in developed countries)

- For example, sudden drop in fertility is expected to cause rapid aging in China; the number of Chinese aged 65+ is expected to swell from 88 million in 2000 to 199 million in 2025 and 349 million in 2050

- The demographic transition has not proceeded smoothly in Sub-Saharan Africa due high prevalence of AIDS

- HIV/AIDS has thrust older people into the role of primary providers for children

- Within countries, the elderly tend to be more concentrated in rural areas as the young move to cities

- The compression of morbidity refers to the hypothesis that as life expectancy rises, so too will the average age of the onset of chronic illness (phrase first used by Fries in the 1980s)

- This appears to be what is happening, at least in the US

- Older married people tend to be healthier and more financially secure than unmarried

- Male widows are more likely than female widows to lose most of their support system after their spouse dies

- Increasing trends toward childlessness will affect the availability of old age support

- Increasing life expectancy implies increasing contact across generations

- Debate over whether or not the family is “declining”

- Living arrangements among the elderly have changed dramatically in recent decades

- For example, in Japan in 1960 87% of elderly lived with their child and 4% lived alone; in 2010, 42% are expected to live with their child at 13% are expected to live alone

- Wealthier countries tend to have much lower labor participation rates among the elderly than do poorer countries

- Aging experts John Rowe and Robert Kahn view successful aging as the confluence of 3 factors: 1) decreasing the risk of diseases and disease-related disability, 2) maintaining physical and mental functioning, and 3) being actively engaged with life

- Currently in OECD countries poverty rates living standards among the elderly is quite good; in 1960 one-third of all older US citizens were below the poverty line, whereas by the mid-1990s, only 10% were below poverty (lower than the rate for children)

 Purpose of article is to provide a historical overview of demographic transition theory

- Demographic transition theory states that societies that experience modernization progress from a pre-modern regime of high fertility and high mortality to a post-modern regime of low fertility and low mortality

- The theory is descriptive rather than explanatory

- Most demographers find fertility decline harder to explain than mortality decline

- Notestein attributed fertility decline to primarily socio-economic causes

- Industrialization stripped the family of many of its fxns in production, consumption, recreation, and education; education and a rational point-of-view became more important and as a result the cost of child-rearing grew; falling death rates lowered the inducements to have a lot of births; etc.

- Criticisms of demographic transition theory

- Its accuracy based on data from European demographic history (for instance, ignored variation in pre-modern fertility)

- Fertility decline doesn’t always occur after mortality decline

- Fertility decline not accurately predicted by socio-economic factors (some countries appear to experience decline before reaching modernization)

Coale posits three conditions necessary for fertility to fall:

1. Fertility must be within the realm of conscious choice.

2. Reduced fertility must be perceived as advantageous.

3. Effective contraceptive techniques must be available.

European Fertility Project designed to study historical fertility decline in Europe

- One of its key contributions was the discovery that the fertility transition has occurred under diverse socio-economic circumstances

- Empirical data suggests that both the mortality and fertility transitions have picked up tempo over time

- Fertility transition now beginning at increasingly lower levels of socioeconomic development

- Mortality reduction and fertility reduction believed to be linked by economic development

- Various factors have been hypothesized to be the leading factor in fertility decline

- Economic theories of fertility decline propose that reduced demand for children due to income, prices, and tastes were to blame

- However, Caldwell points out that modernization isn’t a necessary precursor of fertility decline

- He hypothesizes that Westernization is a more important force of change, which includes ideas of progress, secularization, mass education, and mastery over environment

- Cultural and ideational theories hypothesize that fertility decline is related to the degree of secularism, materialism, and individuation in a culture

Government policy may also play a key role in fertility decline

- Nativity policy (ex. China)

- Policies related to female education and women’s rights

Kitagawa and Hauser (1973) paved the way for studies of SES differences in mortality by estimating cause-specific mortality differences by education, income, occupation, marital status, etc.

Find evidence of an educational health gradient in the US

Critical period approach suggests that negative events during developmentally salient periods may alter later life health trajectory

Etimate that combined sex life expectancy in the US would equal 86.1 in 2065, whereas official estimates suggested it would equal 80.7

“Death and taxes: Longer life, consumption, and Social Security.” Demography, 34(1), 67-81.

Paper examines the influence of mortality decline on the long run finances of the Social Security system (excluding Medicare)

- Estimate the adjustments that must be made to an individual’s present level of consumption or labor earning to provide for the additional years of life gained through reductions in mortality

- Review of how mortality decline affects the age distribution of the population

- The age distribution of a stable population depends on the population growth rate and on the shape of the survival schedule

- Changes in fertility only affect the growth rate of the population

- In contrast, changes in mortality affect both the growth rate the survival schedule

- For instance, declines in mortality cause more people to reach reproductive age and have more births, thereby lowering the mean age of the population, and they cause more people to survive to older ages, thereby raising the mean age of the population

- In countries that already have low mortality at younger ages, like the US, the second effect predominates, making populations older

- Official SSA forecasts of mortality declines tend to be much smaller than those indicated by recent trends

- Rates of decline among the oldest-old have been accelerating quite rapidly

- In another paper, Lee and Carter (1992) estimated that combined sex life expectancy in the US would equal 86.1 in 2065, whereas official estimates suggested it would equal 80.7

- Uncertainty about the future course of mortality entails uncertainty about the future financial adequacy of Social Security

- Gains in life expectancy at older ages (a period of leisure and consumption) require that consumption be reduced or labor supply be increased to fund these extra years

- Authors estimate that each additional year of life expectancy entails a 3.6% increase in payroll tax rate or a 3.6% reduction in benefits

- Authors propose that generations that are predicted to benefit from these gains in life expectancy should be the ones to pay the extra cost

“Social conditions as fundamental cause of disease.” Journal of Health and Social Behavior, 35, 80-94.

- Most research on SES and health has focused on identifying proximal factors through which SES might affect health, such as diet, cholesterol, hypertension, and exercise

- Purpose of present paper is to highlight the past accomplishments of medical sociologists and social epidemiologists in advancing understanding of the social conditions that cause disease and to offer a conceptual framework to enhance this research

- One downside of examining intervening mechanisms is that researchers may neglect to study the social conditions that produce the intervening mechanisms in the first place

- One way to counteract this trend is to contextualize risk factors

- By contextualizing the authors mean understanding way people come to be exposed to risk or protective factors and to determine the social conditions under which individual risk factors are related to disease

- For instance, without understanding why poor people tend to have a poor diet, providing information about a healthy diet is unlikely to have the intended positive impact

- A second approach to enhancing the study of social conditions rather than proximal conditions is to consider social conditions as “fundamental causes of disease”

- The term “fundamental causes” is meant to imply that the health effects of social conditions cannot be eliminated by addressing the mechanisms that appear to link them to disease

- As certain diseases among the poor have been eradicated, new ones have taken their place

- SES is a fundamental causes of disease because it regulates access to resources such as money, knowledge, power, prestige, and interpersonal networks

- Furthermore, SES influences multiple risk factors and multiple disease outcomes

- Considering social conditions as fundamental causes of disease suggest 3 criteria for policymakers to use when evaluating proposed health interventions

1) Does the intervention contain an analysis of factors that put people at risk of certain behaviors?

2) Does the intervention target just one disease or does it target a fundamental cause that will impact many diseases?

3) Does the intervention claim to address broader social conditions even though it only focuses on intervening variables?

- Purpose of book is to outline the history of population growth and to understand the mechanisms that have contributed to population growth, stagnation, or decline

Population size can be viewed as a proxy for prosperity

The size of the human species varies relatively slowly compared to other species

The growth potential of a population is a fxn of

1) # of births per woman and

2) life expectancy at birth

- Increasing life expectancy even beyond reproductive age might have biological effects (example: helping to care for the younger generation)

- High life expectancy and low TFR or low life expectancy and high TFR may produce = population growth rates

            - (20) Population growth is limited by the availability of resources

- The Neolithic revolution (i.e. the development of agriculture) -> increased potential for human growth

- The Industrial Revolution had a similar effect

- One environmental factor that continues to check population growth is degradation stemming from technology

- (30) Forces that constrain population growth include climate, disease, land, energy, food, space, and settlement patterns

- Choices that affect population growth include nuptiality, fertility, and migration

- (33) There exists a debate over why population growth occurred in the Neolithic period

- The classic hypothesis states that increased nutrition -> decreased mortality

-The alternative hypothesis states that mortality actually increased due to less varied diet and increased transmission of diseases, but that fertility increased by a larger amount

What were the effects of various historical “shocks” on population growth?

- The Black plague greatly reduced the size of the European population; took nearly 400 years for the population to rebound to pre-plague levels

- Smallpox brought by Spanish invaders to the New World came close to decimating many indigenous populations

          Why did mortality decline between 1750 and 1850?

- McKeown hypothesizes that it was due to increased nutrition, but this is debatable

  “Measuring the global burden of disease and epidemiological transitions: 2002-2030. Annals of Tropical Medicine and Parasitology, 100(5), 481-499.

- The aim of the Global Burden of Disease Study was to assess global patterns of disease burden and recommend interventions

- This articles utilizes a measure called the Disability Adjusted Life Year (DALY)

- Composed of years of life lost due to premature death and years of life lived with disability

Diseases classified into 3 groups

   - Group I: Communicable diseases

   - Group II: Non-communicable diseases

   - Group III: Injuries

- Find that globally ½ of deaths among 15-59 year olds in 2002 due to Group II and 1/3 due to Group I

- If HIV is removed, only 1/5 of death due to Group I

- Group I deaths predominate in low and middle income countries (esp. in Africa)

- Ten leading causes of disease differ in low/middle income countries versus high income countries

- 3 main causes of death globally are cardiac diseases, stroke, and respiratory diseases

- In high income countries, depression, heart disease, and cardiovascular disease are the three main causes of loss of productive life years

- In low/middle income countries, perinatal conditions, respiratory infections, and AIDS are the three main causes of loss of productive life years

- These diseases rank much higher in terms of years of life lost than the leading causes in high income countries

- People in developing countries not only have lower life expectancies, but they also live a larger proportion of their lives in poor health

Small number of risk factors account for a large percentage of mortality and disease burden

These include poor nutrition, unsafe sex, smoking, and alcohol use

- Policies and programs that target these risk factors could reduce multiple causes of poor health

- Over the next 30 years, authors predict decrease in overall Group I diseases, except for HIV/AIDS

Also predict increase number of deaths caused by Group II and III diseases

First to distinguish between senescent and non-senescent mortality

Senescent mortality is the result of biological aging; reflects the types of death that generally increase with age; it can be postponed through medical interventions and lifestyle adjustments, but it cannot be avoided

Non-senescent mortality is unrelated to aging; involves things like accidents and many infections; also called background mortality

“Long-term trends in life expectancy and active life expectancy in the US.” Population and Development Review, 32(1), 81-105.

Increasing life expectancy and the dramatic growth of the US elderly and oldest-old populations have implications of federal health policy—specifically for the Old Age Insurance, Medicare, and Medicaid

- Authors use multiple data sources to produce estimates of life expectancy and active life expectancy at various dates from 1935-2080 to identify the burden assumed by Social Security and its relation to Medicare and Medicaid

- Use Sullivan method of the proportion of people without disability at a given age to estimate active life expectancy with cross-sectional data

Results

- From 1935-1982 (institution of Social Security and year at which change in age necessary to receive benefits occurred) life expectancy and active life expectancy grew at about the same rate

- Between 1982 and 1999, ALE grew much faster than LE

- The ratio of ALE/LE at ages 85+ in 1935 was 23.3%, whereas in 1999 it was 63.0%

- A 65 year old in 1999 could expect to live 13.9 more years in an economically and socially productive state

- Active life expectancy at age 65 in 2022 is projected to be 16.4 years, and it 2080 it is projected to be 20.8 years

- In light of these findings, the authors recommend raising the age at which people start receiving Social Security benefits  (suggest age should be set at 72.0 years by 2022)

- This would still provide an average of 8.8 years of Social Security benefits to persons in an active state (the same as when SS was first introduced in 1935)

- Authors also recommend lowering the age requirement for Medicare so more people can stay healthy enough to remain economically productive in old age

- However, one factor that may throw a wrench in these projections is obesity

- Previous research has yielded mixed resulted regarding the magnitude of the effects of obesity on LE and ALE

“The influence of income on health: Views of an epidemiologist.” Health Affairs, 21(2), 31-46.

- Marmot assesses two ways in which income might affect health:

1) through a direct effect on the material conditions necessary for survival and

2) through an effect on social participation and opportunity to control life circumstances

- In more developed countries, most individuals have moved beyond the threshold where they don’t have enough money to secure material conditions necessary for survival

- The Whitehall studies (Marmot et al. 1984) shed light on the modern relationship between poverty and inequality

- This longitudinal study began in 1960 and examined the health of British civil service workers

- None of the workers were poor

- Nevertheless, their mortality still varied according to their position in the occupational hierarchy

- Ex: members of the lowest pay grade had 2 times the rates of cardiovascular disease as members of the highest pay grade

- This suggests that among populations above the poverty level, position in social hierarchy, rather than income per say, predicts health

- This may be due to psychological factors related to relative, rather than absolute, deprivation

- Income inequality in a country is a better predictor of health than mean income

- Even in the US, income inequality at the state level is associated with higher mortality rates

- Evidence suggests that the relationship between income and mortality is curvilinear, which means that although the rich gain from income inequality and the poor lose, the health advantage to the rich will be less than the disadvantage to the poor

- Marmot argues that this evidence suggests that wealth in and of itself may be standing in as a placeholder for other variables that more directly affect health

- Wealth ascribes benefits and social power

- Social participation, alienation from work, and stress may be reasons why health declines along a gradient related to social class

- In light of these findings, Marmot suggests that public policies should redistribute income, not for the purpose of addressing material deprivation, but rather for allowing all people to participate fully in society

- Presumably, government providing more goods and services so that access is not so dependent on income would also be beneficial

Whitehall Studies

shed light on the modern relationship between poverty and inequality

- This longitudinal study began in 1960 and examined the health of British civil service workers

- None of the workers were poor

- Nevertheless, their mortality still varied according to their position in the occupational hierarchy

- Ex: members of the lowest pay grade had 2 times the rates of cardiovascular disease as members of the highest pay grade

- This suggests that among populations above the poverty level, position in social hierarchy, rather than income per say, predicts health

- This may be due to psychological factors related to relative, rather than absolute, deprivation

- Income inequality in a country is a better predictor of health than mean income

“Reform and support systems for the elderly in developing countries: Capturing the second demographic dividend.” Genus, 62(2), 11-35.

The authors show that the demographic transition and population aging present two opportunities for economic growth

The first demographic dividend arises because the working age population is growing more rapidly than the consuming population due to decreases in fertility and mortality at younger/middle ages

- Provides an extra boost to income per capita

- However, this demographic dividend is transitory because the number of consumers will grow faster than the number of workers as a large part of the population becomes concentrated at older ages

The second demographic dividend arises because fewer children and a longer life create a powerful incentive for individuals to accumulate capital to provide for old age

- Investing this capital in the domestic or global economy will result in rapid growth of output per worker

- Parents investing in the human capital of their children (through education) would also produce a second demographic dividend

- Furthermore, this process could have a permanent positive effect on the economy

If, however, individuals rely on familial or public transfers to provide for old age, this will not increase output per worker

- It is therefore the responsibility of law-makers and public policy to encourage people to save and invest their money by creating and supporting the necessary financial institutions

- Authors conclude that the pessimistic predictions regarding the effects of population aging on economic growth are not necessarily warranted, so long as aging countries exploit the economic potential of the second demographic dividend

Age 45-64

gradient with increased risk of death at lower incomes

even when age, sex, race, family size, period are controled.

Premature Death in Easter Europe

-Young men espeically ___ to communist policies in Eastern Europe (pre-1990)

Leading cause of increased mortality is Injuries and violence, CVD,

-High alcohol comsumuption esp. binge drinking

-Smoking and nutrition are also a part of it.

Men who experience a rapid ecoomic transition who have the least social support are most effected.

-not uniqure pattern of premature mortality - it's seend in Western Europe too.

Big difference in LE between women and men

 Book is concerned with the growth of population that began in the late 17^th century and has continued until the present day

-The modern rise in population is distinguished from previous increases by 3 things—its size, continuity, and duration

- Reliable data from vital records only available after 1838 in Britain and Wales

- McKeown’s method involves using data from this “post-registration period” to infer mortality patterns in the “pre-registration period”

-Believes that a declining death rate—rather than an increasing fertility rate—is the trend that needs to be explained in relation to population growth

- Decline in infectious diseases was primary contributor to decline in mortality

- Concludes that response to infectious diseases was modified by improved nutrition after ruling out the role of

1) change in the character of disease,

2) reduced exposure to micro-organisms, and

3) immunization (except smallpocs)

For TB:

1. Not genetics

2. Not environment, stress, physical or mental, still crowded and still have airborne diseases

3. Not a change in the frequency or amount of exposure to the disease

4. Not a change in the virus

therefore diet and higher SoL -> living

Public Health/santination about 25% of decline of mortaltiy

Decline in mortality not increase in fertility leads to increase in poulaiton

- This is essentially a negative conclusion, meaning that he arrived at it by process of elimination

- However, there are also positive reasons for believing that better nutrition -> reduced mortality, namely that a large increase in food supply coincided with a decrease in death rates

-McKeown uses current data from developing countries to infer what must have been occurring in 18^th and early 19^th century Britain 

- Data collected by the World Health Organization suggests that malnutrition makes people prone to catching and dying from infectious diseases

-Argues that “better nutrition was a necessary condition for a substantial and prolonged decline in mortality; without it immunization and therapy would have been of little value and reduction of exposure to some organisms less effective.”

- It seems to me like McKeown is confounding undernutrition and malnutrition

- Is it more food, a more balanced diet, or both that’s important for mortality declines?

- (138) Moreover, the reductions in mortality occurred primarily in childhood, at ages where nutrition is particularly important in lowering the severity of infectious diseases

- (142) Reduced exposure to disease due to improved quality of water and food more important in the reduction of mortality in the late 19^th century than in the late 18^th and early 19^th centuries

Deccline in death due to communicable diseases

Decline in TB, Typhus, Scarlett Fever, Small pox (and small decline in cholera)

Smoking, BMI, and mortality

BMI

Increase mortality @ BMI 15 or less.

Mortality declines until BMI = 20

relatively stable until BMI = 35

then mortality increases againg (but never as high as the very underweight)

HR of death is higher at underweight and class 2/3 obese compared to normal weight, overweight, obese.

No difference in HR between normal weight, overweight and class 1 obese.

Smoking accounts for a many fold percent increase in death than obest cat 2/3

Children born in the Harvest Season in Gambia have better survival rates at every age.

This is slight until 20-25 when it gets larger and widens for the rest of the lifespan.

estimate that air pollution accounts for 1% of annual deaths worldwide

racial mortality crossover:

blacks tend to have lower mortality than whites at oldest ages

- The human population is projected to reach 9 billion by 2050

- This will be accompanied by downward growth in Europe and Japan

- Nearly all future growth is expected to occur in less developed regions (Africa, Asia, and Latin America)

- The world population is also expected to age dramatically

- Factors influencing population growth include fertility, mortality, migration, and population momentum

- Over half of the expected population growth by 2050 is attributable to the momentum inherent in the young age structure found in the developing world

3 steps to population projections using the cohort-component method

1) Collection of baseline data to determine the current size of the population,

2) projection of component rates (fertility, mortality, and migration by age), and

3) calculation of population projections

Issues with this method

- Difficult to predict future trends in vital rates

- Feedback from population size to vital rates not considered

    - For instance, environmental constraints may lead to changes in the birth and death rates

- The role of social policy is difficult to consider

- No probabilities associated with high, medium, and low variants of population projection developed by the UN

Notestein’s Theory of the First Demographic Transition

- Developed in 1945 in his article “Population—The long view”

- Describes the move from high fertility, high mortality regimes to low fertility, low mortality regimes

- Stage 1

            - Pre-industrial societies

            - Birth and death rates are high and approximately =

            - Population limited by food availability, fresh water, &  disease

- Stage 2

            - Early industrial societies

            - Characterized by technological innovations such as the   agricultural revolution and technological advances

            - Death rates plummet

             - Fertility does not plummet right away

             - High birth and low death rates -> population explodes

- Stage 3

             - Industrial societies

             - Birth rates fall

- Stage 4

            - Post-industrial societies

            - Low birth and death rates

            - Relatively stable population

 “The 1918 influenza epidemic’s effects on sex differentials in mortality in the United States.” Population and Development Review, 26(3). 565-581.

- Authors suggest that the 1918 flu had a strong and long-lasting effect on differential mortality by sex, reducing the female advantage

- Operated through a selection effect whereby young men with TB were particularly likely to die from the flu, reducing the number of male deaths to TB in the years following 1918

- By selection effect, the authors mean the increased robustness of a cohort over age and time due to a shift in the unobserved heterogeneity among mortality risk factors

            - 4 aspects of the 1918 flu epidemic that set it apart from other flu epidemics

                        - It’s magnitude

                        - It’s high mortality rate

- It’s W-shaped mortality profile (infants, the elderly, and young adults were all especially likely to die from the flu)

- It’s unique molecular composition

- Just after the 1918 flu, TB death rates experienced their steepest decline of the century, and the decline was much more pronounced for males than females

- TB infection was a key risk factor for contracting and dying from the flu

- The authors find that if pre-1918 trends in male and female ASDRs had continued through 1932, the number of deaths to TB in the US would have been 500,000 greater than actually occurred and the majority of deaths would have occurred among males

“The hidden penalties of gender inequality: Fetal origins of ill-health.” Economics and Human Biology, (1), 105-121.

Missing Women

- Main argument is that gender inequality harms the health of the entire population

- Overlapping health transitions in the developing world describe a regime in which both communicable diseases and chronic diseases are prevalent simultaneously

- Communicable diseases tend to affect children in poorer segments of the population whereas chronic diseases tend to affect adults in relatively better-off segments of the population

- Authors argue that both of these patterns are exacerbated by the common factor of maternal deprivation operating via fetal deprivation

- In Southeast Asia, mortality rates of women much higher than men

- Estimate 37 million “missing women” in India alone (women that would be alive if it were not for gender inequality)

- 100 million missing women worldwide

- Systematic biases against women -> higher mortality rates among women and averting of women that would have been born

- Authors suggest that gender bias -> maternal undernutrition -> low birthweight -> both child malnutrition and adult poor health

Two types of pathways link low birthweight to adult ill health

- Low birth weight babies may suffer from malnutrition and growth retardation in childhood and typically grow up to be adults of short stature and low BMI

- Barker Hypothesis: Low birthweight infants have bodies and organs that expect to be in a nutrient-poor environment for the rest of their lives

- Babies born with a low birthweight may be better-off in a nutrient poor environment than babies born at normal birthweight because their bodies adapted in the womb

- Babies born with a low birthweight that grow up in a normal or nutrient-rich environment may have more health problems than if they had grown up in a nutrient poor environment because they are more likely to suffer from hypertension, type II diabetes, cardiovascular disease, lung disease, and renal damage

- This hypothesis is supported by the fact that Indian adults have the highest rates of diabetes in the world

- In sum, gender inequality essentially leads to a double jeopardy—simultaneously aggravating both regimes of communicable and chronic diseases and raising the economic cost of the overlapping health transition

- Policies aimed at reducing gender inequality might be the most effective means of preventing these health problems

 Fatal Years: Child Mortality in Late 19^th Century America. Princeton, NJ: Princeton University Press.

Preface

- Prehistoric man lived an average of 20-25 years; today average life expectancy in the US is 75 years

- Approximately half of the gains in life expectancy occurred in the 20^th century, as life expectancy around 1900 was approximately 50 years

- One aim of book is to provide info on the levels, trends, and differences in child mortality in the US at the turn of the century

- Second aim is to explain these trends

Chapter 1

- At the turn of the century nearly 2 out of 10 children died before reaching their 5^th birthday

- This level of mortality is much higher than in either Asia or Latin America today

- Most deaths due to infectious diseases (diarrheal, respiratory, etc.)

- In the late 19^th century germ theory became increasingly accepted, however old medical practices were slow to change

- Overall, for most diseases, prevention was more important than specific therapy

- The biggest advance related to the new knowledge on disease mechanisms came in the form of public health (sewage disposal, milk cleanliness, pure water, health education)

- Parenting practices (particularly of the mother) exceedingly important for child health

- This is illustrated by the fact that the infant mortality rate for babies whose mother died within 2 months of childbirth was 625 per 1000

- Children whose mother worked outside of the home also had much higher mortality rates

- Breastfeeding reduced child mortality by preventing exposure to unclean milk

- Contemporary reports suggest that parents were motivated to increase their children’s survival chances but often lacked the knowledge to do so

Social and economic influences on mortality

Urbanization: Concentration of many people accelerated spread of disease, but it also facilitated the deployment of health services

Occupation: Percent of population employed in industry positively correlated with infant mortality; mothers’ labor force participation positively correlated with infant mortality

Ethnicity and Nativity: Immigrants tended to have higher death rates than natives, but lots of variability existed in death rates across immigrant groups

Literacy and Income: Inverse relationship between fathers’ earnings and child mortality: appears to operate through access to better housing

Diet: Children’s diets probably improved at the turn of the century as did the diets of the adult population; urban residents likely had access to a greater variety of food

Chapter 5

- In order to better understand the factors that influence child mortality, the authors compared child mortality differentials in England and Wales in 1911 to a set of 11 developing countries in the 1970s

- In England and Wales, large child mortality differentials existed between urban/rural areas, by fathers’ occupational status, by whether the mother worked, by # of rooms in house, and between Irish immigrants and native born

- Compared to the US at the turn of the century, England and Wales had greater health inequality by SES

- This is partially attributable to the fact that professional and white-collar groups in the US had a smaller mortality advantage than those in GB, maybe because these groups in GB had higher social standing

- In general, GB had greater income inequality than the US

 - GB may also have had greater residential segregation by occupational class than the US

- Mortality differences between US at the turn of the 20^th century and developing countries today

- In the US in 1900, urban residents had 28% higher mortality compared to rural residents; in developing countries today, urban residents have 23% lower mortality

- Lower mortality attributable to urban residents’ higher social standing

- Occupational differences in mortality much smaller in the US in 1900 than in developing countries today

- Overall, the US in 1900 had much higher child mortality than today’s developing world in every occupational class except agricultural workers

- Even though occupational differences in mortality were relatively small, racial differences in mortality in the US in 1900 were enormous

- Preston and Haines conclude that the widespread failure to achieve satisfactory child mortality at the turn of the century was due to a lack of knowledge about disease and a failure to implement techniques that had become recently available

- It wasn’t until the first 3 decades of the 20^th century that a recognition of the value of preventative hygienic measures such as handwashing, isolating the sick, boiling milk, and using clean water became widespread

- “Advances in science, diffusion, of knowledge of preventative measures, and improvements in social organization, rather than economic growth per se, appear primarily responsible for the dramatic successes that were to come, both in the US and in much poorer countries.” (p. 207)

Chapter 6

- Despite being the richest country in the world, and having a population that was highly literate and exceptionally well-fed, the US at the turn of the 20^th century had a death rate for children below age 5 that would rank in the bottom quarter of contemporary societies

- One reason for this is that infectious disease processes were poorer understood by public officials, physicians, and parents and the few effective medical technologies that had been developed were slow to diffuse

- Lack of dramatic social class differences in child mortality suggests that a lack of know-how rather than a lack of resources were primarily responsible for child mortality

- Ex: the literate and professionals enjoyed a much smaller mortality advantage than they do today (the mortality of children of doctors was only 6% below the national average)

- Race was the single most important variable in predicting child mortality which suggests that social and economic factors certainly played a role in child mortality, even though growth of income and living standards was not the principal factor causing mortality to decline

- The second most predictive variable was size of place: child mortality much higher in cities than in rural areas

- Suggests that people remained susceptible to natural forces until later in the 20^th century when medical knowledge really expanded

“Socioeconomic differences in adult mortality and health status.” In Demography of Aging. Eds. Linda Martin and Samuel Preston. Pp. 279-319.

- Purpose of chapter is to review recent evidence about the extent and sources of socioeconomic differences in health and mortality among older people in the US .

Trends in mortality by education

- Education differentials in mortality increased between 1960 and 1971-1984

- More pronounced differentials for men than women, especially in the prime working ages

- Education differentials in mortality by education smaller at older ages (basically completely gone by 85+ years)

Trends in health by education

- Education differentials in disability and ill health are quite large by middle age

- At ages 45-54, more than one-third of ppl with 0-8 yrs of schooling are in “fair” or “poor” health, compared with less than 5% of those who finished college

- Differences by education get smaller at older ages (just like mortality)

- Potential sources of socioeconomic differentials in health and mortality

 Income/wages/education

- People with higher SES are able to purchase more health-enhancing goods and services (healthier foods, gym membership, larger living space, less polluted residence)

- This is sometimes referred to as the “deprivation” model: poor people suffer ill health and premature death because they are poor

Price of health related goods and services

- The market price of seeing a doctor may be much higher for a poor person who lacks health insurance

- Opportunity cost of seeing doctor for hourly employees

- Knowledge of medical knowledge and technique

- Poorer classes may not be aware of treatments that are available

Personal endowments from childhood

- Children of higher status may have a healthier disposition, may have

 good health habits, may have parents with good genes, etc.

Tastes

 - Members of higher classes may have a preference for deferring gratification that affects both class and health

 “The daily struggle of poor people to meet their basic needs for food, clothing, and shelter causes them to place lower priority on more distance dangers.” (p. 302)

- Empirical studies reveal that the behavior to which the largest number of excess deaths in the US are attributable is smoking, which is much more prevalent among low SES individuals

-Nevertheless, even accounting for many variables that are believed to account for SES differences in health and mortality typically fails to explain more than 40% of the variance

- Some researchers suggest that some generalized factor or fundamental cause may be responsible for the differences

-Racial differences in health seem primarily attributable to differences in income and education

“Urban French mortality in the nineteenth century.” Population Studies. 32(2), 275-297.

- In the paper, rather than studying mortality at the national level the authors examine mortality in 3 regions in France—Seine (Paris), Rhone (Lyon), and Bouches-du-Rhone (Marseille)

- Comparing life expectancy in these 3 regions to life expectancy in France as a whole reveals that deaths in urban areas are greater than in rural areas

- Authors hypothesize that this is because disease spreads faster in urban areas due to greater frequency of interpersonal contact and sharing common resources

- However, region variation in urban death rates suggests that factors other than improvements in living standard (which occurred in all regions) are at play

- The most appealing candidate for comparing regional variation in death rates is the quality of the water supply and the techniques of sewage disposal

- Lyon improved water supply first and saw earliest drop in death rates, Paris was second, and Marseille third

- Mortality advantage did not occur immediately after cities improved their water supply because it took a while for households to implement new water facilities

- In addition, children saw the benefits more than adults, so mortality really improved on a cohort-by-cohort basis, rather than all at once

- Cause of death statistics confirm favored position of Lyon and disadvantaged position of Marseilles with respect to water-borne diseases (mostly diarrhoeal diseases like cholera and typhoid fever)

- However, air-borne diseases also related to quality of water supply because presumably people who are more sickly due to poor-quality water are more susceptible to these diseases as well

- In sum, the authors propose that improved water supply and sewage disposal, most likely in conjunction with improved nutrition, reduced the incidence of diarrhoeal disease among children and the incidence of other infectious disease

- These factors resulted in improved physical growth and development, which protected cohorts from later death from many causes, both infectious and non-infectious

- This argument accords with McKeown’s in that it finds little evidence that improvements in scientific medicine caused the reduction in death rates at the end of the 19^th century

- However, the authors place much greater emphasis on hygienic factors, which were largely the result of public health measures, and less on standards of living than does McKeown

“The Changing Relation between Mortality and Level of Economic Development”

demonstrated that since at least 1930, constant levels of income has been associated with greater levels of life expectancy (positive shift in life expectancy relative to income)

“Causes and consequences of mortality decline in less developed countries during the twentieth century.” In Population and Economic Change in Developing Countries. Edited by Richard A. Easterlin. Pp. 289-360.

Less developed countries have experienced dramatic increases in life expectancy since 1940

Largest absolute declines in mortality have occurred to those below age 5 and above age 40

2 objectives of paper are

1. to identify the factors responsible for these mortality improvements and

2. to begin tracing the effects of these improvements on demographic and economic processes

3 possible causes of reduced mortality:

1. by-product of social and economic development,

2. social policy,

3. technical changes

- Preston demonstrates that individual income does play a significant role in reducing individual mortality

- Decrease in infectious diseases (respiratory, diarrhoeal, and malaria) primary contributor to decrease in mortality

- Poor nutrition may contribute to increase risk of infection and death from disease

- Preventative measures have been more effective than curative ones in decreasing infectious disease fatalities, even though improvements in water supply are occurring much slower in LDCs than they did in MDCs

- Mortality reductions have not merely been a by-product of socioeconomic development, but rather major structural changes have occurred in the relationship between mortality and other indices of development

- Structural factors that are exogenous to national levels of income, calorie consumption, and literacy (such as changes in government investment in health care and technological advances) account for about ½ of the gains in life expectancy between 1940 and 1970

- Structural factors have contributed the most in Latin America and the least in Africa

Consequences of mortality reductions

- Changes in mortality and fertility both influence population size by affecting the total number of births

- Populations may respond to decreased mortality by declines in crude birth rates via quasi-biological effects (proportion of population in childbearing years reduced, extending breastfeeding due to survival of child) and behavioral effects

- However, data indicates that birth rates have not declined much in response to mortality declines in LDCs

- Mortality decline hasn’t really contributed to changes in net migration

- Mortality decline may increase labor production of a population, or it may lead to economic decline due to decreased availability of resources

- Unclear whether shifts in mortality versus fertility should have different effects on economic growth

- Malenbaum (1970) interestingly argues that mortality decline gives people a sense that they can control their own destiny, which contributes to increased labor production

roughly 50% of the reduction in mortality was due to “structural factors” unrelated to nutrition or economic development

decreases in infectious diseases, diarrheal diseases, and influenza/pneumonia/bronchitis were the biggest contributors to the mortality decline

In 1895 and 1905 farmers kids had highest survival

farmers> professionals (doctors) > laborers

By 1922 teachers, drs and managers kids had better survial

i.e. until recently where you live is more important than your class

The change started in the 20th centure with medical advances.

- Preston looks at levels of mortality among US children by fathers’ occupation in 1895, 1905, and 1922/4

- In 1895, farmers and manufacturing managers’ kids have lowest mortality

- Farm and manufacturing laborers’ kids have highest

- In 1922/4, doctors and teachers’ kids have lowest

- Overall in 1922/4, higher educated classes have lower mortality than lower educated classes

           - Shows differential dissemination of information

            - More educated ppl can read and adopt public health info

- Segregation of population along class lines also probably contributed to differential death rate

Different cohorts have different smoking rates by gender. 

In the past there was a large different >10 years, now it's much smaller difference about 2 years.

Likewise in the past, smoking increase mortaltity of men at much greater levels than women, now the difference is shrinking.

Authors estimate that large increase in the numbe who survive from 50-85 if smoking is reduced/eliminated. 

Also the ratio of women surviving to old age vs. men surviving to old age would decrease and there would only be a small difference if there was no smoking.

“Demographic conditions responsible for population aging.” Demography, 26(4), 691-704.

Objective of article is to shed light on the sources of population aging by developing and applying 2 expressions that the relate the rate of change in the mean age of the population to other demographic processes

- The stable population model tells us that population aging cannot be attributed to high or low levels of fertility or mortality, because whatever these levels are, as long as they have been in place long enough (typically 2 or 3 generations) the proportionate age structure of the population will be fixed

- One way to express population aging is in terms of birth and death rates and the current mean ages of people living and dying

- Immigration and emigration can affect the mean age of the population by pulling it up or down

- Comparing the factors responsible for population aging in the US and Japan reveals that Japan’s rate of aging in 1970-1980 is substantially larger than the US’s due to Japan’s lower death rates and the US’s higher rates of immigration

- Population aging can also be expressed as a function of age-specific growth rates

Aging populations are nothing more than ones in which growth rates are higher at older ages than at younger ages

The derivative of the mean age of the population equals the covariance between age and the age specific growth rate

- How much age-specific growth rates for each age interval contribute to the overall change in the mean age in the population depends upon the proportion of the population at a given age (interval) and the distance between that age and the current mean age of the population

- Authors find that about 2/3 of the increase in the mean age of the US population between 1980-1985 was due to mortality decline at older ages and the rest was due to a decline in birth rates

- Because age-specific growth rates are a function of the history of change in births, mortality, and migration, these two expressions actually reflect the same information

In sum, we can conclude that populations are aging when their birth rates and death rates are sufficiently low that a positive correlation exists between age and age-specific growth rates

In most of Europe women are more likely than men to not drink or drink very lightly and fewer drink >40 gram/day (3-4 drinks/day)

Russians drink "worse alchol" France drink wine.

>50% of Russian, Czech Republic and French  men drink >40 grams/day

France more "okay" since it's wine, Czech's drink beer.

Estimate 6000 YLL in Russia males ____ due to drinking.

“Rethinking gender differences in health: Why we need to integrate social and biological perspectives.” Journals of Gerontology, 60B, 40-47.

Review of the literature on gender differences in mortality and morbidity

- Although women have lower rates of mortality than men, they have higher rates of morbidity    

Men are more likely to die of CVD at every age, but more women ultimately die of CVD

- This is because women outlive men

- Women have higher rates of auto-immune disorders

- Women have higher rates of depression, especially in middle age

- Biological and social explanations alone are incapable of explaining these gender differences in health

Authors argue that different constraints placed on men and women by social policies, community actions, work, and family affect the social and health-related choices they make, and ultimately result in health differences

- For instance, workplace policies regarding on-site childcare affect stress levels and lifestyle decisions of men and women differently

- Such a policy might affect how long a woman decides to breastfeed her child, which impacts her hormones and risk of breast cancer

- Obviously, such a policy would not have the same effect on men

- A focus on constrained choices brings much-needed attention to the contribution of multiple levels of contextual effects on men’s and women’s health

“The timing and pace of health transitions around the world.” Population and Development Review, 31(4), 741-764.

Aim of article is to describe regional and global life expectancy gains across time and space

3 divergent trends in life expectancy since the early 1980s

1. Most countries, even those with already high levels of life expectancy, continued to add years at a fairly robust pace

2. A second group of countries that were previously part of the Soviet Union saw a stagnation or slight decline in life expectancy, particularly among males

3. A third group of countries, primarily in central and southern Africa where HIV/AIDS in rampant, saw a dramatic decrease in life expectancy by as much as 19 years

- It is often difficult to determine when a health transition begins

- Population composition can greatly affect death rates

- For example, in GB and FR in the mid-1800s, death rates at the national level appeared to be stagnant, but in reality death rates were decreasing while greater numbers of people were migrating to urban areas (where death rates were higher)

- Countries that began the health transition prior to 1850 experienced slower gains in life expectancy than countries that began the transition more recently

- It is difficult to generalize common causes of life expectancy gain because countries have experienced gains under very diverse circumstances

- Gains have been made under differing stages of economic development, historical conditions, and levels of literacy and education, among other things

- Riley suggests that rather than studying mortality transitions in one country during one period in time, a more comparative approach is necessary to test specific explanations that may be relevant for reducing mortality in countries where life expectancy is still low

“The exceptionally high life expectancy of Costa Rican nonagenarians.” Demography, 45(3), 673-691.

 2 major hypotheses exist for why mortality rates are declining and the death rates of the oldest-old are decelerating

1. The heterogeneity in frailty hypothesis suggests that frail people die off when conditions are harsh at younger ages, leaving only the hearty among the oldest old

- Past improvements in health conditions at early ages may be benefiting today’s elderly

2. The heterogeneity in frailty hypothesis suggests that poor conditions early in life may strengthen a cohort at older ages

- Absence of accurate data about old-age mortality in low-income populations has been a major obstacle to examining this hypothesis

- Author hopes to shed some light on this theory using data from Costa Rica

- Costa Rica has notoriously good vital statistics and exceptionally high old-age longevity

Results

- Costa Rica does have significantly higher life expectancy at age 90 than low-income countries

- A comparison with the US and Sweden suggests that this advantage is mostly due to lower cardiovascular disease mortality among Costa Ricans

- Costa Ricans also have much lower prevalence of obesity

- Government emphasis on health care may also contribute to advantage

- The Costa Rican advantage (compared to high-income countries) is particularly large for males, although male life expectancy at age 90 is still 0.3 years less than that of females

- Although this analysis cannot really get at why these patterns occur, author suspects it may be due to a heterogeneity of frailty effect, in light of the fact that this cohort of individuals survived exceptionally high infant mortality rates due to infectious diseases

- If this is the case, the exceptional longevity of Costa Ricans may decline as new, less hearty cohorts age

“Generational transfers and population aging in Latin America.” Population and Development Review, 37, 143-157.

Author examines some of the probable effects of population aging in Latin America

- Notes that population aging may have negative or positive effects on the economies of these countries

- The human life cycle typically involves long initial and final periods of dependency and an intermediate period in which people produce more than they consume

3 ways in which individuals, families, and societies organize themselves to meet the “life-cycle deficit” at younger and older ages include:

1) intergenerational private transfers (parents to kids or kids to parents),

2) intergenerational public transfers (taxes to support institutions for the young and old), and

3) intragenerational reallocations from middle to older ages (savings and asset accumulation)

Patterns of population aging in Latin America

- Recent fertility decline has led to very rapid population aging

- Much faster than in Western Europe and the US

- The population aged 65+ is expected to grow from about 5% in 2000 to 20% in 2050

- Uses data from the National Transfer Accounts project (NTA) to examine patterns of transfers in Latin America and to simulate their potential effects on various economic indicators

Results

- Finds evidence for first demographic dividend (growth in consumption has been smaller than growth in labor income)

- Finds evidence for second demographic dividend (asset income growing faster than labor income)

- Different types of transfers characteristic of the young and old

- Young more likely to receive private transfers from parents and public transfers in the form of education

- Old more likely to rely on asset accumulation and public income transfers from the government

- Elderly receive much higher public transfers than young people (for instance, in Brazil net public transfers make up 81% of consumption among people over age 65)

- Increase aging may render these old age public transfer systems in Latin America untenable in the near future

- The elderly are far from being a net economic burden on their families; the economic transfers they provide to their families are much larger than those they receive

- Although 71% of elderly do co-reside with children/grandchildren, surveys suggest that it is children who are living in their parents’ hh rather than vice versa

- Overall, the economic effects of population aging in Latin America appear to be positive

- Evidence of capital accumulation (good for national economy) and downward private transfers (good for younger generations)

- Policy changes may need to occur to transform current public transfer systems

More inequity in income in a state or provience (in US or Canada) they higher mortality in the working age men in the poorest 50% of hhs in the state.

May be because of status or income is a proxy for race.

Aging experts

view successful aging as the confluence of 3 factors:

1) decreasing the risk of diseases and disease-related disability,

2) maintaining physical and mental functioning, and

3) being actively engaged with life

- Demographic perspectives of mortality decline

- In England, mortality did not decline steadily until the 19^th century

- Wide regional differences existed in mortality rates within a given country

- The general causes of mortality decline remain unclear

- McKeown (1976) posits that improved nutrition was the main cause of decline

- Main problem with his argument is that he arrives at this conclusion merely by excluding all other possible explanations for decline

- In contrast, Preston argues that public health and sanitation were the main contributors to mortality decline

- The authors of the present article believe that these two explanations should be combined

- Exposure to disease likely more affected by sanitation whereas resistance to disease likely more affected by nutrition

- It is also important to distinguish between the incidence and lethality of disease

- Factors that affect the overall disease environment include urbanization, medicine, and preventative public-health measures

            - Major conclusions of paper

1. There was no simple or unilateral road to low mortality, but rather a combination of many different elements ranging from improved nutrition to improved education

2. Any thoroughgoing understanding of the mortality transition will necessarily be interdisciplinary

Introduces handwashing after seeing birth by med students coming from working on corpses leading to much higher maternal deaths than midwives.

40+ years to catch on.

“Causes of the Russian mortality crisis: Evidence and interpretations.” World Development, 26(11), 1995-2011.

present ssome of the important available information about the sharp rise in mortality in Russia and to examine the causes of the crisis

- Trends in Russian life expectancy before and after 1992

- Russian life expectancy decreased slightly between 1960 and early 1980s

- Increased between 1985 and 1987 due to anti-alcohol campaign

- Experienced dramatic drop between 1992 and 1994

- Increased slightly in recent years

- Main causes of death over this time period were cardiovascular disease and accidents/injuries

- Increased death rates occurred primarily in mid-adulthood, not at youngest and oldest ages

- In 1984, the probability that a 20 year old Russian male would die before age 60 was 35%; by 1994 this had increased to 48%

- Although wide variation existed in official causes of death (accidents, TB, CVD, etc.) authors argues that many of these deaths could be linked to alcohol abuse

- Mortality increases in different population strata

- Gender gap in life expectancy widened between 1960-1994 from 7 years to 13.7 years

- Urban-rural gap decreased over this period due to increased death rates in urban areas

- Education gradient increased over this period (big decline in life expectancy for those with low education)

- Increased mortality disadvantage for single, widowed, and divorced men due to external causes compared to married men

- Some common explanations for the mortality increase that are poorly supported by the evidence include mass impoverishment and malnutrition, deterioration of the health care system, and ecological factors (such as pollution)

- Explanations that are better supported by evidence include increase in alcohol abuse due to maladaption and psychological stress under changing economic and social conditions

- This theory is supported by the fact that some population groups, such as the married and the educated, who most likely had greater psychological resources and support, did not experience dramatic increases in mortality

“Variation in life expectancy during the twentieth century in the United States.” Demography, 43(4), 647-657.

- Variation in death rates dropped very sharply in the 1940s and has remained low ever since

- The official estimates of life expectancy published by the National Center for Health Statistics were computed using an interpolation method based on decennial census data prior to 1948 and using life tables for intercensal years after 1948

- The authors want to know to what extent the decline in variation in life expectancy is an artifact of these two different methods and to what it extent it reflects actual changes

- Calculate life expectancy from 1900 to 2000 using life tables and interpolation for entire period

- Find that much of the change in variation in NCHS-reported life expectancy from the earlier era to the later era is an artifact of the different methods

- Interpolation method yields estimates that are much more variable than life tables

- However, variation is greater in the earlier era than in the later era by either method of estimation

- Also find that life expectancy did not decline nearly as much in 1918 as official estimates suggest

Unmarried versus married men’s mortality risk has widened since 1960

“On the determinants of mortality reductions in the developing world.” Population and Development Review. 33(2), 247-287.

Aim of article is to examine the determinants of the improvements in life expectancy in the developing world after WWII

- Life expectancy at birth in developing countries rose from about 45 years at the end of the 19^th century to above 75 years in 2000

- For many developing countries, gains between 1960 and 2000 exceeded 20 years (World Bank, 2005)

- Life expectancy in less developed countries has been increasing at a much faster rate than in more developed countries

  - Increases in life expectancy have traditionally been linked to increases in income

- Fogel argues that nutrition is the key mechanism via which income influences health

- Social scientists have become increasingly aware of a decoupling of these factors

- Preston (1975, “The Changing Relation between Mortality and Level of Economic Development”) demonstrated that since at least 1930, constant levels of income has been associated with greater levels of life expectancy (positive shift in life expectancy relative to income)

- Preston (1980) finds that roughly 50% of the reduction in mortality was due to “structural factors” unrelated to nutrition or economic development

- Although there still remains a fairly strong relationship between income per capita and life expectancy at birth, most researchers agree that the relationship between economic growth, nutrition, and mortality is insufficient to explain improvements in life expectancy in the 20^th century

- Research on causes of death in the developing world have generally found that about half of the reduction in mortality throughout the second half of the 20^th century was due to improvements in material conditions and half was not

- Preston (1980) found that decreases in infectious diseases, diarrheal diseases, and influenza/pneumonia/bronchitis were the biggest contributors to the mortality decline

- Improved living standards most likely operated primarily through reductions in influenza/pneumonia/bronchitis, whereas improved sanitary conditions likely reduced infectious and diarrheal diseases

- Less developed countries typically witness mortality reductions among children and infants; as development level increases mortality improvements shift toward older ages

- Suggests epidemiological transition in developing countries from infectious diseases being the leading cause of death to chronic conditions being the leading cause of death

- One “structural factor” that likely reduced mortality in poorer countries includes diffusion of new technologies via ideas, personal health practices, and public goods

- These ideas, practices, and public goods include immunization, improved sanitation and access to water, and education; all important for reducing mortality

- Education, sanitation, and access to water and medical services also may explain within country variations in mortality

- In terms of the relative contributions of each of these factors, evidence points toward maternal education as being particularly influential in reducing child and infant mortality

- Haines and Avery (1982) posit that better educated mothers may seek medical care more actively, may be more aware of sanitary precautions, nutritional info, and health services, and may be better able to recognize serious health conditions

- Caldwell (1986) suggests that schooling familiarizes individuals with Western values and makes them less resistant to medical technologies

The greatest change in projected LE would be if everyone were non-smokers and had normal BMI.

However the smoking rates declining would lead to more LE than constant BMI.

 “The importance of social intervention in Britain’s mortality decline c. 1850-1914: A re-interpretation of the role of public health.” Social History of Medicine, Pp. 1-38.

- Response to McKeown’s argument that medical advances and public health measures played little role in GB’s mortality decline

- McKeown’s thesis

- Argued that most of the important diseases involved in decreasing GB’s mortality levels had all but disappeared before the earliest date at which the relevant scientific medical innovations occurred

- Also argued that the major factor accounting for this mortality decline was a rising standard of living of which the most significant feature was an improved diet

- Critique of McKeown’s interpretation of the evidence

- Szreter argues that the main thrust of McKeown’s nutritional thesis is that it was simply the “last explanation standing”

- The main disease that McKeown focuses on is TB, and he dismisses public health measures as a possible cause to the decrease in TB because it is an air-borne disease

- However, Szreter points out that public health measures reduced overcrowding in urban areas, which very likely could have decreased the risk of contracting TB

- Szreter also doesn’t buy McKeown’s argument that airborne diseases such as TB and bronchitis were the first to decline; he argues that food and water-borne diseases declined first and contributed to the decline in airborne diseases

- Szreter’s alternative interpretation of McKeown’s data on mortality in GB

- Argues that death rates actually increased during the first 2/3 of the 19^th century due to overcrowding in urban areas

- Higher life expectancies in the country than in cities supports this claim

- Public health legislation in late 1830s-1875 paved the way for decline in diarrhoeal diseases, but it was not until the final third of the century, when these measures were actually carried out at a local level, that death rates began to decline steadily

- Infant mortality did not decline until the early 20^th century because it was not influenced by the water supply, but rather by the expansion of local housing standards, health and maternity services, and information of how to keep food fresh

- In sum, the “invisible hand” of economic growth did not cause the decrease in death rates at the end of the 19^th century, local government intervention did

- Szreter therefore warns governments not to expect increasing life expectancy to naturally follow from economic growth

- Human agency, in the form of an expanded public health infrastructure, is necessary to increase human longevity

“Social change and mortality decline.” In Women’s Position and Demographic Change.  Edited by Federici, Mason, and Sogner.  New York: Oxford University Press.  Pp. 190-212.

- Women have a mortality advantage in most developed countries

- The excess mortality of men is believed to be largely biological

- Demographers and scientists have attempted long attempted to quantify this “natural” mortality advantage among women;

- Most common estimate is that women can expect to live 2 years longer than men

However, in developing countries, as well as in developed countries in the past, women’s mortality is often higher than men’s

- Lots of excess mortality for women during the reproductive years due to the hazards of childbirth

- Also excess mortality of female children perhaps due to lower valuation of girls compared to boys (girls given less access to nutrition, hygiene, and medical facilities)

- In these countries more girls die of infectious diseases than boys

- Economic and social progress has been accompanied by a reduction of the difference between the social status of men and women and allowed them to gain a mortality advantage over men

This advantage is even greater than what we would expect if men and women behaved in identical ways

- In the period 1974-1978, men had greater mortality than women at every age

- In infancy, boys more likely than girls to die of genetic defects

- In young adulthood, boys more likely than girls to die of accidental causes

- In late adulthood, men more likely than women to die of degenerative diseases, neoplasms, and malnutrition

However, it is difficult to say to what extent the current mortality advantage of women is due to social or biological factors

- However, women’s participation in certain behaviors that have long been characteristic of men, such as smoking, drinking, driving cars, and working outside the home, should have caused their mortality to converge with men’s; why hasn’t this happened?

- Women are still given “protected status” in society more so than men

- Although more women are engaging in risky, masculine behaviors, they do so to lesser degree than men

- Women less likely to perform manual labor than men

- Women tend to utilize medical services more and take better care of their health than men

Levels of mortality by age

- Vallin created graph of mortality in France by age 1720-1914

- Finds that decrease in mortality happened at pretty much all ages

- Main exception: death rates among young adults higher in 1877-1881 than in 1820-1829

- Most likely due to migrating to cities

What explains the rural-urban gap in infant mortality in Africa, household or community characteristics?

In rural 2/3 of increased mortality is due to observed and unobserved hh characteristics

(i.e. safe wather, electricity, quality of housing, finished floors, mom's age, mom's education, birth interval, contraception, birth order)

community characteristics explain 1/4 of gap (2/3 in unobserved hetereogenity and 1/3 observed)

In rural areas IMR is 14%

in Urban 9.6%

“The future of human longevity: A demographer’s perspective.” Science, 280, 395-397.

- The future of human longevity poses questions for public policy and fiscal planning

- Demographers typically extrapolate future mortality levels from past trends

- Wilmoth generally believes that extrapolation is a sound method for predicting future mortality because. . .

a. Mortality decline is drive by a widespread, perhaps universal, desire for a longer, healthier life

b. Historical data shows that mortality has been steadily decreasing for at least 100 years in developed societies

c. Gains in longevity have been shown to result from a wide array of changes, including standards of living, public health, hygiene, and medical care

d. Much of these gains can be attributed to the directed actions of individuals and institutions, whose efforts to improve healthy will continue in the future

- However, Wilmoth also recognizes that a number of errors may result from extrapolation

- One common error of extrapolation is to predict mortality farther into the future than is warranted given the length of time that forms the basis of the extrapolation

- A second common is undue emphasis on recent trends in life expectancy

- In recent decades, increases in life expectancy have slowed while decreases in death rates have increased

- These two trends are not contradictory because they reflect changes in the age patterns of mortality risks

- Reducing death rates at young ages contributes more to increases in life expectancy than reducing death rates at older ages

- Causes for optimism about the future of human longevity include acceleration of mortality decline among the elderly in recent decades, the unusual longevity of certain groups (such as Mormons) that may hint at particular beneficial lifestyle practices, and occasional technological breakthroughs

- However, we must remember that medical breakthroughs have occurred in the past (think Koch’s isolation of the bacteria that causes TB), and that extrapolation from past trends implicitly assume a continuation of scientific advancements

- Causes for pessimism about the future of human longevity include the potential biological limits of human life

- However, trends in death rates at very old ages show no sign of approach a finite limit

- Although extrapolation could not have predicted the rise in mortality in the 1990s in former Society countries or the emergence of AIDS, this is less an indictment of extrapolation than a demonstration of the great social and political uncertainties affecting future mortality trends

“Demographic and socioeconomic impact of AIDS: Taking stock of the empirical evidence.” AIDS, Supplement 2, S1-S7.

Article based on meeting on the Demographic and Socioeconomic Impact of AIDS in Durban, South Africa, March 26-28, 2003

- Most dramatic impact of AIDS on adult mortality 

          - After infection, average person lives 9 years

- Child mortality

            - Increased child mortality among infected mothers

- Family structure

            - Increased orphans and dissolution of infected households

Many reasons make it difficult to assess the socioeconomic impact of AIDS

- Lack of empirical data, too early to tell, lack of data on effects of process of illness

- It is possible that survivors could fare better on the labor market because of decreased labor supply

We have more data on the microeconomic impact of AIDS at the hh level than on the macroeconomic impact at the national level

- Death and sickness affect hh income and assets

- Infected individuals much more likely to live in poverty