1 00:00:01,270 --> 00:00:07,750 I'm well aware that as far as youthful audience is concerned, that death happens to other people, 2 00:00:07,750 --> 00:00:13,950 old people and people quite different than yourselves, people who you will not come to resemble. 3 00:00:13,950 --> 00:00:17,530 Does the end of the day account was all that, father? 4 00:00:17,530 --> 00:00:21,490 I hope it will be from what you're writing and thinking about most of the time. And of course, 5 00:00:21,490 --> 00:00:27,850 it's very important in modern demography because as the the population ageing effect of 6 00:00:27,850 --> 00:00:33,190 low fertility fades away and becomes incorporated into the population age structure, 7 00:00:33,190 --> 00:00:41,560 in due course, all future population ageing will be caused by continued increases or whatever increases that 8 00:00:41,560 --> 00:00:48,250 are in expectations of life at birth that in the future will drive a population ageing and will, 9 00:00:48,250 --> 00:00:53,590 of course, somewhat mitigate the effects of low birth rate on population decline. 10 00:00:53,590 --> 00:01:01,330 It's also, of course, a subject of immense scientific interest and possibly slightly macabre curiosity as well. 11 00:01:01,330 --> 00:01:03,820 This is the direction I'll give on mortality. 12 00:01:03,820 --> 00:01:11,920 It'll have to be a mixture of empirical description and I hope an attempt at some sort of analysis as to what's going on, 13 00:01:11,920 --> 00:01:15,790 why it's going on, what the causes are and all the rest of it. 14 00:01:15,790 --> 00:01:27,370 So. These are the sorts of things that I want to talk about, first of all, a simple description of the trends, 15 00:01:27,370 --> 00:01:33,860 the components of mortality decline, the causes of death, attempts at explaining what's been going on, 16 00:01:33,860 --> 00:01:40,300 and then to look at to the future to see what might happen next, what the prospects for longer life might be, 17 00:01:40,300 --> 00:01:48,060 what the current bits of evidence are for, for the prospects of living longer. 18 00:01:48,060 --> 00:01:56,760 This is just to remind you of the pattern of mortality and remind you of how hugely varied the risk of mortality is by age. 19 00:01:56,760 --> 00:02:07,050 This is a log transformed graph of the life table death rate for males and females in England and Wales around about 2000. 20 00:02:07,050 --> 00:02:10,440 While it's about the same nowadays, slightly better. 21 00:02:10,440 --> 00:02:18,150 It gets better every year. But this is you can take it more or less the pattern of risk that we are all exposed to. 22 00:02:18,150 --> 00:02:25,710 This varies a thousand. That's why it's transformed into a logarithm, because if it's not transformed into a logarithm, 23 00:02:25,710 --> 00:02:33,150 all this variation here, the low end of mortality disappears from view, as you will see in the next slide. 24 00:02:33,150 --> 00:02:40,950 What this shows is that we have an infant mortality rate of about four deaths per thousand per year, which is very, very low. 25 00:02:40,950 --> 00:02:45,240 It's not the lowest in the world by any means. As we'll see, it's very low down here. 26 00:02:45,240 --> 00:02:52,140 Mortality is almost negligible in some European countries to some smaller European countries from time to time, 27 00:02:52,140 --> 00:02:59,580 there are no deaths recorded at certain single years of age. I there were no deaths recorded in children aged eight in Sweden about 10 years ago. 28 00:02:59,580 --> 00:03:06,540 For example, if we could experience the rates of mortality, which we enjoyed when we were little children aged eight, 29 00:03:06,540 --> 00:03:11,110 nine, 10, as you recall from last term, perhaps we could live 800 years. 30 00:03:11,110 --> 00:03:18,030 Unfortunately, that is not given to us from that rather heavenly state of survival. 31 00:03:18,030 --> 00:03:23,250 Things get worse into adolescence peaking around. Forgive my saying so. 32 00:03:23,250 --> 00:03:28,620 Your time of life as a certain kinds of reckless behaviour, especially amongst men, 33 00:03:28,620 --> 00:03:33,150 become predominant with their girlfriends dragging along in their train. 34 00:03:33,150 --> 00:03:35,070 Then things calm down. 35 00:03:35,070 --> 00:03:46,500 And then from about 30 or so onwards, we the Gompertz curve takes over this exponentially increasing progression of rates of mortality with age, 36 00:03:46,500 --> 00:03:50,610 which continues continuously right until old age. 37 00:03:50,610 --> 00:03:55,530 There's some alteration of the exponential rate, the Gompertz curve in very old age. 38 00:03:55,530 --> 00:03:59,430 So things don't go on getting quite as bad as you might expect. 39 00:03:59,430 --> 00:04:06,000 More of that later on. Of course, we all know that when an exponential curve on that's going like that, 40 00:04:06,000 --> 00:04:09,990 getting worse and worse and worse, is transforming this relative mosaic. That is a straight line. 41 00:04:09,990 --> 00:04:11,130 And that's effectively what we've got here. 42 00:04:11,130 --> 00:04:19,500 Two straight lines of mortality going up to that scale, indicating the advance of mortality, first of all, are important. 43 00:04:19,500 --> 00:04:28,380 When it gets to about sort of 60, 70 ish, it starts getting a bit concerning people of my age start getting rather too many 44 00:04:28,380 --> 00:04:34,200 funeral notices of our friends for the comfort that it gets really bad around here. 45 00:04:34,200 --> 00:04:42,330 But more of that later. This is the same data all over the same life tables turned into a different form. 46 00:04:42,330 --> 00:04:50,370 What we got here is a non log transformed rate of mortality, the non transformed Q curve, 47 00:04:50,370 --> 00:04:55,500 the rate of death from one year to the next, as I said, well, it's not long transformed. 48 00:04:55,500 --> 00:05:00,630 All that variation around childhood infancy and young adulthood disappears from view. 49 00:05:00,630 --> 00:05:09,750 It becomes completely invisible because it's so low compared to the mortality which experienced later on after age 60, 70, 80 and so forth. 50 00:05:09,750 --> 00:05:14,520 This is the actual curve of death. This is the number of deaths each year. 51 00:05:14,520 --> 00:05:18,700 And you can see that according to this life table, the the modal age of death, 52 00:05:18,700 --> 00:05:25,800 the most common age of death in the mortality of England and Wales at the present time is just over age 18. 53 00:05:25,800 --> 00:05:29,280 Most people who die nowadays die over age 80. 54 00:05:29,280 --> 00:05:38,570 It's a it's that late. This is the the track of that period expectation of life at birth, 55 00:05:38,570 --> 00:05:45,790 this is just the life table calculation of expectation of life at birth and the wealth from 1850, right. 56 00:05:45,790 --> 00:05:49,670 Until about 2010. 57 00:05:49,670 --> 00:05:58,880 And you can see the two general characteristics, one, a general rate of improvement to the superiority of female survival over male survival. 58 00:05:58,880 --> 00:06:01,190 This is the expectation life of females. 59 00:06:01,190 --> 00:06:08,690 Of course, this is males, the the rather modest pattern of improvement in the first decade or two of this graph. 60 00:06:08,690 --> 00:06:11,780 Hardly any change at all, partly, as you'll recall, 61 00:06:11,780 --> 00:06:19,190 due to the transfer of the population from the more healthy or perhaps I should say less unhealthy countryside to the more unhealthy towns. 62 00:06:19,190 --> 00:06:24,560 The actual rate of improvement, irrespective of that, was was getting what was increasing. 63 00:06:24,560 --> 00:06:31,670 But because the transfer of population to less healthy areas with very rapid urbanisation, no overall change is apparent. 64 00:06:31,670 --> 00:06:40,130 And then we see the improvement getting stronger. From 1860, 1870 onwards, the magnitude of the crisis, 65 00:06:40,130 --> 00:06:43,820 mortality of epidemic disease is getting smaller and smaller and smaller of 66 00:06:43,820 --> 00:06:49,010 particular improvements in the interwar years from between the 1920s and the 1950s. 67 00:06:49,010 --> 00:06:50,630 And then there are the more modest. 68 00:06:50,630 --> 00:06:57,920 But while the linear level of improvement up to the present day with a widening of the gap between males and females down here, 69 00:06:57,920 --> 00:07:02,480 the difference between female expectation, life of birth and male was only about two and a bit years. 70 00:07:02,480 --> 00:07:13,240 By the time we get up to here is four, four and a half or something of that kind or narrowing slightly for reasons we'll go into later on. 71 00:07:13,240 --> 00:07:17,830 Just a reminder that other ways of measuring mortality and to remind you particularly 72 00:07:17,830 --> 00:07:22,660 not to be misled by trends in the crude death rate in developed countries. 73 00:07:22,660 --> 00:07:30,260 If you look at the graph of the crude death rate in recent decades in developed countries, it will appear to you there's no improvement whatsoever. 74 00:07:30,260 --> 00:07:33,910 And in some countries, it's even possible to see an increase in the crude death rate, 75 00:07:33,910 --> 00:07:41,400 which seems contrary to reason that that is a perfectly true reflection of what the true death rate tell you. 76 00:07:41,400 --> 00:07:46,030 But the crude death rate is not telling the truth as opposed to the real risk of mortality. 77 00:07:46,030 --> 00:07:52,120 Crude death rates are stationary or not improving very much or even getting worse in developed countries. 78 00:07:52,120 --> 00:07:59,500 Because the age structure is getting older, more and more of the population is concentrated in areas where the risk of death is very high. 79 00:07:59,500 --> 00:08:05,710 Ergo, the crude death rates simply deaths. Our population per year is bound not to change very much. 80 00:08:05,710 --> 00:08:11,020 If you look at the age standardised death rate, that is to say, a crude death rate, 81 00:08:11,020 --> 00:08:16,240 adjusted for the fact that the population age structure is changing to to remove that factor. 82 00:08:16,240 --> 00:08:24,490 You see quite a different picture here is the death rate for the 15 countries of the old European Union. 83 00:08:24,490 --> 00:08:31,180 This here is the crude death rate, as you see from 1970 to 2002, showing hardly any improvement. 84 00:08:31,180 --> 00:08:37,510 This is the age standardised death rate, getting rid of this age structure, a factor showing the true rate of mortality. 85 00:08:37,510 --> 00:08:43,480 And it indicates just like that, the trend in the expectation of life at birth in England and Wales data in the previous slide. 86 00:08:43,480 --> 00:08:50,890 It shows a continuous and substantial improvement over time, which so far has shown no signs of diminishing. 87 00:08:50,890 --> 00:09:00,280 This is a this is a similar example in the United States is very common throughout the industrial world, 88 00:09:00,280 --> 00:09:08,770 except for Eastern Europe, of which more in a moment. Here is a crude death rate for the United States from 1960 to 2005. 89 00:09:08,770 --> 00:09:17,020 Here's the adjusted pattern. Same thing as we saw in Europe. The adjusted pattern gives you a very substantial improvement over time. 90 00:09:17,020 --> 00:09:20,800 Again, not showing any signs of diminution. 91 00:09:20,800 --> 00:09:31,120 Here are two of the best performers, these these get the prise, as it were, for the longest life so far of the the solid lines are females. 92 00:09:31,120 --> 00:09:37,300 The lines with the markings are males. Leading the pack, of course, is Japan. 93 00:09:37,300 --> 00:09:45,410 Japanese females with an expectation of life at birth by 2008, up to about eighty six and a half exceeding, 94 00:09:45,410 --> 00:09:51,350 of course, the pessimistic speculations of General Shinseki and his colleagues. 95 00:09:51,350 --> 00:09:55,870 But of course, that's just for one country and one sex, not for the developed world. 96 00:09:55,870 --> 00:10:03,040 With Swiss females just behind and for comparison to the rather mediocre performance of the UK, 97 00:10:03,040 --> 00:10:09,500 UK females still following the same trend, but not so, not so impressively and diverging. 98 00:10:09,500 --> 00:10:14,170 If you go back to the 1950s, the mortality rates were really very similar. 99 00:10:14,170 --> 00:10:26,310 We've lost ground compared with the Swiss. Here are the males where the divergence is less great with England, Wales still below the other two. 100 00:10:26,310 --> 00:10:36,120 The story is not always one of substantial improvement here is France, where France, 101 00:10:36,120 --> 00:10:40,710 which has the lowest mortality for females anywhere in continental Europe, 102 00:10:40,710 --> 00:10:48,110 contrasted with Denmark and the US, for males, the pattern of mortality is not dissimilar for females. 103 00:10:48,110 --> 00:10:53,550 An interesting divergence whereby the mortality of French females continues to it to 104 00:10:53,550 --> 00:11:00,180 reduce expectation of life continues to increase just below 85 at the present time, 105 00:11:00,180 --> 00:11:08,100 whereas that of Danish females in blue and American females in green and had a period of almost complete 106 00:11:08,100 --> 00:11:14,400 stagnation here where there was no improvement whatsoever that has now come to an end and is now picking up. 107 00:11:14,400 --> 00:11:20,050 Almost certainly this was due to lifestyle habits, particularly due to levels of smoking. 108 00:11:20,050 --> 00:11:26,620 So the epidemiologists believe so is not always uninterrupted progress is not always plain sailing. 109 00:11:26,620 --> 00:11:33,320 And indeed, you can see if you look at the Danish males here of a period of almost zero improvement in expectation of life, 110 00:11:33,320 --> 00:11:39,370 of birth, stuck at about seventy one ever since the 1950s, are up to the mid 1970s again, 111 00:11:39,370 --> 00:11:43,510 is just thought due to the high prevalence of smoking related deaths from which 112 00:11:43,510 --> 00:11:47,780 most populations are now liberating themselves amongst the male population, 113 00:11:47,780 --> 00:11:51,820 but then really impose a flattening effect on mortality. 114 00:11:51,820 --> 00:11:58,420 So much so and so widespread was that in the developed world that it was suppose back in the 1960s that the 115 00:11:58,420 --> 00:12:04,690 possibility of improvements in expectation of life had ground to a halt and that the patterns of heart disease, 116 00:12:04,690 --> 00:12:10,270 cancer, stroke were inexorable consequences of old age and nothing much be done about the Mambi 117 00:12:10,270 --> 00:12:15,420 sort of hit the buffers as far as improvements in expectation of life were concerned. 118 00:12:15,420 --> 00:12:21,340 And you can see why there should be so much pessimism if you cut the graph of about half of males anyway. 119 00:12:21,340 --> 00:12:27,690 But that is all in the past and things are back on track for improvement. 120 00:12:27,690 --> 00:12:37,940 Not everywhere. These are the the extraordinary divergent patterns of the expectation of life of males in Western 121 00:12:37,940 --> 00:12:43,160 Europe compared with communist or former communist Eastern Europe and the former Soviet Union. 122 00:12:43,160 --> 00:12:54,170 What we have here are the expectations of life for Japan in blue, for Switzerland in pale blue, for this is Greece in purple. 123 00:12:54,170 --> 00:13:04,470 And this I guess this must be France. Compared with Russia, Ukraine, Belarus and Hungary, and as you can see, back in the 1960s, 124 00:13:04,470 --> 00:13:09,480 if you looked at these patterns of mortality, they were not really distinguishable. 125 00:13:09,480 --> 00:13:17,970 Many of the countries of Eastern Europe had rather similar expectations of life at birth to those in Western Europe, and that this was, of course, 126 00:13:17,970 --> 00:13:22,710 a source of enormous consolation to the communist powers in the in the Cold War 127 00:13:22,710 --> 00:13:27,680 period when Khrushchev offers threatening to bury us and all the rest of it. 128 00:13:27,680 --> 00:13:33,170 All that changed, that was the peak in the 1960s, from then onwards, 129 00:13:33,170 --> 00:13:39,200 things went downhill or the very best failed to improve throughout the entire Congress as well. 130 00:13:39,200 --> 00:13:43,700 I've only got three examples from the former Soviet Union and one from Central Europe, Hungary. 131 00:13:43,700 --> 00:13:47,660 But as you can see, that the pattern is very similar. 132 00:13:47,660 --> 00:13:56,360 This various hypotheses advanced to to try to explain this, which I'll try to talk about very briefly later on. 133 00:13:56,360 --> 00:14:01,260 But the fact is, is undoubtedly there is also. 134 00:14:01,260 --> 00:14:10,560 It's important to realise while there was a reduction in survival immediately after the end of communism, 135 00:14:10,560 --> 00:14:18,480 very much in Russia, also in Ukraine and in Belarus, essentially, that was just a brief hiatus. 136 00:14:18,480 --> 00:14:22,620 The important thing about this mortality isn't isn't the transient worsening of the 137 00:14:22,620 --> 00:14:27,780 position after the collapse of communism and all the chaos which accompanied that is 138 00:14:27,780 --> 00:14:32,430 much more that the fact that this pattern continued right until recent years and 139 00:14:32,430 --> 00:14:36,690 only the last two or three years as things have things improved somewhat in Russia. 140 00:14:36,690 --> 00:14:45,750 But this level here, which is like the death of sixty three, it's about 12 or 14 years lower than that in contemporary Western Europe. 141 00:14:45,750 --> 00:14:53,910 And it's the level of a rather poor Third World country. And it's a very, very remarkable phenomenon of which more later, 142 00:14:53,910 --> 00:15:01,440 they do notice that those countries in the former Soviet Union have stayed put in this in this dismal position. 143 00:15:01,440 --> 00:15:09,150 Hungary, which emancipated itself from that system back in 1989, 1990, has now resumed the upward track, 144 00:15:09,150 --> 00:15:19,170 which you would have been expected of it back in the 1950s, but which it was diverted from by this episode of Change of Control. 145 00:15:19,170 --> 00:15:26,760 This is just two to pictorials and to show how interesting, how interesting I can see an East-West gradient in survival. 146 00:15:26,760 --> 00:15:36,040 This is a WHL data from two thousand five expectation of life at birth, divided into quintiles into fifths of the distribution. 147 00:15:36,040 --> 00:15:41,010 The paler the worse. And you can see that it's worse in the east. 148 00:15:41,010 --> 00:15:49,450 It it gets a bit better in Central Europe now. And the darker countries are the ones with the most superior levels of survival. 149 00:15:49,450 --> 00:15:56,820 This is both sexes put together and you can see that France and Spain and Italy do all well. 150 00:15:56,820 --> 00:16:07,570 Scandinavia does rather well. Germany, the little countries, Britain are a bit mediocre along with with Austria. 151 00:16:07,570 --> 00:16:15,610 Infant mortality still varies greatly these days are 10 years old, but the pattern is the same, although it's a bit lower almost everywhere. 152 00:16:15,610 --> 00:16:20,250 You can't read which countries are rich, but I've colour coded them. 153 00:16:20,250 --> 00:16:31,060 The countries of the former Soviet Union are appropriately in red Russia, Moldova, Belarus, Latvia and Estonia, Lithuania. 154 00:16:31,060 --> 00:16:36,580 Countries in the former Yugoslavia are green. 155 00:16:36,580 --> 00:16:45,800 Here is. That's right, in central Europe, agrees, is Poland, Slovakia and Hungary. 156 00:16:45,800 --> 00:16:53,030 Down here, predictably, is Scandinavia, Iceland, Sweden, Finland, Norway, Luxembourg, 157 00:16:53,030 --> 00:16:59,870 Luxembourg sort of GDP per head of forty five thousand dollars per head per year compared to about thirty five thousand dollars anywhere else. 158 00:16:59,870 --> 00:17:08,360 So if that can't buy long life, then I don't know what can here in Central Europe, in Austria, Germany, France. 159 00:17:08,360 --> 00:17:13,700 And so a very interesting gradient from that infant mortality rate of three deaths, 160 00:17:13,700 --> 00:17:24,560 three infant deaths per thousand births per year, up to about 18 or 19 at the other extreme. 161 00:17:24,560 --> 00:17:29,890 Interesting also to point out that there is quite a lot of variation within countries which I haven't got time to go into, 162 00:17:29,890 --> 00:17:33,020 which is certainly an interesting phenomenon, 163 00:17:33,020 --> 00:17:42,110 the the old fashioned pattern whereby mortality rates in the countryside, in lower density rural areas of urban areas, 164 00:17:42,110 --> 00:17:48,410 small towns are superior, lower, as it were, than those in major cities still obtains. 165 00:17:48,410 --> 00:17:53,690 And you can see it in England and Wales, two sorts of gradients which are fairly typical of Western Europe. 166 00:17:53,690 --> 00:18:03,060 First of all, the southern more prosperous part. The Bristol Channel to the wash is pela has a lower mortality, 167 00:18:03,060 --> 00:18:09,360 longer expectation of life than than the that part of the country to the north and to the west. 168 00:18:09,360 --> 00:18:15,900 The former old industrial areas, South Wales here, the Midlands here, North Yorkshire, 169 00:18:15,900 --> 00:18:20,940 Newcastle and such areas, and also most of London have higher death rates. 170 00:18:20,940 --> 00:18:25,950 The country areas have pale death rates. Not all, not all of London I death rates. 171 00:18:25,950 --> 00:18:31,860 This is London magnified. This white blob here is considered a Chelsea, as perhaps you might expect, 172 00:18:31,860 --> 00:18:37,800 but really quite substantial differences in standardised mortality rates here. 173 00:18:37,800 --> 00:18:47,230 This goes from readers from 100 per 100, 120 to up to up to 200 here down to about 50. 174 00:18:47,230 --> 00:18:54,400 Here is a very considerable variation in Smar from one part of the country to another, also, of course, from social class. 175 00:18:54,400 --> 00:19:04,560 These are social class mortality rates. Again, standardised mortality ratios for men in 2064. 176 00:19:04,560 --> 00:19:07,290 From the further knowledge you study and as you can see, 177 00:19:07,290 --> 00:19:17,010 social class one in pink has an estimate of about it's about about 70 or so compared with one of about 170 for a social class, 178 00:19:17,010 --> 00:19:26,780 five unskilled manual workers. And another terrible graph which I borrowed from the Health Inequalities Annual supplement 179 00:19:26,780 --> 00:19:30,850 and sorry for the ghastly colour scheme of the obscurity of it does it does make the point, 180 00:19:30,850 --> 00:19:41,620 if I can explain what the colours mean. This is the diversity within by Smar for men aged 20, 64, by different causes of death. 181 00:19:41,620 --> 00:19:49,990 And these are the look on here. On the left we have strokes. 182 00:19:49,990 --> 00:19:57,370 This is mortality by stroke. And this is social class. One, two, three, no, manual three, manuell four and five. 183 00:19:57,370 --> 00:20:05,900 Major difference here. This is of heart disease, heart attacks, essentially coronary thrombosis, very important cause of death. 184 00:20:05,900 --> 00:20:14,500 This is lung cancer. Even more substantial difference because of the differences in smoking habits between social classes, accidents and violence. 185 00:20:14,500 --> 00:20:22,900 And these are this is this is suicide. The only major difference, as you can see, the exception is skin cancer. 186 00:20:22,900 --> 00:20:28,960 Skin cancer primarily caused by excessive irradiation, by ultraviolet light. 187 00:20:28,960 --> 00:20:34,030 This is mostly malignant melanoma rather than other kinds of skin cancer, which are curable. 188 00:20:34,030 --> 00:20:40,420 Malignant melanoma has all sorts of causes, but it's particularly provoked by strong exposure to sunlight. 189 00:20:40,420 --> 00:20:49,720 This reflects the ability of people to go overseas to the lovely south of France and Spain and such places their holidays back in 1991. 190 00:20:49,720 --> 00:20:55,630 Anyway, that was more customary amongst richer people, amongst social class one and two. 191 00:20:55,630 --> 00:20:59,170 Then elsewhere, that's where the mortality rate is reversed. 192 00:20:59,170 --> 00:21:05,440 This is now much less true, partly because many more people can afford to go abroad to hot countries to enjoy the holidays. 193 00:21:05,440 --> 00:21:11,590 Also, because of the growing popularity of sun beds and clinics for give you artificial suntans, 194 00:21:11,590 --> 00:21:15,250 which are often far too powerful in terms of the radiation which they give. 195 00:21:15,250 --> 00:21:22,370 The only other major exception which would get to that expected social class gradient is in cancer of the female breast, which isn't here, 196 00:21:22,370 --> 00:21:29,410 but where there's a slight higher level amongst higher social class because of the delay in childbearing characteristic of that, 197 00:21:29,410 --> 00:21:32,650 one of the major risk factors for cancer of the female breast is delaying. 198 00:21:32,650 --> 00:21:42,670 Childbearing has an effect upon the hormones which which are generally at risk factors for contracting that disease. 199 00:21:42,670 --> 00:21:47,230 What about the causes? I've talked a bit about the cause already need talk a bit more. 200 00:21:47,230 --> 00:21:52,780 This is a document which you will not see unless you are gazing down from heaven above with your own name on it. 201 00:21:52,780 --> 00:21:58,960 This is the medical certificate of cause of death, which by law has to be signed before you could be buried or cremated. 202 00:21:58,960 --> 00:22:08,050 And it is an attempt to assign the cause of death which led to your demise, which is often very difficult because of course, 203 00:22:08,050 --> 00:22:14,350 the immediate cause of death may not be the one which is clinically and epidemiologically and demographically interesting. 204 00:22:14,350 --> 00:22:20,380 You may have a haemorrhage in your aorta, for example, or a brain haemorrhage, 205 00:22:20,380 --> 00:22:23,350 and that's the immediate cause of death and that's what will be entered here. 206 00:22:23,350 --> 00:22:31,060 But the reason why you might have that is what really matters what the underlying cause of that immediate cause of death would be. 207 00:22:31,060 --> 00:22:36,550 And that could be a diabetes or it could be atherosclerosis or all sorts of other diseases 208 00:22:36,550 --> 00:22:41,920 of a more chronic nature which predispose you to to to to a violent end of that. 209 00:22:41,920 --> 00:22:48,310 Sort, of course, may also be that your loss of blood from haemorrhage might be because someone has stuck a knife in your chest, 210 00:22:48,310 --> 00:22:52,420 in which case that would go under one of the external causes of death, 211 00:22:52,420 --> 00:22:59,680 of accidents and violence that are there is a very elaborate international agreed classification of causes of death. 212 00:22:59,680 --> 00:23:03,850 Nine hundred ninety nine officially agreed ways in which you can die, 213 00:23:03,850 --> 00:23:09,580 each of which is subdivided amongst many other causes because, of course, human body is enormously complicated. 214 00:23:09,580 --> 00:23:14,620 There are lots and lots and lots of ways which can go wrong nowadays. 215 00:23:14,620 --> 00:23:19,480 There are particular problems because, of course, given that most people die when the age of 80, 216 00:23:19,480 --> 00:23:24,700 by the time we're 80, we have acquired all sorts of terrible things. We've got little haemorrhages in our brain. 217 00:23:24,700 --> 00:23:30,190 We've probably got cancer. We're not dying of it. We may well have some kind of diabetes. 218 00:23:30,190 --> 00:23:38,230 And the problem may be working out which of the morbid conditions in which your suffering is actually the one which led to the the cause of death. 219 00:23:38,230 --> 00:23:43,030 And so and that's difficult to do. It requires clinical research to sort it out. 220 00:23:43,030 --> 00:23:49,990 And from time to time, ideas on it are revised. And this down here in this part of the form, 221 00:23:49,990 --> 00:23:57,310 the condition is meant to write down what the other morbid conditions are for which the person is suffering, 222 00:23:57,310 --> 00:24:02,140 which did not directly cause death, might have been indirectly contributed, 223 00:24:02,140 --> 00:24:06,910 contributed to it, and quite often there'd be four or five or six such causes. 224 00:24:06,910 --> 00:24:14,920 It's not allowed to put down died of old age. That that that was that was forbidden because it was too vague and unhelpful many decades ago. 225 00:24:14,920 --> 00:24:21,520 It may well be that as time goes on and people live longer and longer and longer, accumulate more and more morbid conditions, 226 00:24:21,520 --> 00:24:29,850 that it becomes impossible to do anything else except in rather specific circumstances. 227 00:24:29,850 --> 00:24:37,650 The last government was always keen to look on the bright side and this day, just to cheer up for the dead, 228 00:24:37,650 --> 00:24:44,760 they introduced a new attractive death certificate out that great document that I pointed out before. 229 00:24:44,760 --> 00:24:54,370 And in came a nice document in pastel colours embossed with the red rose for England and Wales and for other other devices elsewhere. 230 00:24:54,370 --> 00:25:00,000 Nonetheless, the mortality rate remained the same. 231 00:25:00,000 --> 00:25:07,860 This is the pattern for England and Wales from 1970 to 2009, showing the rise and fall of diseases. 232 00:25:07,860 --> 00:25:14,970 We're accustomed, I think, to supposing that heart disease and stroke and things are always with us, 233 00:25:14,970 --> 00:25:20,910 or possibly even on the increase one hears about an epidemic of cancer. 234 00:25:20,910 --> 00:25:26,970 Neither of these things are true back in the first half of the 20th century. 235 00:25:26,970 --> 00:25:31,620 It's certainly true that here in England and Wales and in other countries as well, 236 00:25:31,620 --> 00:25:39,090 deaths from what came to be called diseases of affluence were predictably unexpectedly going up. 237 00:25:39,090 --> 00:25:48,840 This is the these are age standardised mortality rates for this is for circulation disease that would include the squeamish heart disease, 238 00:25:48,840 --> 00:25:52,170 heart attacks, coronary thrombosis and strokes. 239 00:25:52,170 --> 00:25:59,520 This is respiratory disease, tuberculosis and influenza going down, as you might expect, as health conditions improve. 240 00:25:59,520 --> 00:26:07,160 This is cancer and this is infectious disease diminishing down to more or less nothing. 241 00:26:07,160 --> 00:26:11,420 Until the middle of the century, around about here, as you see, 242 00:26:11,420 --> 00:26:15,830 the standardised death rates from circulation disease, which is most important cause of death, 243 00:26:15,830 --> 00:26:21,020 was actually going up partly because the population was getting older and therefore moving, as it were, 244 00:26:21,020 --> 00:26:27,770 its centre of gravity into that part of the distribution of these risks become very much more severe. 245 00:26:27,770 --> 00:26:29,630 People your age don't get that kind of condition. 246 00:26:29,630 --> 00:26:38,520 People may do, but it also because of a change of diet, a change of activity, all sorts of risk factors were increasing at that time. 247 00:26:38,520 --> 00:26:41,150 Cigarette smoking was increasing at that time. 248 00:26:41,150 --> 00:26:52,040 The so the standardised mortality ratios for for the circulation disease by social class were the reverse of what you saw in that previous graph. 249 00:26:52,040 --> 00:26:58,550 It was the the better off people who are dropping dead from heart attacks, not not the workers doing manual work. 250 00:26:58,550 --> 00:27:05,450 That's now completely reversed. In those days, though, it was it was thought to be really genuinely a disease of the rich. 251 00:27:05,450 --> 00:27:10,490 You got better your diet, the worse things were for the point of view of heart attacks. 252 00:27:10,490 --> 00:27:16,090 Cancer also was creeping upwards and peaked at nineteen seventy one nineteen eighty one. 253 00:27:16,090 --> 00:27:23,170 Since then, things have got a lot better in England and Wales, as elsewhere, there's been a huge reduction in mortality from circulation disease, 254 00:27:23,170 --> 00:27:32,350 partly because of great improvements in lifestyle, the decline in smoking, the recognition of the importance of diet, all sorts of other things. 255 00:27:32,350 --> 00:27:35,770 Plus, of course, really important innovations in it, 256 00:27:35,770 --> 00:27:42,550 in drug control of blood pressure and cholesterol and other risk factors of secondary disease and surgical intervention, 257 00:27:42,550 --> 00:27:52,630 bypass surgery, stents, all the other things which you read about, which can save life in a way completely impossible 30 or 40 years ago. 258 00:27:52,630 --> 00:27:57,230 And that's why it's going down so dramatically now, lower than it was in 1911. 259 00:27:57,230 --> 00:28:04,480 And so I'm heading down this cancer. Much more troublesome cancer, of course, is a whole variety of diseases. 260 00:28:04,480 --> 00:28:10,090 Almost every organ in the body can become cancerous. And so it's a complex of diseases, 261 00:28:10,090 --> 00:28:18,940 some of which are improving in terms of their survival after treatment and also declining in terms of their prevalence, 262 00:28:18,940 --> 00:28:26,350 like stomach cancer, for example, others of which remain rather intractable with rather poor five year or 10 year survival rates, 263 00:28:26,350 --> 00:28:31,360 but nonetheless, generally going down. That's for males, a similar pattern for females, but of course, 264 00:28:31,360 --> 00:28:39,100 not reflecting the female advantage and in especially in circulation disease and also in cancers, 265 00:28:39,100 --> 00:28:46,300 although showing a slight bulge here as the late onset of smoking related diseases amongst women starts to make an effect 266 00:28:46,300 --> 00:28:55,600 around here is it peaked some sometime earlier amongst males because males take up these bad habits before women do. 267 00:28:55,600 --> 00:29:05,440 This is just to point out the interruptions which you get when the international classification is is revised, it's as I pointed out earlier on, 268 00:29:05,440 --> 00:29:12,400 it's very difficult sometimes to work out exactly what the clinical, physiological, biological changes are, 269 00:29:12,400 --> 00:29:17,350 which are leading to causes of death and therefore the international classification of diseases. 270 00:29:17,350 --> 00:29:24,340 The ICD is revised every few years. The revisions are marked by these vertical lines in this graph from the US. 271 00:29:24,340 --> 00:29:30,100 And you can see that there are sometimes some discontinuities, mostly small, but there's a bigger one here. 272 00:29:30,100 --> 00:29:38,440 For example, when when certain subdivision's is the cause of death, alveoli is actually to belong somewhere else and to be misdiagnosed. 273 00:29:38,440 --> 00:29:44,830 Also important to realise that sometimes rapid increases in causes of death are caused not so much, 274 00:29:44,830 --> 00:29:48,160 because that particular condition is genuinely becoming more common, 275 00:29:48,160 --> 00:29:53,110 but because it is being recognised as a genuine chemical entity and previously wasn't. 276 00:29:53,110 --> 00:29:58,360 The obvious example is Alzheimer's disease. This pale green line here is the mortality. 277 00:29:58,360 --> 00:30:03,200 Alzheimer's disease almost negligible in about 1980. 278 00:30:03,200 --> 00:30:10,240 Now, of course, rising up to to a high level and reclassified in 2000 Alzheimer's disease. 279 00:30:10,240 --> 00:30:15,580 But certainly with us back here, it just wasn't diagnosed or rather recognised as a clinical entity. 280 00:30:15,580 --> 00:30:24,160 Another example of that is the is the so-called cot deaths, the sudden, unexpected death syndrome of infants, which isn't on this graph. 281 00:30:24,160 --> 00:30:27,730 But it was not recognised at all back in the 1970s. 282 00:30:27,730 --> 00:30:36,340 And then once it became recognised, shot up to quite a high level within the context of infant mortality, which, of course, is absolutely low level. 283 00:30:36,340 --> 00:30:43,690 This is a long scale graph. And so it gives you a misleading impression of the decline of heart disease and cancer in the US. 284 00:30:43,690 --> 00:30:50,600 The reduction which this graph bodies from nineteen fifty eight until 2005 is actually very great. 285 00:30:50,600 --> 00:30:56,210 It's even bigger than that which we saw in England and Wales. 286 00:30:56,210 --> 00:31:06,290 Japan is different. Generally speaking, the developed world, it's the same the same trio of bad things that cause, of course, death in older age. 287 00:31:06,290 --> 00:31:10,700 In Japan, the pattern has always been a different cerebrovascular disease. 288 00:31:10,700 --> 00:31:16,100 Stroke started off being more important and heart disease quite unlike Western Europe. 289 00:31:16,100 --> 00:31:24,210 Cancer, malignant neoplasms was a has become the most important cause of death, putting these in the shade. 290 00:31:24,210 --> 00:31:29,870 And the cancer is going off in Japan despite the fact that, as we know, equitation life of birth is very favourable. 291 00:31:29,870 --> 00:31:40,400 It may well be that if this trend continues and this goes up to 2008, that the Japanese superiority in survival may may stutter to an end. 292 00:31:40,400 --> 00:31:48,230 We will have to wait and see. Huge variation within Europe in these causes. 293 00:31:48,230 --> 00:31:53,630 The left hand column is ischaemic heart disease, chronic and acute heart disease, 294 00:31:53,630 --> 00:32:01,760 the single most important cause of death in most developed countries. These are the standardised death rates that mind all the data, all the detail. 295 00:32:01,760 --> 00:32:07,670 This is ranked the table as ranked according to the magnitude of the death rate from circulation disease. 296 00:32:07,670 --> 00:32:13,730 As you can see, France has the largest burden 49. Ukraine has ten times the level. 297 00:32:13,730 --> 00:32:15,350 Four hundred and ninety nine. 298 00:32:15,350 --> 00:32:24,170 UK not doing terribly well, but things get a lot worse when you when you move from Western Europe into into Eastern Europe with Romania, 299 00:32:24,170 --> 00:32:28,100 Russia, Ukraine and Europe as a whole. Two hundred and sixty. 300 00:32:28,100 --> 00:32:33,040 So we're less than the European average, but not doing terribly well compared with others. 301 00:32:33,040 --> 00:32:38,810 CVRD is cerebrovascular disease, which is stroke is pulmonary artery disease, 302 00:32:38,810 --> 00:32:44,030 blood clot to the top of the artery, which is an important cause of death, but often misdiagnosed very lightly. 303 00:32:44,030 --> 00:32:50,390 I think this very great variation here is partly due to changes in diagnosis. 304 00:32:50,390 --> 00:32:59,530 It's difficult to believe that the pulmonary artery disease in UK could be only about a third of the level in Germany, for example. 305 00:32:59,530 --> 00:33:07,330 Cancer, likewise, this is this table is ranked according to the magnitude of cancer, according to various different causes, 306 00:33:07,330 --> 00:33:14,320 Shakir Bumpus and lung lung cancer here very about two fold between Portugal and Poland. 307 00:33:14,320 --> 00:33:21,630 That was Hungary. The worst of the worst ones are a heavy type. 308 00:33:21,630 --> 00:33:26,040 These are the patterns for ischaemic heart disease, biogeography, reflecting, 309 00:33:26,040 --> 00:33:30,480 as you would imagine, given the enormous importance in the scheme and heart disease, 310 00:33:30,480 --> 00:33:37,500 the pattern of overall mortality, which I displayed earlier on, dark is worse in this particular graph. 311 00:33:37,500 --> 00:33:44,070 And we see the east west gradient, NBC, also the traditional superiority of France, 312 00:33:44,070 --> 00:33:51,390 Italy and Scandinavia compared with Germany, Poland, Austria and England and Wales. 313 00:33:51,390 --> 00:33:55,410 So there's a north south, rather patchy north south U. 314 00:33:55,410 --> 00:34:00,510 Shaped gradient, as well as a very clear east west gradient in these patterns of mortality, 315 00:34:00,510 --> 00:34:04,800 of substantial levels of difference in mortality between countries, you know, 316 00:34:04,800 --> 00:34:10,770 doing living rather similar ways of life, doing the same kind of job, driving the same kind of car, 317 00:34:10,770 --> 00:34:14,640 eating more, not quite the same kind of food, but not all that different. 318 00:34:14,640 --> 00:34:19,980 Nonetheless, enormous differences in mortality risk, which are very interesting as well as other serious. 319 00:34:19,980 --> 00:34:28,780 That's just stroke. And we'll move on from that. So we have we have a lot to explain. 320 00:34:28,780 --> 00:34:31,270 Lots of possible explanations for it. 321 00:34:31,270 --> 00:34:40,570 There are obviously within these countries in the world differences in national wealth from 45000 US dollars per year, 322 00:34:40,570 --> 00:34:47,080 equivalent in Luxembourg, down to about 15000 in some of the East European countries, or even less than that. 323 00:34:47,080 --> 00:34:54,160 National health expenditure, private and public, varies considerably between countries. 324 00:34:54,160 --> 00:35:01,180 Inequality of health, which Wilkinson is very keen on, on emphasising as an important determinant of overall mortality, 325 00:35:01,180 --> 00:35:06,730 notably in his controversial new book called The Spirit Level, is another important contender. 326 00:35:06,730 --> 00:35:11,410 All that's related to the underlying clinical risk factors and mortality. 327 00:35:11,410 --> 00:35:17,200 Typically, of course, the kinds of diseases we're talking about of high levels of cholesterol, blood pressure, 328 00:35:17,200 --> 00:35:22,820 smoking habits, excessive drinking, especially binge drinking and other aspects of lifestyle. 329 00:35:22,820 --> 00:35:30,580 But those are the most important. And also we'll find, I think in Eastern Europe, especially in that politics matters. 330 00:35:30,580 --> 00:35:36,220 Politics matters in terms of the extent to which the national wealth is turned into health expenditure. 331 00:35:36,220 --> 00:35:42,160 Different countries have different priorities. Politics also matters in terms of freedom of information, 332 00:35:42,160 --> 00:35:49,330 in the extent to which it's possible or easy to discuss causes of death if the extent to which public 333 00:35:49,330 --> 00:35:58,030 discussion can really take account of what's going on with with with the national mortality levels, 334 00:35:58,030 --> 00:36:00,140 what are the risk factors? 335 00:36:00,140 --> 00:36:07,660 We are accustomed to a situation where there are dozens and dozens of magazines devoted to healthy living and all kinds of gossip and information, 336 00:36:07,660 --> 00:36:13,930 some of it contradictory about how to live a long and healthy life in other countries, particularly in the East. 337 00:36:13,930 --> 00:36:16,480 In the past especially, this has not been possible, 338 00:36:16,480 --> 00:36:24,910 partly because the data haven't been there and partly because the freedom of information has been there to discuss it. 339 00:36:24,910 --> 00:36:38,650 This is a total health expenditure in dollars US dollars per head around about around about two thousand five, as you might expect, 340 00:36:38,650 --> 00:36:44,500 there's an east west gradient which fits the pattern we saw before I saw this graph does not actually show 341 00:36:44,500 --> 00:36:51,880 very closely the difference between the the top quartile and the and the middle and the next quartile down, 342 00:36:51,880 --> 00:36:56,180 which is a shame because it is better on the screen. 343 00:36:56,180 --> 00:37:04,480 It shows that there's more expenditure, as you see here in Germany and in France and the Netherlands, 344 00:37:04,480 --> 00:37:12,520 in Switzerland and Austria, rather less, in Italy and Spain and the U.K., rather, more and more or less in Sweden. 345 00:37:12,520 --> 00:37:19,120 The data aren't here, but I think you probably already know from other sources that the correlation between health expenditure 346 00:37:19,120 --> 00:37:25,060 in the US dollars per head is standardised for exchange rates or any other measure on the one hand. 347 00:37:25,060 --> 00:37:27,910 And any measure of national health is not very great. 348 00:37:27,910 --> 00:37:36,070 Of course, it's true that the richer countries which spend more of their bigger GDP on health in the poorer countries tend to do better. 349 00:37:36,070 --> 00:37:41,500 That's not surprising, but within the richer countries, the correlation is really quite weak. 350 00:37:41,500 --> 00:37:46,690 The US spends about 15 percent of its very considerable GDP upon health and 351 00:37:46,690 --> 00:37:50,530 produces really rather mediocre results no better than the average Western Europe, 352 00:37:50,530 --> 00:37:58,630 where health expenditure is, I think, universally lower. Germany, which spends about the same per capita as France, 353 00:37:58,630 --> 00:38:06,460 it does not have the same French superior levels of survival, particularly amongst females, Italy and Spain, 354 00:38:06,460 --> 00:38:10,900 which don't spend all that much compared with others on on health, 355 00:38:10,900 --> 00:38:16,990 taking all expenditure together as we saw how very superior levels of survival compared with the rest, 356 00:38:16,990 --> 00:38:22,960 Norway and Sweden aren't that different in health expenditure. So are that different in health expenditure? 357 00:38:22,960 --> 00:38:32,750 But they're about the same in terms of survival rates. So there's a lot more to it than proportion of GDP spent on health. 358 00:38:32,750 --> 00:38:34,580 What about these diseases of affluence? 359 00:38:34,580 --> 00:38:42,740 Can we understand anything, anything from those, are they as used to be thought, the inevitable consequence of old age, 360 00:38:42,740 --> 00:38:51,110 something which is powerfully age related and inexorably age related and which cannot really be controlled or modified very much? 361 00:38:51,110 --> 00:38:59,090 Or are they susceptible to intervention either by a more knowledge based form of 362 00:38:59,090 --> 00:39:05,090 healthy living and high powered medical intervention or the latter appears to be true. 363 00:39:05,090 --> 00:39:11,230 And it's clear that there has been a shift in the disease of affluence are no longer diseases of affluence. 364 00:39:11,230 --> 00:39:16,700 These these governments, the heart disease, the cancer, the strokes and all the rest of them, 365 00:39:16,700 --> 00:39:20,240 which used to be more common in richer countries and poorer countries, 366 00:39:20,240 --> 00:39:27,860 more common amongst richer people than poorer people in the first half of the 20th century, for example, has now shifted around. 367 00:39:27,860 --> 00:39:32,150 They are now more common amongst poorer people than richer people in the developed world. 368 00:39:32,150 --> 00:39:35,960 As you saw from the standardised mortality ratios, which I showed earlier on, 369 00:39:35,960 --> 00:39:41,060 there are also more common amongst the poorer group of the developed world countries and amongst the richer ones. 370 00:39:41,060 --> 00:39:48,080 And increasingly, too, as a reprise the pattern of the early 20th century that becoming more common 371 00:39:48,080 --> 00:39:53,390 amongst the more developed the developing world countries where heart disease, 372 00:39:53,390 --> 00:40:00,290 obesity and all sorts of other problems are now quite a problem in amongst the middle class in India and also amongst the 373 00:40:00,290 --> 00:40:10,160 middle class in Brazil and other countries that came with obesity levels at almost European or even British sorts of levels. 374 00:40:10,160 --> 00:40:17,000 One of the important variables which helps to to explain the the relative weakness 375 00:40:17,000 --> 00:40:23,390 of the of the financial aspect of investment in health are lifestyle patterns, 376 00:40:23,390 --> 00:40:28,460 particularly the so-called Mediterranean diet, at the risk of sounding like a margarine advert? 377 00:40:28,460 --> 00:40:31,130 It really does appear to work. 378 00:40:31,130 --> 00:40:40,370 This is a simple diagram of what the ideal Mediterranean diet is based upon the diet characteristics of parts of Greece, 379 00:40:40,370 --> 00:40:42,830 like Crete some some decades ago. 380 00:40:42,830 --> 00:40:49,430 The Cretans have now moved on from this very healthy thing and are becoming fat because they're eating lots of beef and things. 381 00:40:49,430 --> 00:40:58,910 But this is the real meat, just mantri eggs, poultry, fish and sweet things that we create plus and wine, lots of cheese and yoghurt. 382 00:40:58,910 --> 00:41:07,100 Olive oil very central to this daily consumption of cheese and olive oil, fruits and vegetables. 383 00:41:07,100 --> 00:41:12,650 This sounds terribly wholesome and boring of me, but it does appear to be true that this does make a difference. 384 00:41:12,650 --> 00:41:20,090 Not only does it make a difference in terms of helping to explain international differences and why relatively poor countries, 385 00:41:20,090 --> 00:41:30,200 especially poor in the past, like Italy and Spain and Greece, had low levels of mortality, but also in terms of clinical treatment. 386 00:41:30,200 --> 00:41:36,470 One of the interestingly clinching evidence is that this is a pattern in Albania. 387 00:41:36,470 --> 00:41:40,070 Albania is a country in Eastern Europe, as you know, 388 00:41:40,070 --> 00:41:48,410 it was a sort of communist country where the communist dictator and the Hodja quarrelled not only with Stalin, 389 00:41:48,410 --> 00:41:55,880 but also with Mao and became a completely isolated entity all by himself, deeply impoverished. 390 00:41:55,880 --> 00:42:03,890 He covered the country with over 100000 little forts which are still there and saw concrete bunkers to protect himself from attack from anywhere, 391 00:42:03,890 --> 00:42:13,340 behave with great ferocity towards outsiders of any kind, exterminated religion and whatever, and kept the country put. 392 00:42:13,340 --> 00:42:21,290 Despite that, the expectation of life at birth in Albania continue to improve from admittedly low levels throughout the whole of the communist period. 393 00:42:21,290 --> 00:42:25,880 Quite unlike that pattern which which I showed earlier on. 394 00:42:25,880 --> 00:42:28,250 And of course, it is now believed. 395 00:42:28,250 --> 00:42:35,990 The reason for that is, is partly because the poverty of Albania protected it from high levels of meat and fat intake, but also because Albania, 396 00:42:35,990 --> 00:42:43,610 being a country on the Adriatic, part of the Mediterranean, benefitted from this pattern of of Mediterranean diet for quite a long while. 397 00:42:43,610 --> 00:42:47,570 Things will not change now that Albania is becoming more affluent. 398 00:42:47,570 --> 00:42:54,980 And even more interestingly, was the fact that those coastal parts of Albania, where this kind of diet was easy to obtain, 399 00:42:54,980 --> 00:43:00,560 had superior survival levels to the more mountainous inland parts of Albania where this is less often practised. 400 00:43:00,560 --> 00:43:08,830 So a curious little tiny piece of evidence from from the from the more remote parts of eastern southeastern Europe. 401 00:43:08,830 --> 00:43:16,690 And this rather complex graph is just to try and lend some scientific verisimilitude to my generalisations about this diet. 402 00:43:16,690 --> 00:43:24,700 Not only is it is it a very good contender for helping to explain why some poor Southern countries have superior survival rates, 403 00:43:24,700 --> 00:43:29,680 it also, even more convincingly, when used as a therapeutic measure, 404 00:43:29,680 --> 00:43:35,680 has a dramatic and predictable results upon levels of mortality from heart disease, 405 00:43:35,680 --> 00:43:41,500 stroke and also, surprisingly, Alzheimer's, Parkinson's and other conditions. 406 00:43:41,500 --> 00:43:49,480 This is a meta analysis of 12 prospective studies whereby people at risk of death from these conditions are very different. 407 00:43:49,480 --> 00:43:59,950 Countries have been divided into one group which was put onto a conventionally good diet, and another group put onto a more severe Mediterranean diet. 408 00:43:59,950 --> 00:44:05,380 A total sample size of one point five million people. And all the studies show an improvement. 409 00:44:05,380 --> 00:44:11,560 This is the details don't matter, but this is an improvement on the left hand side improvement. 410 00:44:11,560 --> 00:44:19,510 Two steps in the scale of of the Mediterranean diet produce between 10 and 30 percent improvement in survival. 411 00:44:19,510 --> 00:44:27,850 Yeah, the alternative diet was one which tried to avoid the excesses of meat and fat, 412 00:44:27,850 --> 00:44:32,770 which some of those in the study had previously been been following, 413 00:44:32,770 --> 00:44:40,900 and which was what we would regard as a reasonable diet of the kind we normally eat, as opposed to something rather more specialised. 414 00:44:40,900 --> 00:44:48,470 It varied between sizes. There were 12 studies. So I don't really know what the average of 12 was. 415 00:44:48,470 --> 00:44:55,160 This has been responsible for some interesting reversals in immortality or so we believe, 416 00:44:55,160 --> 00:45:05,000 this shows the the pattern of mortality in Italy on the left and France on the right in different provinces from the beginning of the 20th century, 417 00:45:05,000 --> 00:45:13,050 up to the latter part of the 20th century. This, for example, is Italy in in nineteen hundred and eleven. 418 00:45:13,050 --> 00:45:23,310 The darker areas are the areas with the the lower survival, with higher death rates, and as you can see, as you might imagine, poverty stricken, 419 00:45:23,310 --> 00:45:29,170 malaria infested southern Italy had higher death rates in those days than that, than the more prosperous, 420 00:45:29,170 --> 00:45:35,690 more as a European north, partly because infectious disease was much less well controlled. 421 00:45:35,690 --> 00:45:39,480 Here it is, much more a poor rural area. 422 00:45:39,480 --> 00:45:43,830 By the time we get to eighty one, the position is totally reversed here. 423 00:45:43,830 --> 00:45:49,440 The higher mortality levels are found in the more developed, richer northern part of Italy, 424 00:45:49,440 --> 00:46:00,240 where people are very much living ways of life similar to those experiencing in neighbouring Austria and other parts of Europe down here in the south. 425 00:46:00,240 --> 00:46:03,450 The pattern of mortality is much, much lower. 426 00:46:03,450 --> 00:46:09,360 The burden of infectious disease has been eradicated by this time, as it has been throughout Europe, east and west. 427 00:46:09,360 --> 00:46:16,920 But this part of the country is experiencing the benefits of still was the uniting, if you want anyway, the benefits of the Mediterranean diet. 428 00:46:16,920 --> 00:46:25,380 This was not not the case here where the diet is much more like that, which the neighbouring Germanic populations tend to eat. 429 00:46:25,380 --> 00:46:33,590 Likewise in France back in. This is nineteen hundred and one of the highest mortality areas in France. 430 00:46:33,590 --> 00:46:42,960 But down here in the south and some in poverty stricken Brittany and Normandy, by the time we get to nineteen eighty one is completely reversed. 431 00:46:42,960 --> 00:46:49,770 It's believed the same sort of all sorts of interesting changes going on of that kind. 432 00:46:49,770 --> 00:47:00,370 The special problem of the high mortality levels amongst males in Eastern Europe, which I mentioned, has puzzled many people. 433 00:47:00,370 --> 00:47:09,300 The proximate causes are quite clear. It's to do with very high and not diminishing rates of heart disease quite high and increasing rates of cancer, 434 00:47:09,300 --> 00:47:12,750 very high levels of accidents and violence particularly related to drink. 435 00:47:12,750 --> 00:47:18,660 But it's by no means all of that, although that's the best known aspect to this high mortality. 436 00:47:18,660 --> 00:47:26,130 I guess of one general theory put forward by Albert Carlsen is the pattern of mortality in these countries, 437 00:47:26,130 --> 00:47:33,240 which which is unique to the former communist countries and also is concentrated amongst men of older working age, 438 00:47:33,240 --> 00:47:37,830 not so much amongst women, not so much amongst children, not so much amongst older people. 439 00:47:37,830 --> 00:47:47,640 He calls this the state socialist mortality syndrome and in brief attributes it to the the forced industrialisation and the forced urbanisation, 440 00:47:47,640 --> 00:47:51,990 which took place more or less throughout this era from, well, 441 00:47:51,990 --> 00:47:59,760 from 1917 or 1920, in the case of Russia, from 1945, in the case of Central and Eastern Europe, 442 00:47:59,760 --> 00:48:08,820 outside Russia, which transformed a rural poor population, practising mostly primary activities into one, 443 00:48:08,820 --> 00:48:13,470 forced into into secondary and tertiary activities, particularly secondary ones, industrial activity, 444 00:48:13,470 --> 00:48:23,790 often a very extremely dangerous kind, which which led to major changes in social organisation, the disruption of family structure, 445 00:48:23,790 --> 00:48:28,620 the concentration of population, and very inadequate, rapidly built urban housing and all the rest of it, 446 00:48:28,620 --> 00:48:35,730 which you can see that a complex theory, one which it will take a long time to expand properly. 447 00:48:35,730 --> 00:48:43,920 But as far as Earlwood, Karlson and others to concerned, the primary ultimate reason for these interesting and very distinctive patterns of mortality 448 00:48:43,920 --> 00:48:52,260 is socio political and what not to do with random changes in mortality for other reasons. 449 00:48:52,260 --> 00:49:02,270 What happens next? Onwards and upwards appears to be the sign that the graphs are all pointing upwards in in in the West anyway, 450 00:49:02,270 --> 00:49:06,320 I mean, Western Europe, the US and other countries outside Eastern Europe, 451 00:49:06,320 --> 00:49:10,850 those parts of Eastern Europe, which are which are reformed like those parts which are joining the EU, 452 00:49:10,850 --> 00:49:16,910 Hungary, Poland, the Czech Republic, Slovakia, which are joining the European Union. 453 00:49:16,910 --> 00:49:23,500 Their death rates are all moving upwards again, as they should have been for the last 50 years, but haven't been. 454 00:49:23,500 --> 00:49:28,640 How long can this continue? All sorts of factors argue one way or the other. 455 00:49:28,640 --> 00:49:33,950 And this is a strong argument, a strong source of dispute amongst my colleagues. 456 00:49:33,950 --> 00:49:39,350 In fact, of all the arguments within within demography, aside from migration, 457 00:49:39,350 --> 00:49:46,430 the argument as to the as to the likelihood of continued improvements onwards and upwards for a long 458 00:49:46,430 --> 00:49:52,100 time and survival compared with the likelihood of this grinding to a halt thanks to obesity and so on, 459 00:49:52,100 --> 00:50:00,070 generate some of the most fierce arguments, even personally hostile arguments anywhere in the subject. 460 00:50:00,070 --> 00:50:04,730 All sorts of reasons lead one to suppose that things will continue to improve. 461 00:50:04,730 --> 00:50:12,890 Fundamental objections are raised to this in terms of the impossibility of any organism being capable of of self repair 462 00:50:12,890 --> 00:50:22,940 for for endless periods of time and the difficulty of reinventing the entire human body through technical innovation. 463 00:50:22,940 --> 00:50:29,420 And also the more more practical objections arranged against the prospect of continual 464 00:50:29,420 --> 00:50:33,740 mortality improvement arising from this really very alarming level of rising obesity, 465 00:50:33,740 --> 00:50:40,250 which will doubtless know a great deal through Stanley Olegas lectures and other sorts of problems, 466 00:50:40,250 --> 00:50:49,970 the possible re-emergence of old diseases, the possibility of bird flu mutating into something seriously academically damaging and so on. 467 00:50:49,970 --> 00:50:56,120 The improvements are clearly going to take place and have been taking place at older ages. 468 00:50:56,120 --> 00:51:03,290 Mortality below age 60 is now so low that were totally abolished it would not make a very big difference of expectation in life. 469 00:51:03,290 --> 00:51:08,780 At birth, about 97 percent of newborn babies now can expect to live to age 60. 470 00:51:08,780 --> 00:51:14,210 So getting rid of that mortality is is going to be difficult and also will not make much difference. 471 00:51:14,210 --> 00:51:22,940 The improvement is going to take place as it has been taking place over the last 40 years or so in the population aged over 65, which cheers me up. 472 00:51:22,940 --> 00:51:27,770 No end, as you can see in this graph from eighteen fifty after the middle of the century, 473 00:51:27,770 --> 00:51:35,030 very little improvement in the expectation of life at age 65 from the normal, starting particularly with the females. 474 00:51:35,030 --> 00:51:36,740 And then later on amongst males, 475 00:51:36,740 --> 00:51:45,680 it's been increasing at an exponential rate and it is there that further improvement must take place in order for the overall 476 00:51:45,680 --> 00:51:53,530 expectation of life to continue increasing at the very satisfactory linear pattern which has been showing for some time now. 477 00:51:53,530 --> 00:52:01,480 He is just one of very large numbers of warnings against expectation of a continued 478 00:52:01,480 --> 00:52:05,620 improvement arising out of obesity and the transmission of obesity from children to parents, 479 00:52:05,620 --> 00:52:12,790 which is a very serious problem. These are the the uncertain expectations, the Office of National Statistics. 480 00:52:12,790 --> 00:52:19,930 This is their projection for expectation of life at birth from the 2008 projections 481 00:52:19,930 --> 00:52:27,820 going up by two thousand eighty one to about 93 for females and about 88 for males. 482 00:52:27,820 --> 00:52:35,830 Typically, the pattern of linear improvement, which they allow to continue in these projections until 2030 is then bent downwards. 483 00:52:35,830 --> 00:52:42,760 Actuaries hate linear improvements in mortality and partly for scientific reasons and partly for reasons of caution. 484 00:52:42,760 --> 00:52:49,200 It is as see here in the official projections, the higher projection, the alternative, 485 00:52:49,200 --> 00:52:55,560 the face saving alternative projection of a higher level of disease to be continued in a linear fashion, 486 00:52:55,560 --> 00:53:00,940 reaching nearly 100, as you see for females by 2030. One set of males. 487 00:53:00,940 --> 00:53:06,100 That will be really very interesting. This is this is the pessimistic possibility. 488 00:53:06,100 --> 00:53:14,050 This is the other alternative projection showing no improvement at all, up to twenty, thirty one with, um, sticking it more or less Japanese levels. 489 00:53:14,050 --> 00:53:20,230 That really very, very pessimistic. But we what we will see which of those is right. 490 00:53:20,230 --> 00:53:25,150 That's the difference between England and Wales and Scotland will pass on away from that. 491 00:53:25,150 --> 00:53:31,870 Well, getting to some very interesting expectations of life here, as Madame John Caldmore, who died aged 122, 492 00:53:31,870 --> 00:53:35,680 I am very sorry that I couldn't find a photograph of her with a customary glass of 493 00:53:35,680 --> 00:53:41,350 red wine in her hand and her previously frequently smoked cigarettes in her mouth. 494 00:53:41,350 --> 00:53:45,880 But that's what she used to do. And she felt that all that stuff about cigarettes and wine was all nonsense. 495 00:53:45,880 --> 00:53:52,750 And here she is in nineteen ninety seven hundred twenty two is so far unbeaten. 496 00:53:52,750 --> 00:54:02,440 Here is Edgar Sharpe, born 1886 and died aged 108 in 1994 in his youth, in his marriage and in his old age. 497 00:54:02,440 --> 00:54:09,400 Here is Henry Allegan, who is the world's oldest man, born in 1899, fought the Battle of Jutland. 498 00:54:09,400 --> 00:54:15,320 And here is that the Cenotaph in 2004 and just died a couple of years ago. 499 00:54:15,320 --> 00:54:20,620 So the maximum age of expectation of life is is getting greater. 500 00:54:20,620 --> 00:54:30,070 The numbers of centenarians is hugely increasing. The centenarians are the most rapidly increasing group of people in Western Europe. 501 00:54:30,070 --> 00:54:35,110 They'll be numbered in the millions by the end of the century if things go on as they are. 502 00:54:35,110 --> 00:54:38,830 So the pattern is a favourable one. 503 00:54:38,830 --> 00:54:46,900 Mortality is falling. Every year that passes, we get a bonus of three months extra in terms of expectation of life on current trends, 504 00:54:46,900 --> 00:54:55,060 which is way up, no end, big twentieth century divergences between West and Eastern Europe, which by no means yet entirely of. 505 00:54:55,060 --> 00:54:59,500 They're still alive and unwell in Eastern Europe. 506 00:54:59,500 --> 00:55:08,710 Persistent differences in levels of mortality also between the social groups, the occupational groups, income groups, social classes. 507 00:55:08,710 --> 00:55:13,570 The interest nowadays, of course, is powerfully focussed upon survival of people in older ages. 508 00:55:13,570 --> 00:55:20,930 That's where all the improvement has been happening and has to continue to happen if the overall level of survival is going to continue to increase. 509 00:55:20,930 --> 00:55:28,990 Something I have not spoken of for lack of time is of paramount importance of these extra years of life being predominantly years of active, 510 00:55:28,990 --> 00:55:32,710 enjoyable, useful and possibly employable life. 511 00:55:32,710 --> 00:55:41,470 If the extra years of life are primarily going to be spent drooling in a wheelchair, this is not going to be very beneficial to anyone at all. 512 00:55:41,470 --> 00:55:48,280 All sorts of unsolved scientific problems about the likelihood of future future improvements in survival, 513 00:55:48,280 --> 00:55:59,110 the extent to which the human genome in its present form can sustain a continual repair of DNA and cell processes into older life. 514 00:55:59,110 --> 00:56:07,360 And important also to realise that given that the birth rate has now ceased to fall in the first with creeping upwards even that beyond, 515 00:56:07,360 --> 00:56:08,740 after the next two or three decades, 516 00:56:08,740 --> 00:56:15,940 all future patterns of population ageing are going to be determined by future levels of human survival and not by the birthrate. 517 00:56:15,940 --> 00:56:20,291 I will stop there. Thank you very much.