I'm well aware that as far as youthful audience is concerned, that death happens to other people,
old people and people quite different than yourselves, people who you will not come to resemble.
Does the end of the day account was all that, father?
I hope it will be from what you're writing and thinking about most of the time. And of course,
it's very important in modern demography because as the the population ageing effect of
low fertility fades away and becomes incorporated into the population age structure,
in due course, all future population ageing will be caused by continued increases or whatever increases that
are in expectations of life at birth that in the future will drive a population ageing and will,
of course, somewhat mitigate the effects of low birth rate on population decline.
It's also, of course, a subject of immense scientific interest and possibly slightly macabre curiosity as well.
This is the direction I'll give on mortality.
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,
why it's going on, what the causes are and all the rest of it.
So. These are the sorts of things that I want to talk about, first of all, a simple description of the trends,
the components of mortality decline, the causes of death, attempts at explaining what's been going on,
and then to look at to the future to see what might happen next, what the prospects for longer life might be,
what the current bits of evidence are for, for the prospects of living longer.
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.
This is a log transformed graph of the life table death rate for males and females in England and Wales around about 2000.
While it's about the same nowadays, slightly better.
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.
This varies a thousand. That's why it's transformed into a logarithm, because if it's not transformed into a logarithm,
all this variation here, the low end of mortality disappears from view, as you will see in the next slide.
What this shows is that we have an infant mortality rate of about four deaths per thousand per year, which is very, very low.
It's not the lowest in the world by any means. As we'll see, it's very low down here.
Mortality is almost negligible in some European countries to some smaller European countries from time to time,
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.
For example, if we could experience the rates of mortality, which we enjoyed when we were little children aged eight,
nine, 10, as you recall from last term, perhaps we could live 800 years.
Unfortunately, that is not given to us from that rather heavenly state of survival.
Things get worse into adolescence peaking around. Forgive my saying so.
Your time of life as a certain kinds of reckless behaviour, especially amongst men,
become predominant with their girlfriends dragging along in their train.
Then things calm down.
And then from about 30 or so onwards, we the Gompertz curve takes over this exponentially increasing progression of rates of mortality with age,
which continues continuously right until old age.
There's some alteration of the exponential rate, the Gompertz curve in very old age.
So things don't go on getting quite as bad as you might expect.
More of that later on. Of course, we all know that when an exponential curve on that's going like that,
getting worse and worse and worse, is transforming this relative mosaic. That is a straight line.
And that's effectively what we've got here.
Two straight lines of mortality going up to that scale, indicating the advance of mortality, first of all, are important.
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
funeral notices of our friends for the comfort that it gets really bad around here.
But more of that later. This is the same data all over the same life tables turned into a different form.
What we got here is a non log transformed rate of mortality, the non transformed Q curve,
the rate of death from one year to the next, as I said, well, it's not long transformed.
All that variation around childhood infancy and young adulthood disappears from view.
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.
This is the actual curve of death. This is the number of deaths each year.
And you can see that according to this life table, the the modal age of death,
the most common age of death in the mortality of England and Wales at the present time is just over age 18.
Most people who die nowadays die over age 80.
It's a it's that late. This is the the track of that period expectation of life at birth,
this is just the life table calculation of expectation of life at birth and the wealth from 1850, right.
Until about 2010.
And you can see the two general characteristics, one, a general rate of improvement to the superiority of female survival over male survival.
This is the expectation life of females.
Of course, this is males, the the rather modest pattern of improvement in the first decade or two of this graph.
Hardly any change at all, partly, as you'll recall,
due to the transfer of the population from the more healthy or perhaps I should say less unhealthy countryside to the more unhealthy towns.
The actual rate of improvement, irrespective of that, was was getting what was increasing.
But because the transfer of population to less healthy areas with very rapid urbanisation, no overall change is apparent.
And then we see the improvement getting stronger. From 1860, 1870 onwards, the magnitude of the crisis,
mortality of epidemic disease is getting smaller and smaller and smaller of
particular improvements in the interwar years from between the 1920s and the 1950s.
And then there are the more modest.
But while the linear level of improvement up to the present day with a widening of the gap between males and females down here,
the difference between female expectation, life of birth and male was only about two and a bit years.
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.
Just a reminder that other ways of measuring mortality and to remind you particularly
not to be misled by trends in the crude death rate in developed countries.
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.
And in some countries, it's even possible to see an increase in the crude death rate,
which seems contrary to reason that that is a perfectly true reflection of what the true death rate tell you.
But the crude death rate is not telling the truth as opposed to the real risk of mortality.
Crude death rates are stationary or not improving very much or even getting worse in developed countries.
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.
Ergo, the crude death rates simply deaths. Our population per year is bound not to change very much.
If you look at the age standardised death rate, that is to say, a crude death rate,
adjusted for the fact that the population age structure is changing to to remove that factor.
You see quite a different picture here is the death rate for the 15 countries of the old European Union.
This here is the crude death rate, as you see from 1970 to 2002, showing hardly any improvement.
This is the age standardised death rate, getting rid of this age structure, a factor showing the true rate of mortality.
And it indicates just like that, the trend in the expectation of life at birth in England and Wales data in the previous slide.
It shows a continuous and substantial improvement over time, which so far has shown no signs of diminishing.
This is a this is a similar example in the United States is very common throughout the industrial world,
except for Eastern Europe, of which more in a moment. Here is a crude death rate for the United States from 1960 to 2005.
Here's the adjusted pattern. Same thing as we saw in Europe. The adjusted pattern gives you a very substantial improvement over time.
Again, not showing any signs of diminution.
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.
The lines with the markings are males. Leading the pack, of course, is Japan.
Japanese females with an expectation of life at birth by 2008, up to about eighty six and a half exceeding,
of course, the pessimistic speculations of General Shinseki and his colleagues.
But of course, that's just for one country and one sex, not for the developed world.
With Swiss females just behind and for comparison to the rather mediocre performance of the UK,
UK females still following the same trend, but not so, not so impressively and diverging.
If you go back to the 1950s, the mortality rates were really very similar.
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.
The story is not always one of substantial improvement here is France, where France,
which has the lowest mortality for females anywhere in continental Europe,
contrasted with Denmark and the US, for males, the pattern of mortality is not dissimilar for females.
An interesting divergence whereby the mortality of French females continues to it to
reduce expectation of life continues to increase just below 85 at the present time,
whereas that of Danish females in blue and American females in green and had a period of almost complete
stagnation here where there was no improvement whatsoever that has now come to an end and is now picking up.
Almost certainly this was due to lifestyle habits, particularly due to levels of smoking.
So the epidemiologists believe so is not always uninterrupted progress is not always plain sailing.
And indeed, you can see if you look at the Danish males here of a period of almost zero improvement in expectation of life,
of birth, stuck at about seventy one ever since the 1950s, are up to the mid 1970s again,
is just thought due to the high prevalence of smoking related deaths from which
most populations are now liberating themselves amongst the male population,
but then really impose a flattening effect on mortality.
So much so and so widespread was that in the developed world that it was suppose back in the 1960s that the
possibility of improvements in expectation of life had ground to a halt and that the patterns of heart disease,
cancer, stroke were inexorable consequences of old age and nothing much be done about the Mambi
sort of hit the buffers as far as improvements in expectation of life were concerned.
And you can see why there should be so much pessimism if you cut the graph of about half of males anyway.
But that is all in the past and things are back on track for improvement.
Not everywhere. These are the the extraordinary divergent patterns of the expectation of life of males in Western
Europe compared with communist or former communist Eastern Europe and the former Soviet Union.
What we have here are the expectations of life for Japan in blue, for Switzerland in pale blue, for this is Greece in purple.
And this I guess this must be France. Compared with Russia, Ukraine, Belarus and Hungary, and as you can see, back in the 1960s,
if you looked at these patterns of mortality, they were not really distinguishable.
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,
a source of enormous consolation to the communist powers in the in the Cold War
period when Khrushchev offers threatening to bury us and all the rest of it.
All that changed, that was the peak in the 1960s, from then onwards,
things went downhill or the very best failed to improve throughout the entire Congress as well.
I've only got three examples from the former Soviet Union and one from Central Europe, Hungary.
But as you can see, that the pattern is very similar.
This various hypotheses advanced to to try to explain this, which I'll try to talk about very briefly later on.
But the fact is, is undoubtedly there is also.
It's important to realise while there was a reduction in survival immediately after the end of communism,
very much in Russia, also in Ukraine and in Belarus, essentially, that was just a brief hiatus.
The important thing about this mortality isn't isn't the transient worsening of the
position after the collapse of communism and all the chaos which accompanied that is
much more that the fact that this pattern continued right until recent years and
only the last two or three years as things have things improved somewhat in Russia.
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.
And it's the level of a rather poor Third World country. And it's a very, very remarkable phenomenon of which more later,
they do notice that those countries in the former Soviet Union have stayed put in this in this dismal position.
Hungary, which emancipated itself from that system back in 1989, 1990, has now resumed the upward track,
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.
This is just two to pictorials and to show how interesting, how interesting I can see an East-West gradient in survival.
This is a WHL data from two thousand five expectation of life at birth, divided into quintiles into fifths of the distribution.
The paler the worse. And you can see that it's worse in the east.
It it gets a bit better in Central Europe now. And the darker countries are the ones with the most superior levels of survival.
This is both sexes put together and you can see that France and Spain and Italy do all well.
Scandinavia does rather well. Germany, the little countries, Britain are a bit mediocre along with with Austria.
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.
You can't read which countries are rich, but I've colour coded them.
The countries of the former Soviet Union are appropriately in red Russia, Moldova, Belarus, Latvia and Estonia, Lithuania.
Countries in the former Yugoslavia are green.
Here is. That's right, in central Europe, agrees, is Poland, Slovakia and Hungary.
Down here, predictably, is Scandinavia, Iceland, Sweden, Finland, Norway, Luxembourg,
Luxembourg sort of GDP per head of forty five thousand dollars per head per year compared to about thirty five thousand dollars anywhere else.
So if that can't buy long life, then I don't know what can here in Central Europe, in Austria, Germany, France.
And so a very interesting gradient from that infant mortality rate of three deaths,
three infant deaths per thousand births per year, up to about 18 or 19 at the other extreme.
Interesting also to point out that there is quite a lot of variation within countries which I haven't got time to go into,
which is certainly an interesting phenomenon,
the the old fashioned pattern whereby mortality rates in the countryside, in lower density rural areas of urban areas,
small towns are superior, lower, as it were, than those in major cities still obtains.
And you can see it in England and Wales, two sorts of gradients which are fairly typical of Western Europe.
First of all, the southern more prosperous part. The Bristol Channel to the wash is pela has a lower mortality,
longer expectation of life than than the that part of the country to the north and to the west.
The former old industrial areas, South Wales here, the Midlands here, North Yorkshire,
Newcastle and such areas, and also most of London have higher death rates.
The country areas have pale death rates. Not all, not all of London I death rates.
This is London magnified. This white blob here is considered a Chelsea, as perhaps you might expect,
but really quite substantial differences in standardised mortality rates here.
This goes from readers from 100 per 100, 120 to up to up to 200 here down to about 50.
Here is a very considerable variation in Smar from one part of the country to another, also, of course, from social class.
These are social class mortality rates. Again, standardised mortality ratios for men in 2064.
From the further knowledge you study and as you can see,
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,
five unskilled manual workers. And another terrible graph which I borrowed from the Health Inequalities Annual supplement
and sorry for the ghastly colour scheme of the obscurity of it does it does make the point,
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.
And these are the look on here. On the left we have strokes.
This is mortality by stroke. And this is social class. One, two, three, no, manual three, manuell four and five.
Major difference here. This is of heart disease, heart attacks, essentially coronary thrombosis, very important cause of death.
This is lung cancer. Even more substantial difference because of the differences in smoking habits between social classes, accidents and violence.
And these are this is this is suicide. The only major difference, as you can see, the exception is skin cancer.
Skin cancer primarily caused by excessive irradiation, by ultraviolet light.
This is mostly malignant melanoma rather than other kinds of skin cancer, which are curable.
Malignant melanoma has all sorts of causes, but it's particularly provoked by strong exposure to sunlight.
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.
Anyway, that was more customary amongst richer people, amongst social class one and two.
Then elsewhere, that's where the mortality rate is reversed.
This is now much less true, partly because many more people can afford to go abroad to hot countries to enjoy the holidays.
Also, because of the growing popularity of sun beds and clinics for give you artificial suntans,
which are often far too powerful in terms of the radiation which they give.
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,
but where there's a slight higher level amongst higher social class because of the delay in childbearing characteristic of that,
one of the major risk factors for cancer of the female breast is delaying.
Childbearing has an effect upon the hormones which which are generally at risk factors for contracting that disease.
What about the causes? I've talked a bit about the cause already need talk a bit more.
This is a document which you will not see unless you are gazing down from heaven above with your own name on it.
This is the medical certificate of cause of death, which by law has to be signed before you could be buried or cremated.
And it is an attempt to assign the cause of death which led to your demise, which is often very difficult because of course,
the immediate cause of death may not be the one which is clinically and epidemiologically and demographically interesting.
You may have a haemorrhage in your aorta, for example, or a brain haemorrhage,
and that's the immediate cause of death and that's what will be entered here.
But the reason why you might have that is what really matters what the underlying cause of that immediate cause of death would be.
And that could be a diabetes or it could be atherosclerosis or all sorts of other diseases
of a more chronic nature which predispose you to to to to a violent end of that.
Sort, of course, may also be that your loss of blood from haemorrhage might be because someone has stuck a knife in your chest,
in which case that would go under one of the external causes of death,
of accidents and violence that are there is a very elaborate international agreed classification of causes of death.
Nine hundred ninety nine officially agreed ways in which you can die,
each of which is subdivided amongst many other causes because, of course, human body is enormously complicated.
There are lots and lots and lots of ways which can go wrong nowadays.
There are particular problems because, of course, given that most people die when the age of 80,
by the time we're 80, we have acquired all sorts of terrible things. We've got little haemorrhages in our brain.
We've probably got cancer. We're not dying of it. We may well have some kind of diabetes.
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.
And so and that's difficult to do. It requires clinical research to sort it out.
And from time to time, ideas on it are revised. And this down here in this part of the form,
the condition is meant to write down what the other morbid conditions are for which the person is suffering,
which did not directly cause death, might have been indirectly contributed,
contributed to it, and quite often there'd be four or five or six such causes.
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.
It may well be that as time goes on and people live longer and longer and longer, accumulate more and more morbid conditions,
that it becomes impossible to do anything else except in rather specific circumstances.
The last government was always keen to look on the bright side and this day, just to cheer up for the dead,
they introduced a new attractive death certificate out that great document that I pointed out before.
And in came a nice document in pastel colours embossed with the red rose for England and Wales and for other other devices elsewhere.
Nonetheless, the mortality rate remained the same.
This is the pattern for England and Wales from 1970 to 2009, showing the rise and fall of diseases.
We're accustomed, I think, to supposing that heart disease and stroke and things are always with us,
or possibly even on the increase one hears about an epidemic of cancer.
Neither of these things are true back in the first half of the 20th century.
It's certainly true that here in England and Wales and in other countries as well,
deaths from what came to be called diseases of affluence were predictably unexpectedly going up.
This is the these are age standardised mortality rates for this is for circulation disease that would include the squeamish heart disease,
heart attacks, coronary thrombosis and strokes.
This is respiratory disease, tuberculosis and influenza going down, as you might expect, as health conditions improve.
This is cancer and this is infectious disease diminishing down to more or less nothing.
Until the middle of the century, around about here, as you see,
the standardised death rates from circulation disease, which is most important cause of death,
was actually going up partly because the population was getting older and therefore moving, as it were,
its centre of gravity into that part of the distribution of these risks become very much more severe.
People your age don't get that kind of condition.
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.
Cigarette smoking was increasing at that time.
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.
It was the the better off people who are dropping dead from heart attacks, not not the workers doing manual work.
That's now completely reversed. In those days, though, it was it was thought to be really genuinely a disease of the rich.
You got better your diet, the worse things were for the point of view of heart attacks.
Cancer also was creeping upwards and peaked at nineteen seventy one nineteen eighty one.
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,
partly because of great improvements in lifestyle, the decline in smoking, the recognition of the importance of diet, all sorts of other things.
Plus, of course, really important innovations in it,
in drug control of blood pressure and cholesterol and other risk factors of secondary disease and surgical intervention,
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.
And that's why it's going down so dramatically now, lower than it was in 1911.
And so I'm heading down this cancer. Much more troublesome cancer, of course, is a whole variety of diseases.
Almost every organ in the body can become cancerous. And so it's a complex of diseases,
some of which are improving in terms of their survival after treatment and also declining in terms of their prevalence,
like stomach cancer, for example, others of which remain rather intractable with rather poor five year or 10 year survival rates,
but nonetheless, generally going down. That's for males, a similar pattern for females, but of course,
not reflecting the female advantage and in especially in circulation disease and also in cancers,
although showing a slight bulge here as the late onset of smoking related diseases amongst women starts to make an effect
around here is it peaked some sometime earlier amongst males because males take up these bad habits before women do.
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,
it's very difficult sometimes to work out exactly what the clinical, physiological, biological changes are,
which are leading to causes of death and therefore the international classification of diseases.
The ICD is revised every few years. The revisions are marked by these vertical lines in this graph from the US.
And you can see that there are sometimes some discontinuities, mostly small, but there's a bigger one here.
For example, when when certain subdivision's is the cause of death, alveoli is actually to belong somewhere else and to be misdiagnosed.
Also important to realise that sometimes rapid increases in causes of death are caused not so much,
because that particular condition is genuinely becoming more common,
but because it is being recognised as a genuine chemical entity and previously wasn't.
The obvious example is Alzheimer's disease. This pale green line here is the mortality.
Alzheimer's disease almost negligible in about 1980.
Now, of course, rising up to to a high level and reclassified in 2000 Alzheimer's disease.
But certainly with us back here, it just wasn't diagnosed or rather recognised as a clinical entity.
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.
But it was not recognised at all back in the 1970s.
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.
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.
The reduction which this graph bodies from nineteen fifty eight until 2005 is actually very great.
It's even bigger than that which we saw in England and Wales.
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.
In Japan, the pattern has always been a different cerebrovascular disease.
Stroke started off being more important and heart disease quite unlike Western Europe.
Cancer, malignant neoplasms was a has become the most important cause of death, putting these in the shade.
And the cancer is going off in Japan despite the fact that, as we know, equitation life of birth is very favourable.
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.
We will have to wait and see. Huge variation within Europe in these causes.
The left hand column is ischaemic heart disease, chronic and acute heart disease,
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.
This is ranked the table as ranked according to the magnitude of the death rate from circulation disease.
As you can see, France has the largest burden 49. Ukraine has ten times the level.
Four hundred and ninety nine.
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,
Russia, Ukraine and Europe as a whole. Two hundred and sixty.
So we're less than the European average, but not doing terribly well compared with others.
CVRD is cerebrovascular disease, which is stroke is pulmonary artery disease,
blood clot to the top of the artery, which is an important cause of death, but often misdiagnosed very lightly.
I think this very great variation here is partly due to changes in diagnosis.
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.
Cancer, likewise, this is this table is ranked according to the magnitude of cancer, according to various different causes,
Shakir Bumpus and lung lung cancer here very about two fold between Portugal and Poland.
That was Hungary. The worst of the worst ones are a heavy type.
These are the patterns for ischaemic heart disease, biogeography, reflecting,
as you would imagine, given the enormous importance in the scheme and heart disease,
the pattern of overall mortality, which I displayed earlier on, dark is worse in this particular graph.
And we see the east west gradient, NBC, also the traditional superiority of France,
Italy and Scandinavia compared with Germany, Poland, Austria and England and Wales.
So there's a north south, rather patchy north south U.
Shaped gradient, as well as a very clear east west gradient in these patterns of mortality,
of substantial levels of difference in mortality between countries, you know,
doing living rather similar ways of life, doing the same kind of job, driving the same kind of car,
eating more, not quite the same kind of food, but not all that different.
Nonetheless, enormous differences in mortality risk, which are very interesting as well as other serious.
That's just stroke. And we'll move on from that. So we have we have a lot to explain.
Lots of possible explanations for it.
There are obviously within these countries in the world differences in national wealth from 45000 US dollars per year,
equivalent in Luxembourg, down to about 15000 in some of the East European countries, or even less than that.
National health expenditure, private and public, varies considerably between countries.
Inequality of health, which Wilkinson is very keen on, on emphasising as an important determinant of overall mortality,
notably in his controversial new book called The Spirit Level, is another important contender.
All that's related to the underlying clinical risk factors and mortality.
Typically, of course, the kinds of diseases we're talking about of high levels of cholesterol, blood pressure,
smoking habits, excessive drinking, especially binge drinking and other aspects of lifestyle.
But those are the most important. And also we'll find, I think in Eastern Europe, especially in that politics matters.
Politics matters in terms of the extent to which the national wealth is turned into health expenditure.
Different countries have different priorities. Politics also matters in terms of freedom of information,
in the extent to which it's possible or easy to discuss causes of death if the extent to which public
discussion can really take account of what's going on with with with the national mortality levels,
what are the risk factors?
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,
some of it contradictory about how to live a long and healthy life in other countries, particularly in the East.
In the past especially, this has not been possible,
partly because the data haven't been there and partly because the freedom of information has been there to discuss it.
This is a total health expenditure in dollars US dollars per head around about around about two thousand five, as you might expect,
there's an east west gradient which fits the pattern we saw before I saw this graph does not actually show
very closely the difference between the the top quartile and the and the middle and the next quartile down,
which is a shame because it is better on the screen.
It shows that there's more expenditure, as you see here in Germany and in France and the Netherlands,
in Switzerland and Austria, rather less, in Italy and Spain and the U.K., rather, more and more or less in Sweden.
The data aren't here, but I think you probably already know from other sources that the correlation between health expenditure
in the US dollars per head is standardised for exchange rates or any other measure on the one hand.
And any measure of national health is not very great.
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.
That's not surprising, but within the richer countries, the correlation is really quite weak.
The US spends about 15 percent of its very considerable GDP upon health and
produces really rather mediocre results no better than the average Western Europe,
where health expenditure is, I think, universally lower. Germany, which spends about the same per capita as France,
it does not have the same French superior levels of survival, particularly amongst females, Italy and Spain,
which don't spend all that much compared with others on on health,
taking all expenditure together as we saw how very superior levels of survival compared with the rest,
Norway and Sweden aren't that different in health expenditure. So are that different in health expenditure?
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.
What about these diseases of affluence?
Can we understand anything, anything from those, are they as used to be thought, the inevitable consequence of old age,
something which is powerfully age related and inexorably age related and which cannot really be controlled or modified very much?
Or are they susceptible to intervention either by a more knowledge based form of
healthy living and high powered medical intervention or the latter appears to be true.
And it's clear that there has been a shift in the disease of affluence are no longer diseases of affluence.
These these governments, the heart disease, the cancer, the strokes and all the rest of them,
which used to be more common in richer countries and poorer countries,
more common amongst richer people than poorer people in the first half of the 20th century, for example, has now shifted around.
They are now more common amongst poorer people than richer people in the developed world.
As you saw from the standardised mortality ratios, which I showed earlier on,
there are also more common amongst the poorer group of the developed world countries and amongst the richer ones.
And increasingly, too, as a reprise the pattern of the early 20th century that becoming more common
amongst the more developed the developing world countries where heart disease,
obesity and all sorts of other problems are now quite a problem in amongst the middle class in India and also amongst the
middle class in Brazil and other countries that came with obesity levels at almost European or even British sorts of levels.
One of the important variables which helps to to explain the the relative weakness
of the of the financial aspect of investment in health are lifestyle patterns,
particularly the so-called Mediterranean diet, at the risk of sounding like a margarine advert?
It really does appear to work.
This is a simple diagram of what the ideal Mediterranean diet is based upon the diet characteristics of parts of Greece,
like Crete some some decades ago.
The Cretans have now moved on from this very healthy thing and are becoming fat because they're eating lots of beef and things.
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.
Olive oil very central to this daily consumption of cheese and olive oil, fruits and vegetables.
This sounds terribly wholesome and boring of me, but it does appear to be true that this does make a difference.
Not only does it make a difference in terms of helping to explain international differences and why relatively poor countries,
especially poor in the past, like Italy and Spain and Greece, had low levels of mortality, but also in terms of clinical treatment.
One of the interestingly clinching evidence is that this is a pattern in Albania.
Albania is a country in Eastern Europe, as you know,
it was a sort of communist country where the communist dictator and the Hodja quarrelled not only with Stalin,
but also with Mao and became a completely isolated entity all by himself, deeply impoverished.
He covered the country with over 100000 little forts which are still there and saw concrete bunkers to protect himself from attack from anywhere,
behave with great ferocity towards outsiders of any kind, exterminated religion and whatever, and kept the country put.
Despite that, the expectation of life at birth in Albania continue to improve from admittedly low levels throughout the whole of the communist period.
Quite unlike that pattern which which I showed earlier on.
And of course, it is now believed.
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,
being a country on the Adriatic, part of the Mediterranean, benefitted from this pattern of of Mediterranean diet for quite a long while.
Things will not change now that Albania is becoming more affluent.
And even more interestingly, was the fact that those coastal parts of Albania, where this kind of diet was easy to obtain,
had superior survival levels to the more mountainous inland parts of Albania where this is less often practised.
So a curious little tiny piece of evidence from from the from the more remote parts of eastern southeastern Europe.
And this rather complex graph is just to try and lend some scientific verisimilitude to my generalisations about this diet.
Not only is it is it a very good contender for helping to explain why some poor Southern countries have superior survival rates,
it also, even more convincingly, when used as a therapeutic measure,
has a dramatic and predictable results upon levels of mortality from heart disease,
stroke and also, surprisingly, Alzheimer's, Parkinson's and other conditions.
This is a meta analysis of 12 prospective studies whereby people at risk of death from these conditions are very different.
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.
A total sample size of one point five million people. And all the studies show an improvement.
This is the details don't matter, but this is an improvement on the left hand side improvement.
Two steps in the scale of of the Mediterranean diet produce between 10 and 30 percent improvement in survival.
Yeah, the alternative diet was one which tried to avoid the excesses of meat and fat,
which some of those in the study had previously been been following,
and which was what we would regard as a reasonable diet of the kind we normally eat, as opposed to something rather more specialised.
It varied between sizes. There were 12 studies. So I don't really know what the average of 12 was.
This has been responsible for some interesting reversals in immortality or so we believe,
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,
up to the latter part of the 20th century. This, for example, is Italy in in nineteen hundred and eleven.
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,
malaria infested southern Italy had higher death rates in those days than that, than the more prosperous,
more as a European north, partly because infectious disease was much less well controlled.
Here it is, much more a poor rural area.
By the time we get to eighty one, the position is totally reversed here.
The higher mortality levels are found in the more developed, richer northern part of Italy,
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.
The pattern of mortality is much, much lower.
The burden of infectious disease has been eradicated by this time, as it has been throughout Europe, east and west.
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.
This was not not the case here where the diet is much more like that, which the neighbouring Germanic populations tend to eat.
Likewise in France back in. This is nineteen hundred and one of the highest mortality areas in France.
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.
It's believed the same sort of all sorts of interesting changes going on of that kind.
The special problem of the high mortality levels amongst males in Eastern Europe, which I mentioned, has puzzled many people.
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,
very high levels of accidents and violence particularly related to drink.
But it's by no means all of that, although that's the best known aspect to this high mortality.
I guess of one general theory put forward by Albert Carlsen is the pattern of mortality in these countries,
which which is unique to the former communist countries and also is concentrated amongst men of older working age,
not so much amongst women, not so much amongst children, not so much amongst older people.
He calls this the state socialist mortality syndrome and in brief attributes it to the the forced industrialisation and the forced urbanisation,
which took place more or less throughout this era from, well,
from 1917 or 1920, in the case of Russia, from 1945, in the case of Central and Eastern Europe,
outside Russia, which transformed a rural poor population, practising mostly primary activities into one,
forced into into secondary and tertiary activities, particularly secondary ones, industrial activity,
often a very extremely dangerous kind, which which led to major changes in social organisation, the disruption of family structure,
the concentration of population, and very inadequate, rapidly built urban housing and all the rest of it,
which you can see that a complex theory, one which it will take a long time to expand properly.
But as far as Earlwood, Karlson and others to concerned, the primary ultimate reason for these interesting and very distinctive patterns of mortality
is socio political and what not to do with random changes in mortality for other reasons.
What happens next? Onwards and upwards appears to be the sign that the graphs are all pointing upwards in in in the West anyway,
I mean, Western Europe, the US and other countries outside Eastern Europe,
those parts of Eastern Europe, which are which are reformed like those parts which are joining the EU,
Hungary, Poland, the Czech Republic, Slovakia, which are joining the European Union.
Their death rates are all moving upwards again, as they should have been for the last 50 years, but haven't been.
How long can this continue? All sorts of factors argue one way or the other.
And this is a strong argument, a strong source of dispute amongst my colleagues.
In fact, of all the arguments within within demography, aside from migration,
the argument as to the as to the likelihood of continued improvements onwards and upwards for a long
time and survival compared with the likelihood of this grinding to a halt thanks to obesity and so on,
generate some of the most fierce arguments, even personally hostile arguments anywhere in the subject.
All sorts of reasons lead one to suppose that things will continue to improve.
Fundamental objections are raised to this in terms of the impossibility of any organism being capable of of self repair
for for endless periods of time and the difficulty of reinventing the entire human body through technical innovation.
And also the more more practical objections arranged against the prospect of continual
mortality improvement arising from this really very alarming level of rising obesity,
which will doubtless know a great deal through Stanley Olegas lectures and other sorts of problems,
the possible re-emergence of old diseases, the possibility of bird flu mutating into something seriously academically damaging and so on.
The improvements are clearly going to take place and have been taking place at older ages.
Mortality below age 60 is now so low that were totally abolished it would not make a very big difference of expectation in life.
At birth, about 97 percent of newborn babies now can expect to live to age 60.
So getting rid of that mortality is is going to be difficult and also will not make much difference.
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.
No end, as you can see in this graph from eighteen fifty after the middle of the century,
very little improvement in the expectation of life at age 65 from the normal, starting particularly with the females.
And then later on amongst males,
it's been increasing at an exponential rate and it is there that further improvement must take place in order for the overall
expectation of life to continue increasing at the very satisfactory linear pattern which has been showing for some time now.
He is just one of very large numbers of warnings against expectation of a continued
improvement arising out of obesity and the transmission of obesity from children to parents,
which is a very serious problem. These are the the uncertain expectations, the Office of National Statistics.
This is their projection for expectation of life at birth from the 2008 projections
going up by two thousand eighty one to about 93 for females and about 88 for males.
Typically, the pattern of linear improvement, which they allow to continue in these projections until 2030 is then bent downwards.
Actuaries hate linear improvements in mortality and partly for scientific reasons and partly for reasons of caution.
It is as see here in the official projections, the higher projection, the alternative,
the face saving alternative projection of a higher level of disease to be continued in a linear fashion,
reaching nearly 100, as you see for females by 2030. One set of males.
That will be really very interesting. This is this is the pessimistic possibility.
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.
That really very, very pessimistic. But we what we will see which of those is right.
That's the difference between England and Wales and Scotland will pass on away from that.
Well, getting to some very interesting expectations of life here, as Madame John Caldmore, who died aged 122,
I am very sorry that I couldn't find a photograph of her with a customary glass of
red wine in her hand and her previously frequently smoked cigarettes in her mouth.
But that's what she used to do. And she felt that all that stuff about cigarettes and wine was all nonsense.
And here she is in nineteen ninety seven hundred twenty two is so far unbeaten.
Here is Edgar Sharpe, born 1886 and died aged 108 in 1994 in his youth, in his marriage and in his old age.
Here is Henry Allegan, who is the world's oldest man, born in 1899, fought the Battle of Jutland.
And here is that the Cenotaph in 2004 and just died a couple of years ago.
So the maximum age of expectation of life is is getting greater.
The numbers of centenarians is hugely increasing. The centenarians are the most rapidly increasing group of people in Western Europe.
They'll be numbered in the millions by the end of the century if things go on as they are.
So the pattern is a favourable one.
Mortality is falling. Every year that passes, we get a bonus of three months extra in terms of expectation of life on current trends,
which is way up, no end, big twentieth century divergences between West and Eastern Europe, which by no means yet entirely of.
They're still alive and unwell in Eastern Europe.
Persistent differences in levels of mortality also between the social groups, the occupational groups, income groups, social classes.
The interest nowadays, of course, is powerfully focussed upon survival of people in older ages.
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.
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,
enjoyable, useful and possibly employable life.
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.
All sorts of unsolved scientific problems about the likelihood of future future improvements in survival,
the extent to which the human genome in its present form can sustain a continual repair of DNA and cell processes into older life.
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,
after the next two or three decades,
all future patterns of population ageing are going to be determined by future levels of human survival and not by the birthrate.
I will stop there. Thank you very much.