Current Trends in European and Middle Eastern Mortality
- Extra Reading
29 November 2012 Current Trends in European and Middle Eastern Mortality Professor Jon Anson When John Graunt published the first life table (Graunt, 1662, reproduced in Smith & Keyfitz, 1977, see also Glass, 1950), life expectancy at birth in London was probably less than 30 years. Indeed, his figures imply a life expectancy of less than 20 years. Thirty years later, when Halley published a more extensive life table for Breslau (today Wrocław) in Silesia (Bacaër, 2011, Chapter 2), the implied life expectancy was about 33.5 years. Today, life expectancy at the national level in Western Europe is around 80 years, and is rising at the rate of almost 2.5 years every decade. Most of this increase in life expectancy has been achieved through a dramatic reduction in mortality amongst children and young adults: just to give one example, in the Graunt and Halley life tables one third of those born died before the age of five. Children born in many West European countries today face little more than a hundredth of that risk, about 3 - 4 per thousand will not reach their fifth birthday (for an extensive list of updated life tables, see the Human Mortality Database ). In the following pages I want to look at the way mortality has changed over the past 150 years in Western Europe and then compare what is happening in Western Europe today with the current level and changes in mortality in Eastern Europe and in the Arab countries of the Middle East. I say mortality and not just life expectancy, as one of the points I want to make is that mortality is not a uniform process, and while differences in life expectancy at birth will enable us to see most of the changes, particularly over the long term, there are important differences which are obscured when we focus on just this one measure. To do so I shall start by explaining what life expectancy is (and is not), why it is an important measure of mortality, but also what its limitations are. The Life Table and Life Expectancy The level of mortality, the risk of dying to which members of a particular population are exposed, varies by age and sex. Comparisons between populations must therefore find a way of allowing for the age or age-sex composition of the populations, for otherwise the reported value (the Crude Death Rate , for instance) will reflect the population structure as much, if not more, that it will the overall level of mortality in the population. Graunt's great insight, from which the life table model was developed, was that we can abstract from these variations in order to obtain a measure of the average level, or force, of mortality in a manner that does not depend on the particular age or age-sex composition of the population at hand. Fig 1: Survivorship Curves and Life Expectancy about here The life table starts with a hypothetical birth cohort (usually of 100,000 people, but it could be any number) and asks: what proportion are still alive at each age, given the current risks of dying at every age (Shryock et al., 1980, Vol. 2, H. 15). The result is a survivorship curve as shown in Figure 1a for four different mortality schedules: Graunt's original proposal (1662); Halley's Breslau model (1693) and contemporary UK (2009) Males and Females (HMD). If all those born lived to 110 and died on their 110th birthday then 100,000 people would live altogether exactly 11 million years of live (100,000∙110) and the average length of life would be 110 years. In practice, the number of people alive each year in this hypothetical cohort declines, at a rate determined by the age-specific mortality rate. The faster it declines, the fewer people are still alive at each birthday, and the smaller the total, and hence the average, number of years lived. In the Graunt life table 100 people lived altogether 1,820 years, to give an average, or life expectancy, of only 18.2 years. In the Halley table (which is considerably more credible) life expectancy is 33.4 years, 15.2 years higher but still less than a third of the potential. The increase of 44.7 years for the contemporary UK (males) and a further 4.2 years for females shows how much life expectancy has risen in the past 300 years -- but also how much room for further increases in life expectancy there may yet be. It is worth stopping to consider exactly what the concept of life expectancy means. The survivorship curve on which life expectancy is based is derived from the current mortality risk at each age. The survivorship curve itself is thus a synthetic construct whose sole purpose is to present a summary measure of the present level of mortality which is totally independent of the age structure of the population. By using life expectancy we may thus compare the level of mortality between men and women in the same population; between people in the same population 50 or 100 years apart, or in two different populations, even though one may have a concentration of young people (say, 50 per cent of the population under age 20) and another a concentration of older people (say 50 per cent of the population over age 40). The term “life expectancy” itself is a probably unfortunate misnomer, as it implies that this is the average age of death in the population, which it is not. Imagine a population in which exactly 100,000 people are born every year, 100,000 people die every year, and the risk of dying stays constant for time immemorial. The number of people actually alive in such a hypothetical population will be constant, and will depend strictly on the level of mortality in the population. In fact, the number alive at each age will the number surviving in our hypothetical cohort of 100,000 people. If the level of mortality is high, many people will die young, and the actual number of people alive will be small. If mortality is low, many people will survive to old age, and the total number of people will be large. The Crude Death Rate in this synthetic population will thus be as the total number of births is the same as the total number of deaths. However, we have already defined life expectancy as and the total population is the same as the total years of life lived, for it is the people left alive after death has taken its toll, so So life expectancy is simply the inverse of the synthetic Crude Death Rate, itself a weighted average of all the age specific deaths rates in the population. It is thus a measure of the average level of mortality, and herein lies its value -- as a measure of the level of mortality which abstracts from the age structure of the population, and which depends strictly on the level of mortality at each age in the population, at the particular point in time at which it is measured. In any natural population the number of deaths will not equal the number of births, so that the population will either be growing or declining, on top of which the population will probably be gaining and losing people through migration, and of course the ages of the immigrants will not match those of the emigrants. Furthermore, over time, both mortality and fertility rates will fluctuate, or may even change quite dramatically in response to changes in material conditions, in family structures, in the pattern of social relationships, and so on. The age structure of the actual population may thus bear little relation to that of the synthetic life-table population. The mortality risks will be identical, by definition, but the total number of deaths and the Crude Death Rate will be completely different, as will the average age at death. The same problem arises if we think in terms of a cohort of people born at the same time. If (and only if) mortality rates stay identical for all of their lifetime will the life table as measured at one point of time enable us to reconstruct the mortality history of this cohort, and this has never been the case. Even at times when mortality levels were ostensibly stable, there were always fluctuations due to particularities of the weather, political stability and other natural and man-made forces which affected the provision of essential supplies for that population (Galloway, 1985, Winter, 1985). Even if we look at mortality rates as they evolve over the life of that cohort, these will be not be pure, as both the nominator and the denominator will contain people who have moved into the population, and exclude those who have left. Specific follow-up studies, focussing on one particular cohort, also lose a large part of the population over the time. One of the most famous studies, the National Child Development Study which followed up all children born in a single week in 1958, had lost almost a quarter of the sample by the time they were 23, and over 40 per cent of the sample by 2003, when the cohort was 45 years old (Power and Elliot, 2006). Life expectancy, then, is a synthetic measure of the level of mortality, but it is not strictly a measure of the average length of life. It is, nonetheless, an extremely useful measure of the average level of mortality in the population, a measure which can be used to rank populations in terms of their current mortality risk. It may not particularly useful to say that mortality in a population with a life expectancy of 40 is twice as high as that in a population with a life expectancy of 80, or that the latter live twice as long as the former. However, we can say that the risk of dying in the one population is considerably higher than in the other, and we can relate this risk to material standards of living (Marmot, 2003), to equality in the distribution of resources in society (Wilkinson & Pickett, 2009), to levels of religiosity (Musick et al, 2004; Hummer et al., 1993), to forms of family organisation (Anson, 2010), to economic and political organisation (Stuckler et al., 2009) and to political stability (Kaplan, 2012), to name just a few important correlates of life expectancy. 2.1 Long term trends in life expectancy Figure 2 Long term trends in Life Expectancy about here For a few countries, we have life table data going back to the middle of the nineteenth century (and for some, even the middle of the eighteenth century). Figure 2 looks at the long-term trends in life expectancy at birth for these countries, for males and females separately (data from HMD). Perhaps the most striking feature of these figures is how closely and consistently life expectancy has increased in these countries, despite their very different social, political and economic histories. What little variation there was at the beginning of this period had almost completely disappeared by the final third of the twentieth century. Women have consistently higher life expectancy than men, and over most of this period we can distinguish two main groups, with the Scandinavian countries having slightly higher life expectancy than their neighbours to the south. Life expectancy appears to have been fairly stable at about 42 years till around the 1870's, after which it began to increase steadily till the end of the Second World War. Since the early 1970's life expectancy has been increasing almost linearly, at a rate of about 2.25 years per decade, though, of course, there is no guarantee that it will continue to do so (Leon, 2011). 2.2 Beyond the gold standard Figure 3: Life Expectancy Trends in Western and Eastern Europe since 1950 about here The six countries discussed above (together with Finland, Japan and a few others) may be considered as the gold standard countries: those that at any point in time define the minimum level of mortality for that period (Oeppen & Vaupel, 2002, but see also Vallin & Meslé, 2009). Not all countries have been so lucky, however. Using the raw data provided by WHO , we have constructed life tables for most countries of Western and Eastern Europe, and Figure 3 presents changes in their life expectancies since the early 1950's. The countries are listed in table A1 in the Appendix. We shall consider the countries in the Arab countries of the Middle-East below. There are some interesting and important contrasts between these two groups, but it is clear that they are a very meaningful way of distinguishing mortality histories. Males, as is to be expected, show lower life expectancy than females, in both Western and in Eastern Europe. In Western Europe the trend in life expectancy has been consistently upwards throughout this period, and although there are differences between the countries, in general there has been a tendency for them to draw closer together in their life expectancies over time, while maintaining the same general rank order. Thus, the Scandinavian countries have maintained their primacy yet, particularly for males, their life expectancies changed very little over the first two decades as other countries caught up with them. Portugal, by contrast, which commenced the period with a particularly low level of life expectancy has largely caught up and, especially for women, now has a higher life expectancy than the countries of the British Isles. In Eastern Europe the picture is completely different. The general trend, for males, has been one of stagnation followed by a rise only since the mid-1990's. However, within this general trend there have been a variety of different paths taken. Yugoslavia and East Germany increased steadily, if slowly; others, such as Bulgaria, Czechoslovakia, Romania and Poland, fluctuated around the same level, while others, in particular the countries of the Soviet Union (the Baltic States, Belarus, Moldova and Ukraine) showed a real decline particularly in the period leading up to and after the fall of Communism, a decline from which not all have recovered. Only Slovenia and the Czech Republic show clear signs of life expectancy gains since 1990, of the type seen in Western Europe. For women the picture is more consistent with a slow but steady increase for most countries (Moldova and Ukraine are important exceptions), but here, too, only Slovenia shows real signs of a Western style mortality decline over the past two decades. De-constructing Life Expectancy Figure 4 Mortality Divergence in mid-Adulthood about here How should we explain this stagnation in mortality in Eastern Europe, particularly among men, and should we be talking of a general collapse, or is there something more specific. In order to answer this question, we need to look more carefully at the way mortality evolves over the lifespan. Although the general shape of the mortality curve is constant, there is, nonetheless, considerable room for variation. Two populations may have the same life expectancy at birth, but nonetheless may have different mortality and survivorship curves, so that the one has higher mortality rates than the other at young ages, whereas the other has higher mortality rates at older ages. Alternately, populations may have very similar levels of survivorship in the early years of life, and yet diverge considerably in later years. Figure 4 compares mortality and survivorship curves for Japan in 1965 and Russia in 1994. Although almost 30 years separate these two life tables, Japanese males in 1965 had a life expectancy at birth of 67.7 years, ten years greater than that of Russian males in 1993, whose life expectancy at birth was only 57.4 years. In the early years of life, up to about age 20, their two mortality curves followed almost exactly the same trajectory, but beyond that age mortality in Russia rose precipitously, while that in Japan remained low for another 25 years or so. In order to compare these life tables at different ages, it is useful to use the partial life expectancy (Hickman and Estell, 1969), the average number of years lived between two ages by people who survived to the beginning age. Thus the PLE for ages 35 to 60 is the total years of life lived between ages 35 and 60 by people who have survived to age 35. It provides a measure which is easily interpretable, and which relates to mortality within the specified age range only. The average length of life between birth and age 15, the PLE, was effectively the same in both Japan and Russia, 14.6 years. In other words, a person born into both these population would live an average of 14.6 years out of the first 15. Beyond this age their paths diverge considerably. The Japanese who attained the age of 35 could expect to live on average 23.6 years out the next 25 years. For the Russians the comparable expectancy was only 20.4 years, three years less, and this despite the fact that Russian mortality was measured 30 years later, and the mortality risk at young ages was no higher. Figure 5 Partial Life expectancies, Ages 0 to 15 about here Consider now the evolution of mortality in Eastern and Western Europe in these two age ranges (Figures 5 and 6). The patterns for Partial Life Expectancy in the early years (0 to 15) are very similar. In both regions, the PLE increased consistently, and those countries which had a low PLE at the beginning of the period (Portugal, Spain Italy in the West, Albania, Romania, Moldova in the East) had essentially caught up by the beginning of the twenty-first century. Variation remains considerably greater in the East, but the trend is clearly upwards towards the maximum of 15 years lived in the first 15 years of life. Figure 6 Partial Life expectancies, Ages 35 to 60 about here At ages 35 to 60, by contrast, the picture is very different. In the West there has been a consistent upward trend, and a similar pattern of convergence to that seen for PLE in the early years of life. Amongst men, the Nordic countries have lost their advantage and Finland its disadvantage, and the latest figures show that all countries now exceed a PLE of 24 years out of the 25 in this age range. Amongst women, too, there has been an even tighter convergence as the variation between countries has declined and as all move slowly up towards the limit of 25 years. In Eastern Europe the development has been very different. Amongst women PLE for ages 35 to 60 has moved up slightly if at all, and there has been a clear divergence with the front runner, Slovenia, having a half year advantage over Ukraine and Moldova, for instance. However, these differences pale when compared with the divergence between male levels of PLE in these countries. For about 40 years, from the early 1960's to the late 1990's, the general level of PLE was downwards, with a strong divergence between the countries of the former Soviet Union (Ukraine, Belarus, and the Baltic Countries) who lost a year or more in PLE, and the East European countries, for whom the level remained fairly constant, but clearly below 24 years. In the past decade there has been some increase in a few countries (notably Slovenia and the Czech Republic) and the Baltic Republics have regained their lost PLE. Not so Ukraine and Moldova, however. The general picture is thus one of a very broad divergence not only internally, within Eastern Europe, but also from the path followed by the West European Countries. There is, of course, a certain arbitrariness in choosing these specific ages, but not in choosing this general age range. Mid-adulthood is a critical time in a population's mortality trajectory, for it is during this age period that mortality rates move from a gradual to a rapid increase as the population enters senescence. The later the acceleration begins, the more we may say that senescent mortality is postponed. The earlier the acceleration, the greater the extent of premature mortality, deaths which under other circumstances could have been avoided. Furthermore, the causes of this prematurity or postponement may be very different from those governing the level of mortality at younger years. By distinguishing between PLEs at younger ages and at mid adulthood, we are able to see that the different trajectories of life expectancy (average mortality) in East and West Europe are not the results of a general collapse in the life-sustaining conditions in the East. Rather, the crisis has been focussed on men far more than on women, and in particular on men in middle (and perhaps also later) adult life. If we are to judge from the improvements in mortality in the early years of life, amongst boys as amongst girls, the general conditions supportive of lower mortality continued to improve in Eastern Europe just as they did in Western Europe, albeit at a somewhat slower pace. However, what was lacking, and even deteriorated, in the East, and in particular in the countries of the Soviet Union, were conditions amenable to the postponement of mortality in the critical mid-adult years and the reduction of premature mortality. Mortality in the Arab Middle East Figure 7: The States of the Arab Middle East about here 4.1 Long Term Trends Figure 8 Mortality Trends in the Arab Middle East, 1990-2009 about here WHO has recently published a series of life tables for (almost) all countries of the world in 1990, 2000 and 2009. In the absence of adequate data, these tables include estimated life tables for the countries of the Arab League (see map in Figure 7). Working with estimates based on what little data is available can give us an insight into the mortality conditions in these countries, but nonetheless the results need to be treated with caution. Figure 8 presents the trends in life expectancy at birth and the partial life expectancies discussed above for these countries. The Arab countries are far more heterogeneous than the Europeans, and this is reflected in their life expectancies, from the oil states of the Persian Gulf, with life expectancies at West European levels, particularly the men, to the poverty stricken second line states of Africa, those not bordering the Mediterranean (Comoros, Djibouti, Somalia, Sudan and Mauritania, to which we should also add Yemen). Over the past 20 years median life expectancy has risen by about five years, which is about the pace at which life expectancy is rising in Western Europe. However, the life expectancy gap between men and women is smaller than in Europe. Furthermore, there is a major distinction between the second-line states, the Mediterranean basin and the Gulf States. The first group is typified by life expectancy values at birth that have stayed constant for the past 20 years. In Somalia it barely rises above 50 years, a level not seen in Western Europe since the beginning of the last century. At young ages the general tendency has been for a convergence of the Mediterranean and Gulf states, leaving the second line African countries even further behind than they were before. The same is true for women at ages 35-60, but not for men, where we see a certain divergence between the Gulf States which have forged ahead and the rest of the Arab World where progress appears to have been somewhat slower. In the second line states, by contrast, there has been no real change and the partial life expectancies remains largely as they were 20 years ago. These data end in 2009, before the so-called Arab Spring and the political violence in its wake, so the situation may not have improved since, and in some countries will have deteriorated. Nonetheless, the main lines can be drawn. Unlike Europe, where mortality levels are converging and rising, the situation in the Arab world is far more complex. Based on the mortality data above we can identify three major blocs: The Gulf States, where male mortality matches West European levels, though the male-female gap is particularly small and female mortality remains somewhat lower than in Western Europe; The Mediterranean basin, where mortality is declining though more slowly than in the Gulf States. In particular, the mortality decline has been slow among middle aged males, indicating that preventable mortality remains relatively high. Finally, the poverty and strife-stricken second-line African states south of the Mediterranean coast, where mortality is not declining, neither in young nor in middle ages. Comparisons with Europe Figure 9 Life Expectancies in the Regions, 2009 about here To compare the mortality patterns of the Arab countries with Western and Eastern Europe, Figure 9 presents Life Expectancies at birth, for males and females, in the three regions, Western Europe, Eastern Europe and Arab Middle East for 2009. We exclude the second-row countries and focus on the countries of the Mediterranean Basin and the Gulf States. As we already saw, Western Europe has the highest level of life expectancy for both males and females. Male life expectancies in the Gulf States of the Arabian Peninsula are similar to those in Western Europe and clearly above the level of Eastern Europe, whereas life expectancy for females is on a par with Eastern Europe. For the main group of Arab States (the Mediterranean basin) male life expectancy is slightly below Western Europe and on a par with Eastern Europe, while female life expectancy is lower than both European regions. Iraq (after a decade of sanctions, war, occupation and continual violence), is lower still. There are also important differences in the gender-gap in life expectancy. Most of the Gulf States show a gender gap in mortality of less than 3 years, whereas in West European and Mediterranean countries there is a gender gap of between 3 and 7.5 years, and in East European countries the gender gap rises to 12 years. Figure 10 Partial Life Expectancies about here Overall, then, mortality in the Arab Middle East is generally higher than in Europe, particularly so for women when compared with Western Europe. Figure 10 looks at the relationship between partial life expectancies at younger and at middle ages. For men, we can see three, even four distinct regional groupings. In Western Europe the PLE at ages 0-15 is high, as is the PLE for ages 35 to 60. For Eastern Europe, by contrast, although the PLE for ages 0 to 15 is very similar to Western Europe, PLE for ages 35 to 60 is considerably lower, especially for the countries that were once in the Soviet Union. Albania, on the other hand, in notable for having a Western level of PLE35-60, a finding that is consistent for the Albanian data since the late 1980's. The Middle East countries show a linear rise in PLE35-60 as PLE15 rises, with a trajectory pointing to the upper end of the Western European distribution. It would thus appear that the pattern in the Arab States is much closer to the West European than to the East European pattern, allowing for the generally higher level of mortality in these countries. Plotting on the same scale, we can see there is far less variation in female life tables, and far less of a contrast between Eastern and Western Europe. On the other hand a number of states, in particular Gulf and North African States show high partial life expectancy in mid-life relative to its level in childhood. 5 Conclusion The life table is undoubtedly one of the great steps forward in social sciences, for it provides us with a means of comparing the levels of mortality in different populations, irrespective of their age composition, and using no other information than current age-specific mortality rates. It does this by focussing on a hypothetical population, or cohort, and asks, what would happen if the mortality experience of the population at hand were to operate under these exceptional circumstances? The result is a synthetic measure of the average level of mortality in the population, based strictly on the mortality rates themselves. Using this synthetic measure we can compare the levels of mortality in a variety of different populations at the same and at different times, compare between the mortality of men and women, and so on. When we look at life expectancy over the past century and a half, in those countries for which such data is available at least, we see a continuous trend of mortality decline. We also see a remarkable convergence in the levels of mortality in these countries, and a decrease in between-country variation, a convergence which appears quite independent of the particular pace and nature of each country's transition from a traditional agricultural to an industrial market economy. In the more recent past, since the Second World War, we can see that this conclusion can be generalised to all the countries of Western Europe, those on the western side of the old Iron Curtain. However, mortality decline in Eastern Europe and the countries of the Soviet Union has followed a different path. For women the general trend of decline has been very similar to that in the West, but rather than a convergence there has been a growth in disparities between the countries of the ex-Soviet Union and the ex-Communist countries of East European. The mortality of men in Eastern Europe, as expressed in their life expectancy at birth, has followed an even more divergent path. Over the first 40 years, in effect until the collapse of Communism, the various countries all followed the same path of a stagnated life expectancy. Since the early 1990's there has been a growing divergence between them. Some countries, particularly those of the ex-USSR, have seen a dramatic reduction in life expectancy at birth, with some recovery in recent years. Others, on the hand, have moved in a Western style of mortality decline, in particular Slovenia and the Czech Republic. A population's mortality, however, cannot be simply summarised in one figure, the life expectancy at birth. Although there is, in general, a close relation between mortality levels at different ages, it is important to distinguish between mortality at young ages and that at mid-adult ages. At young ages the individual is subject to external forces beyond his or her control, be they material standards of living, of sanitation or the physical environment that controls the risk of accidental, violent death. The mortality level at these ages, therefore, represents the mortality (or survivorship) potential of that population in the particular circumstances in which it lives. At later ages, however, and in particular in the middle years of adult life, other forces come into play. Specifically, individual behaviours may attenuate or exacerbate environmental threats, and these in turn will be related to such psychological aspects of the situation as hope, despair and the individual’s sense of the world as comprehensible, manageable and meaningful (Antonovsky, 1972, 1979). When we break down mortality into young and middle-age components, we see that at young ages Eastern Europe very much followed the western pattern. Partial life expectancy in the years 0 to 15 has increased, and differences between the different countries have narrowed, even though variation is still greater than in the West. When we consider mid-life mortality, however, the partial life expectancy between ages 35 to 60, a different story emerges. In the West, PLE35-60 has increased, the differences between the countries have decreased, particularly for women, and all countries now lie in a very narrow band closely approaching the maximum value of 25 years. In the East, by contrast, there have been large divergences, between men and women, and between the different countries. For women, the PLE has increased slightly, but there has been a growing divergence, in particular between the countries of the ex-Soviet Union and those of Eastern Europe. For the men, PLE declined in most countries until the mid-1990's, particularly, but not only, in the ex-Soviet Union, and only in the past decade has there been some recovery in some countries. Two important exceptions here are Albania, which has maintained a high PLE35-60 throughout this period, and Slovenia, which has shown a dramatic increase since the mid 1980's. On the other hand, Ukraine, Belarus and Moldova have only just begun to show signs of recovery after a very dramatic decline in PLE. Reliable data on the countries of the Arab Middle East are still rather limited, and much of what we know is based on models and reconstructions rather than hard data. The area is very heterogeneous however. In the Afro-Arab countries, the second line of countries south of the Mediterranean coastline, mortality has essentially stagnated and there have been only minor improvements in the past 20 years, both overall and within specific age bands. By contrast, the oil-rich Gulf States have reduced mortality to the point where male mortality matches that of Western Europe, with the countries of the Mediterranean basin following behind. These advances have benefited men more than women, so that female levels of mortality are closer to those of Eastern than of Western Europe. Nonetheless, it would appear that the decline in mortality is to be seen at young as well as at older ages, so that the general pattern is much closer to that of Western Europe - though still with a lag - than to that of Eastern Europe. The comparison with mortality developments in the Middle East bring out the tragedy of Eastern Europe, and of the countries that once comprised the Soviet Union in particular. Mortality in the Middle East is still higher than in Western Europe, and the small gender-gap in mortality means that the disadvantage is particularly acute for women. On the other hand the relation of young to middle age PLE's shows the relation to be following the West European pattern, so that whatever the survivorship potential is in these countries (and there is considerable variation), the potential exhibited at younger years is largely being realised at later years. In Eastern Europe there has been a collapse, but as developments for young children and for women show, what these countries have suffered is not a total collapse of the mortality system. Mortality at young ages, and female mortality in middle life, have followed the path of the Western Countries, with very little delay. The tragedy is that of the adult men, whose life expectancy not only has not kept pace with advancements at young ages and among the women, it has in many cases seriously deteriorated. Consequently, even as the potential for a long life has developed, the actual realisation of this potential has receded. This is true for most of Eastern Europe, it is particularly true for the countries of the Soviet Union. Whatever our views on the events that occurred in Russia after the First World War, it must be considered one of the major tragedies of the twentieth century that a movement and a revolution that were born in hope, that served as an inspiration for so many Western intellectuals critical of their own society, created, and has left in its wake, a society in which so many millions of men have died and continue to die prematurely. References Anson, J., 2010, Beyond Material Explanations: Family Solidarity and Mortality, a Small Area-level Analysis, Population and Development Review, 36(1): 27-45. Antonovsky, A. 1972, Breakdown: A needed fourth step in the conceptual armamentarium of modern medicine, Social Science & Medicine, 6: 537–544 Antonovsky, A. 1979, Health, Stress and Coping, San Francisco: Josey-Bass. 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A., 2012, Economic crises: Some thoughts on why, when and where they (might) matter for health -- A tale of three countries, Social Science & Medicine 74: 643-646 Leon, D., 2011, Trends in European life expectancy: a salutary view, International Journal of Epidemiology, 40: 271–277 Lopez, A. D., Salomon, J. A., Ahmad, O. B., Murray, C. J. L. & Mafat, D. 2001, Life tables for 191 countries : data, methods and results, Geneva: World Health Organization Marmot M. 2004, The Status Syndrome. New York, NY: Henry Holt. 14. Musick, M. A., House, J. S. & Williams, D. R. 2004, Attendance at Religious Services and Mortality in a National Sample, Journal of Health and Social Behavior, 45(2): 198-213. Oeppen, J. & Vaupel, J. 2002, Broken Limits to Life Expectancy, Science, 296(5570): 1029-1031 Power, C. & Elliott, J. 2006, Cohort profile: 1958 British birth cohort (National Child Development Study), International Journal of Epidemiology, 35: 34–41 Shryock, H. S., Siegel, J. S. & Larmon, E. A. 1980, The methods and materials of demography, Washington, D.C.: U.S. Bureau of the Census, Vol. 2, H. 15, pp. 429-461. Stuckler, D., King, L. K. & McKee, M., 2009, Mass privatisation and the post-communist mortality crisis: a cross-national analysis, The Lancet, 373(9661): 399 - 407 Vallin, J. & Meslé, F. 2009, The Segmented Trend Line of Highest Life Expectancies, Population and Development Review, 35(1):159–187. Wilkinson, R. & Pickett, K. 2009, The Spirit Level: Why More Equal Societies Almost Always Do Better, London: Allen Lane. Winter, J. M. 1985, The Great War and the British People, London: Macmillan
© Professor Jon Anson 2012
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