Weeks (2007), hal 146-148, 159-174, 182-185, 188-194.

It isn’t that people now breed like rabbits, it’s that we no longer die like flies— declining mortality, not rising
fertility, is the root cause of the revolutionary in- crease in the world’s population size and growth over the past two
centuries. Only within that time has mortality been brought under control to the point that most of us are now able to
take a long life pretty much for granted. Human triumph over disease and early death represents one of the most
significant improvements ever made in the condition of human life and is tightly bound up in all other as- pects of
the vastly higher standard of living that we now enjoy. Nevertheless, an important unintended by-product of
declining mortality is the mushrooming of the human population from just one billion two hundred years ago to an
expected nine billion by the middle of this century. This increase has literally changed every- thing in the world, and
you cannot fully understand the world in which you live without knowing how the health and mortality transition
came about and what this means for the future.

I begin the chapter with a brief description of the health and mortality transi- tion and then illustrate its impact by
reviewing the changes in health and mortality over time, up to the present. The transition is by no means over,
however, so I next consider how far it can go, given what we know about human life span and longevity, and about
the things that can and do kill us and what we are doing about them. We will measure the progress of the transition
using a variety of indices that I review in the chapter, and I employ some of those tools in the last part of the chap-
ter to examine important inequalities that exist in the world with respect to health and mortality.

Defining the Health and Mortality Transition

Health and death are really two sides of the same coin—morbidity and mortality, re- spectively—with morbidity
referring to the prevalence of disease in a population and mortality the pattern of death. The link is a familiar one to
most people—the healthier you are, the longer you are likely to live. At the societal level, this means that
populations with high mortality are those with high morbidity; therefore, as health levels improve, so does life
expectancy. Most of us in the richer countries take our long life expectancy for granted. Yet scarcely a century ago,
and for virtually all of human history before that, death rates were very high and early death was com- monplace.
Within the past 200 years, and especially during the twentieth century, country after country has experienced a
transition to better health and lower death rates—a long-term shift in health and disease patterns that has brought
death rates down from very high levels in which people die young, primarily from communica- ble diseases, to low
levels, with deaths concentrated among the elderly, who die from degenerative diseases. This phenomenon was
originally defined by Omran (1971; 1977) as the “epidemiological transition,” but since the term “epidemiol- ogy”
technically refers only to disease and not to death, I have chosen to broaden the term to the health and mortality
transition.

As a result of this transition, the variability by age in mortality is reduced or compressed, leading to an increased
rectangularization of mortality. This means that most people survive to advanced ages and then die pretty quickly
(as I will discuss in more detail later in the chapter). The vast changes in society brought about as more people
survive to ever older ages represent important contributions to the overall de- mographic transition. We can begin to
understand this most readily by examining how health and mortality have changed dramatically during the course of
human history, especially European history, for which we tend to have better data than for the rest of the world.

Health and Mortality Changes Over Time

In much of the world and for most of human history, life expectancy probably fluc- tuated between 20 and 30 years
(United Nations 1973; Weiss 1973). At this level of mortality, only about two-thirds of babies survived to their first
birthday, and only about one-half were still alive at age five, as seen in Table 5.1. This means that one- half of all
deaths occurred before age five. At the other end of the age continuum, around 10 percent of people made it to age
65 in a premodern society. Thus, in the premodern world, about one-half the deaths were to children under age five
and only about one in 10 were to a person aged 65 or older.
In hunter-gatherer societies, it is likely that the principal cause of death was poor nutrition—people literally starving
to death—combined perhaps with selective infanticide and geronticide (the killing of older people) (McKeown
1988), although there is too little evidence to do more than speculate about this (Livi-Bacci 1991). As humans
gained more control over the environment by domesticating plants and ani- mals (the Agricultural Revolution), both
birth and death rates probably went up, as I mentioned in Chapter 2. It was perhaps in the sedentary, more densely
settled vil- lages common after the Agricultural Revolution that infectious diseases became a more prevalent cause
of death. People were almost certainly better fed, but closer contact with one another, with animals, and with human
and animal waste would encourage the spread of disease, a situation that prevailed for thousands of years.

Disease and Death Over the Life Cycle

Age Differentials in Mortality

Disease and death are not randomly distributed across the life cycle. Humans are like most other animals with
respect to the general pattern of death by age—the very young and the old are most vulnerable, whereas young
adults are least likely to die. In Figure 5.3, you can see that the pattern of death by age is similar whether the actual
death rates are high or low. After the initial year of life, there is a period of time, usually lasting at least until middle
age, when risks of death are relatively low. Beyond middle age, mortality increases, although at a decelerating rate
(Manton and Land 2000; Manton, Stallard, and Corder 1997).

The genetic or biological aspects of longevity have led many theorists over time to believe that the age patterns of
longevity shown in Figure 5.3 could be explained by a simple mathematical formula similar perhaps to the law of
gravity and other laws of nature. The most famous of these was put forward in 1825 by Benjamin Gompertz and
describes a simple geometric relationship between age and death rates from the point of sexual maturity to the
extreme old ages (Olshansky and Carnes 1997). These mathematical models are interesting, but they have so far not
been able to capture the actual variability in the human experience with death. Part of the problem, as we are
reminded by Carey and Judge (2001), is that we may know what kills us, but we are less certain about what it is that
allows us to survive. This is why, even if we were able to rid ourselves of all diseases, we do not know how long we
might live. We do know, however, that since our susceptibility to dis- ease and death varies over the life cycle, it is
important to look at those differences in more detail.

Infant Mortality There are few things in the world more frightening and awesome than the responsibility for a
newborn child, fragile and completely dependent on others for survival. In many societies, the fragility and
dependency are translated into high infant mortality rates (the number of deaths during the first year of life per
1,000 live births). Infant death rates are closely correlated with life ex- pectancy, and Figure 5.4 shows the infant
mortality rates for a sample of coun- tries around the world. Japan and Sweden have had the world’s lowest rates of
infant mortality among the more populous countries for a number of years and both have rates that are now below
three deaths per 1,000 live births. All western European countries have rates that are below four per 1,000. Canada’s
rate is slightly above five per 1,000, whereas the United States has a slightly higher rate of just under seven per
1,000. Mexico’s level of 21 per 1,000 is obviously higher, but it is still well below the world average of 52 per
1,000. By contrast, in some of the less-developed nations, especially in equatorial Africa, infant death rates are as
high as 163 deaths per 1,000 live births. That figure is for Sierra Leone as of 2006, plagued by drought and famine
and in a region of the world that has some of the highest mortality rates ever recorded for a human population (Mc-
Daniel 1992).

Why are babies so vulnerable? One of the most important causes of death among infants is dehydration, which can
be caused by almost any disease or dietary imbalance, with polluted water being a common source of trouble for
babies. How can dehydration and other causes of death among infants be avoided? In the broad- est sense, the
answer can be summed up by two characteristics common to people in places where infant death rates are low—
high levels of education and income. These are key ingredients at both the societal level and the individual level. In
general, those countries with the highest levels of income and education are those with enough money to provide the
population with clean water, adequate sanitation, food and shelter, and, very importantly, access to health care
services.
At the individual level, education here can refer simply to knowledge of a few basic rules that would avoid
unnecessary infant death. Afghanistan has one of the highest infant death rates and the highest maternal mortality
rate in the world. An important reason is that the lack of medical facilities in that country means that most births are
attended by a traditional midwife who may be “dangerously ignorant. Some refuse to tie umbilical cords, so that
‘dirty’ blood can flow from the baby. Others seek to cure infections by placing dead mice—and other treats—in the
vagina. Many insist babies be born in a bowl of dirt. Tetanus contracted by newborns from the dirt is dismissed as
demonic possession” (The Economist 2003:42).

Higher incomes increase the chance that babies will have a nutritious, sanitary diet that prevents diarrhea, an
important cause of death among infants. Nursing mothers can best provide this service if their diet is adequate in
amount and quality. Income is also frequently associated with the ability of a nation to provide, or an individual to
buy, adequate medical protection from disease. In places where infant death rates are high, communicable diseases
are a major cause of death, and most of those deaths could be prevented with medical assistance. We know, for
example, that between 1861 and 1960 the infant death rate in England and Wales dropped from 160 to 20 and more
than two-thirds of that decline was due to the control of communicable diseases.

Throughout the world, infant health has been aided especially by the fact that the World Health Organization of the
United Nations has promoted the use of oral rehydration therapy (ORT), which involves administering an
inexpensive glucose and electrolyte solution to replenish bodily fluids. Oral rehydration therapy was first shown to
be effective in clinical trials in Bangladesh in 1968 (Nalin, Cash, and Islam 1968), and it has proven to be very
effective in controlling diarrhea among in- fants (and adults as well) all over the world (Centers for Disease Control
and Pre- vention 1992), as I mentioned earlier.

When infant mortality drops to low levels, such as in advanced nations like the United States and Canada,
prematurity becomes the single most important reason for deaths among infants, and in many cases prematurity
results from lack of proper care of the mother during pregnancy. Pregnant women who do not maintain an ade-
quate diet, who smoke, take drugs, or in general do not care for themselves have an elevated chance of giving birth
prematurely, thus putting their baby at a distinct dis- advantage in terms of survival after birth. Throughout the
world, the infant mortal- ity rate is a fairly sensitive indicator of societal development because as the standard of
living goes up, so does the average level of health in a population, and the health of babies typically improves earlier
and faster than of people at other ages. This greater ability to resist death past infancy generally holds up throughout
the repro- ductive years (with the exception of maternal mortality, which I discuss below), but beyond that time of
life, death rates start to increase.

Mortality at Older Ages It has been said that in the past parents buried their chil- dren; now, children bury their
parents. This describes the health and mortality tran- sition in a nutshell. The postponement of death until the older
ages means that the number of deaths among friends and relatives in your own age group is small in the early years
and then accumulates more rapidly in the later decades of life. But even at the older ages, there are revolutionary
changes taking place in death rates. In the more developed countries of the world, the risk of death has been steadily
going down even at the very oldest ages. We have not yet unlocked the key to living be- yond age 122, but we are
pushing toward the day when a large fraction of people will approach that age before they die.

As life expectancy has increased and people survive in greater proportions to older ages, societies experience less
variability in the ages at which their members die. Instead of people being likely to die at almost any age (even if
most at risk when young or old), death gets compressed into a narrow range of ages. Wilmoth and Horiuchi (1999)
cal- culated, for example, that the variability in ages at death in Sweden in the 1950s was only about one-fourth of
what it had been 100 years before that. The result of this compression of death into a narrow range at the older ages
is called rectangularization (Comfort 1979; Fries 1980). This means that the curve of the proportion of people
surviving to any given age begins to square off, rather than dropping off smoothly. Figure 5.5 gives you an example
of this using data for females in the United States.

Going back to 1901–10, Figure 5.5 shows that the proportion surviving drops off fairly quickly at the younger ages
because of high infant and child mortality and then it drops off fairly smoothly after that until everybody has died
off at around 100. By the middle of the twentieth century, in 1951–60, the proportions alive at each successive age
are noticeably larger than they were at the beginning of that cen- tury, and the trend continued on to the end of the
century. An almost totally rectan- gular situation is shown as the extreme case in Figure 5.5. If everyone survived to
age 100, and then died quickly after that, mortality would be compressed into a very short time period, and the
survival curve would be squared off at the oldest ages, as you can see. In general, the limited data available seem to
support the idea that com- pression and rectangularization are occurring (see, for example, Kannisto 2001; Wilmoth
and Horiuchi 1999), although not everybody agrees (Lynch and Brown 2001). The principal argument against it is
that it assumes a fixed human life span of around 120 years. If we are somehow able to crack that barrier, then
people could live to increasingly older ages, which would “decompress” mortality and smooth out the mortality
curve at the older ages (Caselli and Vallin 2001).

Even if we are never able to crack the 120-year barrier, one of the most dramatic changes in mortality in richer
countries over the past few decades has been the drop in death rates at the older ages. It is not simply that deaths are
being compressed into a relatively short period in old age; that age has been getting progressively older. Consider
that in 1900 a woman who reached age 65 in the United States could expect to live another 12 years. At the time of
World War II that had increased a bit to 14 years, but by 2003 it was up to 20 years (U.S. Centers for Disease Con-
trol 2007). These things may not matter much to you now, but as you approach old age, you’ll start to give them
more thought.

Sex and Gender Differentials in Mortality

Although the age pattern of death is the most obvious way in which biology affects our lives, it is also true that at
every age there are differences between males and fe- males in the likelihood of death. Some of these differentials
seem to be strictly bio- logical in origin (the “sex” differences) whereas others are induced by society (the “gender”
differences), although it is not always easy to tell the difference between the biological and social influences.

The most basic health difference between males and females is that women gen- erally live longer than men do, and
the gap had been widening until recently. In 1900, women could expect to live an average of two years longer than
men in the United States, and by 1975, the difference had peaked at 7.8 years. Since then, the difference has dropped
to 5.8 years as of 2007, but the survival advantage of women is nearly universal among the nations of the world.
Canada has followed a similar pattern, with a 1.8-year advantage in 1920 expanding to a 7.2-year advantage in 1980
before dropping back slightly to a 6.9-year advantage in 2007 (U.S. Census Bureau 2007). Mexico is in catch-up
mode with respect to life expectancy, but not in terms of the sex difference in life expectancy. In 1960, for example,
women in Mex- ico had a life expectancy that was about the same as it had been in Canada and the United States
back in 1920, and their advantage over men was 3.2 years. By 2007, female life expectancy in Mexico had reached
the level of Canada and the United States in 1980, and the advantage for women was 5.7 years. However, for
Mexico, as well as the U.S. and Canada, the biggest gender gap (6.8 years) was experienced in 1980, and it has been
declining a bit since then.

The difference in life expectancy between males and females has attracted cu- riosity for a long time, and it has been
suggested facetiously that the early death of men is nature’s way of repaying those women who have spent a lifetime
with demanding, difficult husbands. However, the situation has been more thoroughly investigated by a variety of
researchers. It is possible, perhaps even probable, that a real biological superiority exists for women in the form of
an immune function, perhaps imparted by the hormone estrogen (1983; Waldron 1986); but it is very difficult to
measure this biological advantage (Vallin 1999). Nonetheless, a bio- logical interpretation of the difference is
supported by studies showing that throughout the animal kingdom females survive longer than males (Retherford
1975), suggesting some kind of basic biological superiority in the ability of females to survive relative to males
(biologists refer to this as an aspect of sexual dimorphism).

In human populations, the survival advantage of women is widespread, but it is not quite universal. In fact, as of
2007, there were still several countries—all in sub- Saharan Africa—where life expectancy for females was the
same as or lower than that for males. This implies that there are also social factors operating. One such factor is the
status of women. It is in those countries where women are most domi- nated by men that women have been least
likely to outlive men (Cardenas and Ober- meyer 1997). In sub-Saharan Africa this shows up in the victimization of
women by men who have HIV but force women to have unprotected sex with them. In south Asia, it is noticeable at
the younger ages, when girls are fed less well than boys, and parents are less likely to seek health care for sick girls
than for sick boys (Muhuri and Preston 1991; Yount 2003).

The social aspect of mortality also shows up in what is probably the most plau- sible explanation for the widening
and then narrowing of the gap in mortality be- tween men and women over the course of the twentieth century—
smoking. Since 1900, males have smoked cigarettes much more than have females, and this has helped to elevate
male risks of death from cancer, degenerative lung diseases (such as chronic bronchitis and emphysema), and
cardiovascular diseases (Preston 1970). However, cigarette smoking by women increased after World War II, and by
now women are nearly as likely as men to be smokers (the smoking version of gender equality). Deaths associated
with smoking tend to occur many years after smoking begins, so the result of women’s post–World War II smoking
habits has been a pre- dictable recent rise in death rates from lung cancer, which has helped to narrow the gap in
male-female mortality (Preston and Wang 2006). Rogers and Powell-Griner (1991) calculated that males and
females who smoke heavily have similar (and lower-than-average) life expectancies, but nonsmoking males still
have lower life ex- pectancies than nonsmoking females (although still higher than smokers). Overall, Rogers and
his colleagues (2000) estimate that smoking accounts for 25 percent of the gender gap.

Causes of Poor Health and Death

The things that make us sick and can kill us have been wrapped into virtually every paragraph up to this point, but it
is useful to discuss them in a more systematic fash- ion, keeping in mind that this is only a brief review of an
incredibly complex field of study. The World Health Organization puts deaths into one of three major cate- gories:
(1) communicable, maternal, perinatal, and nutritional conditions; (2) non- communicable diseases; and (3) injuries.
Within each of these categories are sub-groups, as shown in Table 5.3, and as discussed below.

Communicable Diseases

For most of human history, infectious diseases have been the major cause of death, killing people before they had a
chance to die of something else. Infectious diseases include bacterial (such as tuberculosis, pneumonia, and the
plague), viral (such as influenza and measles) and protozoan (such as malaria and diarrhea). They are spread in
different ways (by different vectors), and have varying degrees of severity. You can see in Table 5.3 that they
account for one-third (32.1 percent) of all deaths in the world, but the higher the life expectancy, the less important
are these diseases as causes of death.

Tuberculosis is an example of a bacterial infection that still kills 1.5 million peo- ple each year, despite the known
treatments for it, and it is estimated that ten times that number of people are infected with the disease worldwide but
do not show symptoms. The World Health Organization has a “Stop TB Department” and the U.S. Centers for
Disease Control have a “Division of TB Elimination,” but the dis- ease remains untreated in many parts of the
world. In Table 5.3 you can see, for ex- ample, that it accounts for more than four percent of all deaths in a very
poor country such as Afghanistan. Somalia is actually the country that has the highest death rate from TB, and eight
of the top ten countries with respect to TB are in sub- Saharan Africa. Some drug-resistant strains of TB have
emerged, and preventing the spread of these forms of the disease is clearly an important issue in the world. China,
for example, has discovered that many migrants from the countryside to cities are infected with tuberculosis and
have stopped taking the months-long treatment course. The surviving germs from these uncompleted treatments are
the ones that are strongest and most resistant to drugs and it is their spread that is particularly worrisome (Zamiska
2006).

Measles is an example of an acute viral disease that is severe in infancy and adulthood but less so in childhood. It is
usually spread by droplets passed through the air when an infected person coughs or sneezes. If left untreated in an
infant or adult, the chance of death is 5–10 percent. Vaccinations now protect most people in the developed world
from measles, and the United Nations has been working to in- crease immunization elsewhere. The countries with
the highest death rates from measles are Guinea-Bissau, Niger, and Somalia. All of the top ten countries in terms of
measles death rates are in sub-Saharan Africa.
Malaria is an example of a complex protozoan disease typically spread by mos- quitoes first biting an infected
person. Then the blood from the malarial person spends a week or more in the mosquito’s stomach, where the
malarial spores de- velop and enter the mosquito’s salivary gland. The disease is passed along with the mosquito’s
next bite to a human. The probability of dying from untreated malaria is more than 10 percent (Heymann 2004). The
countries with the highest death rates from Malaria are Liberia, Niger, and Burkina Faso—all in west Africa. The
top ten countries in terms of death rates from malaria are in sub-Saharan Africa, mainly West Africa.

HIV/AIDS Five percent of all deaths in the world are related to HIV/AIDS, but you can see in Table 5.3 that in
Botswana, as in a few other sub-Saharan African coun- tries, an astounding 80 percent of all deaths are HIV/AIDS-
related, dropping life ex- pectancy to only 35 years—a level that Europeans haven’t seen since the Middle Ages.
HIV/AIDS literally exploded on the scene in the early 1980s to become a worldwide pandemic. UNAIDS (the Joint
United Nations Programme on HIV/AIDS) estimates that there are nearly 40 million people in the world who have
HIV/AIDS, and that each year there are 4 million new infections and nearly 3 mil- lion deaths (UNAIDS 2007). The
disease appears to have the potential to kill virtu- ally everyone who develops its symptoms, unless an infected
person is treated with antiretroviral drugs that slow down the progression of HIV to AIDS. However, it has been
estimated that the lifetime cost of caring for someone with HIV in the United States is at least $300,000 (Schackman
et al. 2006), underlining the impor- tance of prevention, rather than taking a chance that if you get the disease you
can be effectively treated. The spread of HIV can be prevented, as you undoubtedly know, especially by using
condoms during intercourse and by not sharing needles to inject drugs. These relatively simple control measures
have been very effective in North America and Europe, but they have been slow to catch on in sub-Saharan Africa,
where prevalence rates and new infection rates are by far the highest in the world. Although HIV prevalence rates
are still fairly low in Asia and North Africa, they are nonetheless rising in those areas of the world because
governments have been slow to recognize and respond to local risks of transmission among injection drug users,
prostitutes, and men having sex with men.

In North America and Western Europe, the openness with which AIDS has been discussed has helped to slow down
the spread of the disease by encouraging the use of condoms or even abstinence and by increasing the chance that
someone infected with HIV will seek treatment that may forestall or perhaps even prevent HIV from progressing to
AIDS and premature death. But in much of the rest of world, includ- ing Eastern Europe, Asia, and especially
Africa, the situation is dramatically differ- ent because the vast majority of people who are infected with HIV either
do not know of or do not acknowledge their infection, so they continue to spread the dis- ease to others.

In sub-Saharan Africa, women are as likely as men to be infected, since the dis- ease is spread largely through
heterosexual intercourse. The difference between sub- Saharan Africa and much of the rest of the world appears to
be related to the fundamentally different pattern of sexual networking prevalent throughout the re- gion. Premarital
and extramarital sexual intercourse have long been fairly common in sub-Saharan Africa. Factors that seem to
encourage these sexual patterns include long periods of postpartum abstinence on the part of women, which may
encourage males to seek sexual encounters elsewhere; polygyny, which institutionalizes male sexual
adventurousness; and the low status of women, which forces them to be sex- ually submissive, all compounded by
high rates of male migration for employment, which separates husbands and wives for long periods of time and
encourages men, in particular, to have intercourse with other partners (Caldwell 2000). In such an en- vironment,
any sexually related disease has increased opportunities for transmission through heterosexual channels. Other
sexually transmitted diseases are already much more prevalent in sub-Saharan Africa than elsewhere in the world,
and the open sores associated with those diseases increase the risk of HIV transmission.

Probably the most disturbing aspect of AIDS in Africa has been the widespread denial of the disease’s existence,
and the general lack of political support for putting prevention programs into place. In particular, condom use in
Africa has been slowed down by suspicions that condoms themselves carried the disease, and by cultural norms that
associate the use of condoms with prostitution, thus limiting their use within marriage, even though one or both
partners in a marriage may have been at risk for HIV due to their own extramarital sexual activity (Messersmith et
al. 2000). Added to this was the belief of President Mbeki of South Africa that AIDS was not caused by HIV. This
slowed down the government response in that country until 2003, when a report by former president Nelson
Mandela finally forced Mbeki to change his position and respond to the serious problem of HIV/AIDS.
The impact of AIDS on sub-Saharan Africa is devastating. Since people of re- productive age are the principal
victims, the disease has created millions of orphans in Africa. When the disease first hit Africa, it was called the
“slim” disease, because sufferers lost so much weight as a result of the infection. Over time, it has been transformed
into the “grandmother’s disease” because it falls upon the older women to care for the orphans, as well for the sick
and dying. In the Americas, the highest prevalence of HIV/AIDS is found in Haiti, where the sexual networking
patterns are similar to those in sub-Saharan Africa.

Emerging Infectious Diseases Just as malaria may have emerged when humans cleared forests and settled into
agricultural villages (Pennisi 2001), so it is that the desire of humans to add more animal protein to their diet may be
creating opportu- nities for coronaviruses (animal viruses) to be spread to humans. It is generally be- lieved that HIV
crossed to humans from monkeys and/or chimpanzees (de Groot et al. 2002; Gao et al. 1999), and the evidence
suggests that SARS (severe acute respi- ratory syndrome) may have come from animals captured for food in China
(Lin- gappa et al. 2004).

Birds can also be sources of disease. Although West Nile virus has existed in Africa and the Middle East for
decades, it was brought to New York City in 1999, apparently by an imported infected bird that was bitten by a
mosquito which then bit a human who became sick and died. It has since spread to other communities all over the
country. Then, late in 2003, a new H5N1 avian influenza (popularly called “bird flu”) was reported in Asia and has
to date killed dozens of people (World Health Organization 2007). This is a disease that originated in Asian poultry
farms, especially in Indonesia and Vietnam, and has now crossed over to humans and keeps cropping up in different
places around the world, spread especially by migratory birds.

Maternal Mortality A very special category of infectious diseases is that associated with pregnancy and childbirth.
Birth can be a traumatic and dangerous time not only for the infant, as discussed above, but for the mother as well.
More than half a million women die each year from maternal causes—the equivalent of three jumbo jets crashing
each day and killing all passengers. These deaths leave a trail of tragedy throughout the world, but
disproportionately so in less-developed nations, where pregnancies are more frequent among women and health care
systems are less adequate. There are three factors, in particular, that increase a woman’s risk of death when she
becomes pregnant: (1) lack of prenatal care that might otherwise identify problems with the pregnancy before the
problems become too risky; (2) de- livering the baby somewhere besides a hospital, where problems can be dealt
with immediately; and (3) seeking an unsafe abortion because the pregnancy is not wanted (Reed, Koblinsky, and
Mosley 2000; Salter, Johnston, and Hengen 1997; Shiffman 2000).

Women are obviously only at risk of a maternal death if they become preg- nant, and maternal death rates attempt to
take that risk into account. We do not have good data on the number of pregnancies, however, so we must use the
num- ber of live births as an estimate of how many pregnancies there are within a group of women. Thus, the
maternal mortality ratio measures the number of maternal deaths per 100,000 live births. Estimates by the World
Health Organization (2004) indicate that the world average is 400 deaths to women per 100,000 live births. In the
United States, however, the figure is 17 per 100,000 and it is even lower (6) in Canada, though it is higher in Mexico
(83). The lowest levels are in Europe, while the highest levels of maternal mortality are found in sub-Saharan Africa,
led (if that is the right word) by Sierra Leone, with a ratio of 2,000 mater- nal deaths per 100,000 live births. Outside
of Africa, the highest rate, by far, is in Afghanistan.

Another way of measuring maternal mortality that takes into account the num- ber of pregnancies a woman will
have is to estimate a woman’s lifetime risk of ma- ternal death. As a woman begins her reproductive career by
engaging in intercourse, the question asked is: What is the probability that she will die from complications of
pregnancy and childbirth? This risk represents a combination of how many times she will get pregnant and the
health risks she faces with each pregnancy, which are influenced largely by where she lives. For the average woman
in the world, that probability is .014, or one chance in 74, but for women in sub-Saharan Africa, the risk is one in 16
(World Health Organization 2004). Looked at another way, if you line up 16 young African women, statistically one
of them will wind up dying of maternal-related causes. In Sierra Leone (as in Somalia and Afghanistan), the risk is 1
in 6. By contrast, the risk is only 1 in 8,700 in Canada; 1 in 2,500 in the United States; and 1 in 370 in Mexico.

Noncommunicable Conditions
In American medicine, “[C]hronic diseases have been referred to as chronic illnesses, noncommunicable diseases,
and degenerative diseases. They are generally character- ized by uncertain etiology, multiple risk factors, a long
latency period, a prolonged course of illness, noncontagious origin, functional impairment or disability, and in-
curability” (Taylor et al. 1993). As you already know, as we move through the health and mortality transition, these
diseases take precedence over communicable diseases as the important causes of death. As you can see looking back
at Table 5.3, noncommunicable diseases account for 59 percent of all deaths in the world, and in the United States,
they are responsible for nearly 9 out of every 10 (87.6 percent) deaths.

It is also apparent in Table 5.3 that cardiovascular diseases and malignant neo- plasms (cancer) are the major killers
among the degenerative diseases. Cardiovascu- lar diseases include especially the conditions that lead to heart attack
or stroke. Deaths from coronary heart disease occur as a result of a reduced blood supply to the heart muscle, most
often caused by a narrowing of the coronary arteries, which can be a consequence of atherosclerosis, “a slowly
progressing condition in which the inner layer of the artery walls become thick and irregular because of plaque—de-
posits of fat, cholesterol, and other substances. As the plaque builds up, the arteries narrow, the blood flow is
decreased, and the likelihood of a blood clot increases” (Smith and Pratt 1993). Stroke is part of the family of
cardiovascular diseases, but whereas heart disease produces death by the failure to get enough blood to the heart
muscle, stroke is the result of the rupture or clogging of an artery in the brain. This causes a loss of blood supply to
nerve cells in the affected part of the brain, and these cells die within minutes.

Malignant neoplasms represent a group of diseases that kill by generating un- controlled growth and spread of
abnormal cells. These cells, if untreated, may then metastasize (invade neighboring tissue and organs) and cause
dysfunction and death by replacing the normal tissue in your vital organs. In the United States, lung cancer is
responsible for more cancer deaths than any other type, almost certainly reflecting the fact that as recently as 40
years ago more than 50 percent of men and nearly one-third of women were regular cigarette smokers. If a person is
going to smoke, they will probably start as a teenager, a time when they are healthy enough not to be negatively
affected by smoking. The ill effects of smoking take time to catch up with you, so lung cancer rates are high in the
United States despite the rapid decline in smoking over the past few decades. China is currently confronting the fact
that its smoking-related diseases and deaths are on the rise and there are now more smokers in China than there are
people in the United States (Fairclough 2007).

The other important cancers in the United States are colon and rectal cancer, breast cancer, and prostate cancer.
According to the National Cancer Institute, skin cancer is one of the more rapidly growing malignancies in the
United States, encour- aged by long exposure to the sun, but because treatment is available it has not be- come an
important cause of death, despite its increased incidence. Another treatable form of cancer that nonetheless
continues to kill women is cervical cancer. This dis- ease reminds us of the complexity of trying to categorize illness
and cause of death, because cervical cancer is caused by an infection of the human papillomavirus (HPV), which is a
sexually transmitted infection (STI), a category that includes gon- orrhea, syphilis and, of course, HIV/AIDS. Not
surprisingly, then, AIDS is also asso- ciated with certain malignancies such as Kaposi’s sarcoma.

Another noncommunicable condition that is an important cause of death is res- piratory disease (not including TB).
This is a family of problems, including bronchi tis, emphysema, and asthma. The underlying functional problem is
difficulty breath- ing, symptomatic of inadequate oxygen delivery. Also on the list is diabetes mellitus, a disease that
inhibits the body’s production of insulin, a hormone needed to convert glucose into energy. Like most of the other
degenerative diseases, diabetes is part of a group of related diseases, all of which can lead to further health
complications such as heart disease, blindness, and renal failure. Finally, let me note that the rela- tively large
fraction (6.4 percent) of deaths in the U.S. due to “neuropsychiatric dis- orders” does not mean that Americans are
going crazy and then dying. Rather, it reflects the diagnosis of death from Alzheimer’s Disease, which is a disease
involving a change in the brain’s neurons, producing memory loss and behavioral shifts in its victims. This is a
major cause of organic brain disorder among older people and the aging of the American population has put more
people in its path. You will notice that Japan has an even older population than does the U.S., yet Alzheimer’s is less
important as a cause of death, whereas respiratory diseases are more important in Japan than in the U.S. This
comparison cautions us to remember, as I pointed out earlier, that there are many routes to low mortality.

Injuries
Despite the widespread desire of humans to live as long as possible, we have de- vised myriad ways to put ourselves
at risk of accidental or unintentional death as a result of the way in which we organize our lives and deal with
products of our tech- nology. Furthermore, we are the only known species of animal that routinely kills other
members of the same species (homicide) for reasons beyond pure survival, and we seem to be alone in deliberately
killing ourselves intentionally (suicide). These uniquely human causes of death are included among the top killers in
North America.

Though about half of all accidental deaths in the United States are attributable to motor vehicles, compared with
one-third in Canada and less than one-fifth in Mexico, in all three countries they are in the top five causes of death.
Each year there are tens of thousands of lives lost in traffic accidents in Canada, the United States, and Mexico; tens
of thousands more are injured and face permanent disabil- ity. These victims are disproportionately young males,
and alcohol is involved in a high, although declining, fraction of cases.

You can see in Table 5.3 that the World Health Organization estimates that about one million people commit suicide
each year, and it may be that as many as 20 times that number attempt to kill themselves (World Health
Organization 2002a). Suicide rates are highest by far in Eastern Europe, especially in Russia and several of the
countries that were part of the former Soviet Union. At least some of this is due to alcoholism, which also
contributes to the fact that a Russian man is ten times more likely to die accidentally or from violence than is a man
in the United Kingdom.

Throughout the world, suicide rates rise through the teen years (a phenomenon that has always received considerable
publicity), peak in the young adult ages, plateau in the middle years, and then rise in the older ages. Almost
universally among human societies, the suicide rate is considerably higher for males than for females (World Health
Organization 2002), and so around the world it is older men who are most prone to suicide. Beyond these general
patterns, however, the actual difference from one country to another in the suicide rate seems to be a cultural phe-
nomenon (Cutright and Fernquist 2000; Pampel 1996).

Men are not only more successful at killing themselves, they are also more likely to be killed by someone else.
Homicide rates are highest for young adult males in virtually every country for which data are available (World
Health Organization 2002b). In the United States in 2004, males were nearly four times more likely than females to
be homicide victims, with the homicide rate peaking in the young adult ages. Note that for white males the homicide
rate in 2004 was highest at ages 15–24 at 10 per 100,000. Among African American males the rate peaked at 25–34
at an astounding 82 homicides per 100,000 people. Hispanic males peaked at 15–24 with a rate of 30 per 100,000
(U.S. Centers for Disease Control 2007). Homicide death rates in the United States are higher than for any other
industrialized nation except Russia (Anderson, Kochanek, and Murphy 1997; World Health Organization 2002b),
possibly reflecting the cultural acceptance of violence as a response to con- flict (Straus 1983) combined with the
ready availability of guns (which are used in two-thirds of homicides in the United States). The remarkable contrast
between African American and white homicide rates within the United States has existed for decades and appears to
be most readily explained by the proposition that “economic stress resulting from the inadequate or unequal
distribution of resources is a major contribution to high rates of interpersonal violence” (Gartner 1990:95). Put
another way, a “subculture of exasperation” (Harvey 1986) promotes a “masculine way of violence” (Staples 1986).

War is the World Health Organization’s final category of cause of death, as you can see from Table 5.3. The number
killed in war does not take into account the in- juries and disruption that war causes, going well beyond what is
likely to be associ- ated with any other cause of death. The numbers in Table 5.3 are estimates from about the time
the U.S. invaded Iraq, so deaths from that conflict are not included. Estimating war deaths is not easy to do, but a
group of researchers at Johns Hopkins University used a cluster probability sample approach to interview nearly
2,000 households in Iraq about births and deaths prior to the U.S. invasion and subse- quent to the invasion. Their
estimates indicate that somewhere between 400,000 and 800,000 Iraqis have died violently as a result of the war
there (Burnham et al. 2006). This does not include the approximately 3,300 American soldiers who have died in Iraq
as of the time this book went to press. Most conflict in the world gets less publicity than the war in Iraq has, and
information from the Uppasla Conflict Database suggests that in 2005 there were 31 different armed conflicts in the
world (Harbom, Hogbladh, and Wallensteen 2006).
Other Applications of the Life Table

The life table as a measure of mortality is actually a measure of duration—of the length of human life. We can apply
the same techniques to measure the duration of anything else. Life table techniques have been used to study
marriage patterns (see Schoen and Weinick 1993), migration (see Long 1988), school dropouts, labor force
participation, fertility, family planning, and other issues (see Chiang 1984; Preston, Heuveline, and Guillot 2001;
Smith 1992). Life tables are the backbone of the insur- ance industry, since actuaries use life tables to estimate the
likelihood of occurrence of almost any event for which an insurance company might want to issue a policy. For
example, the Retirement Protection Act of 1994 in the United States mandated that standard life tables be
established for use in calculating pension plans, charging the Secretary of the Treasury with the task of generating
those tables in order to pro- tect consumers (Society of Actuaries 2000). Life table analysis has even been used by
General Motors to estimate the cost of maintaining warranties given the probability of a particular car part failing
(“dying”) from a specific modelyear “population” (Merrick and Tordella 1988).

By adding to the mathematical complexity of the table, we can gain additional insights into some of these
phenomena by separating out specific events or by com- bining events. In the former instance we produce a
multiple-decrement table, and in the latter case we get a multistate table (Smith 1992), also known as an increment-
decrement life table (Palloni 2001). A multiple-decrement table can, for example, iso- late the impact of a specific
cause of death on overall mortality levels. In a classic study that served as a precursor to the Global Burden of
Disease Project, Preston, Keyfitz, and Schoen (1972) found that in 1964 the expectation of life for all females in the
United States was 73.8 years. Deleting heart disease as a cause of death would have raised life expectancy by 17.1
years, to 90.9; whereas deleting cancer as a cause of death would have produced a gain of 2.6 years in life
expectancy, to 76.4. In a dif- ferent type of analysis, we might use a multiple-decrement table to ask what are the
probabilities at each age of leaving the labor force before death? Of dying before your spouse? Or of discontinuing a
contraceptive method and becoming pregnant? Or of reaching a specific level of education that will improve
economic productivity?

Multistate tables move us to a level of sophistication that allows for a succes- sion of possible contingencies—
several migrations; entering and leaving the labor force, including periods of unemployment and retirement; school
enrollment, with dropouts and reentries; moving through different marital statuses; and moving from one birth parity
to another. Elaborate discussion of these techniques is, of course, beyond the scope of this book, but you should be
aware that such methods do, in fact, exist to help untangle the mysteries of the social world (see, for example, Key-
fitz 1985; Lutz and Gougon 2004; Siegel 2002).

Health and Mortality Inequalities

The regional differences in mortality that have emerged repeatedly in the chapter are clear reminders that similar
cultural and economic features of societies can have a major impact on human well-being. Our health is very
dependent on massive infrastructure developments such as piped cleaned water, piped sewerage, trans- portation and
communications systems that deliver food and other goods, and a health care system that is affordable and available.
Regions in the world vary con- siderably in their access to these resources, and within the same regions and coun-
tries some people are more advantaged than others in these respects.

Urban and Rural Differentials

Until the twentieth century, cities were deadly places to live. Mortality levels were invariably higher there than in
surrounding areas, since the crowding of people into small spaces, along with poor sanitation and contact with
travelers who might be carrying disease, helped maintain fairly high levels of communicable diseases. For example,
life expectancy in 1841 was 40 years for native English males and 42 years for females, but in London it was five
years less than that (Landers 1993). In Liver- pool, the port city for the burgeoning coal regions of Manchester, life
expectancy was only 25 years for males and 27 years for females. In probability terms, a female child born in the
city of Liverpool in 1841 had less than a 25 percent chance of liv- ing to her 55th birthday, while a rural female had
nearly a 50 percent chance of sur- viving to age 55. Sanitation in Liverpool at that time was atrociously bad.
Pumphrey notes that “pits and deep open channels, from which solid material (human wastes) had to be cleared
periodically, often ran the whole length of streets. From June to October, cesspools were never emptied, for it was
found that any disturbance was inevitably followed by an outbreak of disease” (Pumphrey 1940:141).

In general, we can conclude that the early differences in urban and rural mortality were due less to favorable
conditions in the countryside than to decidedly unfavorable conditions in the cities. Over time, however, medical
advances and environmental im- provements have benefited the urban population more than the rural, leading to the
current situation of better mortality conditions in urban areas. As the world continues to urbanize (see Chapter 9), a
greater fraction of the population in each country will be in closer contact with systems of prevention and cure. At
the same time, the sprawl- ing slums of many third world cities blur the distinction between urban and rural and may
produce their own unhealthy environments (Montgomery and Hewett 2005; Montgomery et al. 2003).

Occupational Differentials in Mortality

Differences in mortality by social status are among the most pervasive inequalities in modern society, and they are
especially apt to show up in cities. This connection be- tween income and health has been obvious for a long time.
Marx attributed the higher death rate in the working classes to the evils of capitalism and argued that mortality
differentials would disappear in a socialist society. That may have been overly optimistic, but data do clearly suggest
that by nearly every index of status, the higher your position in society, the longer you are likely to live.

I should note here that good data are not always easy to come by, since death certificates rarely contain information
on occupation and virtually never on income or education, and when they do have occupation data, many indicate
“retired” or “housewife,” giving no further clues to social status. Thus, more circumlocutory means must be devised
to obtain data on the likelihood of death among members of different social strata. An important method used is
record linkage, such as used in the classic study by Kitagawa and Hauser (1973) for the United States, in which
death certificates for individuals in a census year were linked with census informa- tion obtained for that individual
prior to death. Age and cause of death were ascer- tained from the death certificate, while the census data provided
information on occupation, education, income, marital status, and race.

Among white American men aged 25 to 64 when they died in 1960, mortality rates for laborers were 19 percent
above the average, while those for professional men were 20 percent below the average (Kitagawa and Hauser
1973). Similar kinds of results have been reported more recently for all Americans (not just males) fol- lowed in the
National Longitude Mortality Study, in which the risk of death was clearly lowest for the highest occupational
positions and highest for those in the lowest occupational strata (Gregorio, Walsh, and Paturzo 1997). In England,
re- searchers followed a group of 12,000 civil servants in London who were first inter- viewed in 1967–69 when
they were aged 40 to 64. They were tracked for the next 10 years, and it was clear that even after adjusting for age
and sex, the higher the pay grade, the lower the death rate. Furthermore, within each pay grade, those who owned a
car (a more significant index of status in England than in the United States) had lower death rates than those without
a car (Smith, Shipley, and Rose 1990). A recent update of this study revealed that even as life expectancy has
improved in the United Kingdom, the social class differences have remained very stable (Hattersly 2005). The
importance of this latter set of studies is that it relates to a country that has a highly egalitarian national health
service. Even so, equal access to health ser- vices does not necessarily lead to equal health outcomes. The most
important as- pects of occupation and social class that relate to mortality are undoubtedly income and education
(Johnson, Sorlie, and Backlund 1999)—income to buy protection against and cures for diseases, and education to
know the means whereby disease and occupational risks can be minimized.

Income and Education

There is a striking relationship between income and mortality in the United States. Kitagawa and Hauser’s data for
1960 showed clearly that as income went up, mor- tality went down, and more recent studies have confirmed that
conclusion. Menchik (1993) used data from the National Longitudinal Survey of Older Men to suggest that, at least
for older men in the United States, income is more important than any- thing else in explaining social status
differences in mortality. McDonough and her associates (1997) used data from the Panel Study of Income Dynamics
to show that among people under 65, regardless of race or sex, income was a strong predictor of mortality levels.

As with income, there is a marked decline in the risk of death as education in- creases. Death data for the United
States in 2003 show that age-adjusted death rates for people with at least some college were less than one-third the
level of people with less than a high school education (Hoyert et al. 2006). This is consistent with Kita- gawa and
Hauser’s earlier study, in which they found that a white male in 1960 with an eighth grade education had a 6 percent
chance of dying between the ages of 25 and 45, whereas for a college graduate the probability was only half as high
(Kita- gawa and Hauser 1973). For women, education makes an even bigger difference, es- pecially at the extremes.
A white female with a college education could expect, at age 25, to live 10 years longer than a woman who had only
four or fewer years of schooling.

For virtually every major cause of death, white males with at least one year of college had lower risks of death than
those with less education. The differences ap- pear to be least for the degenerative chronic diseases and greatest for
accidental deaths. This is consistent with the way you might theorize that education would af- fect mortality, since it
should enhance an individual’s ability to avoid dangerous, high-risk situations. Kitagawa and Hauser’s work was
partially replicated by Duleep (1989) using 1973 Current Population Survey data matched to 1973–78 Social
Security records. This study showed a persistence of the pattern of mortality differentials by education. Overall,
death rates were 45 percent higher for white males aged 25 to 64 who had less than a high school education than for
those who had at least some college education. Pappas and his associates used the 1986 Na- tional Mortality
Followback Survey and the 1986 National Health Interview Sur- vey to further replicate Kitagawa and Hauser’s
analysis. They found that “despite an overall decline in death rates in the United States since 1960, poor and poorly
educated people still die at higher rates than those with higher incomes and better education, and the disparity
increased between 1960 and 1986” (Pappas et al. 1993:103). Data from Canada (Choiniére 1993), as well as from
the Netherlands (Doornbus and Kromhout 1991), confirm that these patterns are not unique to the United States.

Race and Ethnicity

In most societies in which more than one racial or ethnic group exists, one group tends to dominate the others. This
generally leads to social and economic disadvan- tages for the subordinate groups, and such disadvantages
frequently result in lower life expectancies for the racial or ethnic minority group members. Some of the dis-
advantages are the obvious ones in which prejudice and discrimination lead to lower levels of education, occupation,
and income and thus to higher death rates. But a large body of evidence suggests that there is a psychosocial
component to health and mortality, causing marginalized peoples in societies to have lower life expectancies than
you might otherwise expect (see, for example, Kunitz 1994; Ross and Wu 1995).

In the United States, African Americans and Native Americans have been particu- larly marginalized and have
historically experienced higher-than-average death rates. In Canada and Mexico, the indigenous populations are
similarly disadvantaged with respect to the rest of society. United States data for 2003 from the National Center for
Health Statistics show that at every age up to 70, African American mortality rates are nearly double the rates for the
white population (Hoyert et al. 2006). Between ages 20 and 59, death rates among blacks are more than double
those for whites. In 1900, African Americans in the United States had a life expectancy that was 15.6 years less than
for whites, and that differential had been reduced to 5.3 years by 2003. Yet that is a larger gap than exists, for
example, between the United States as a whole and the population of Mexico.

African Americans have higher risks of death from almost every major cause of death than do whites (Rogers,
Hummer, and Nam 2000). However, there are three causes of death, in particular, that help to account for the overall
difference. Most im- portant is the higher rate of heart disease for African Americans of both sexes (Hoyert et al.
2006; Keith and Smith 1988; Poednak 1989), which may be explained partly by the stress associated with higher
rates of unemployment among African Americans (Guest, Almgren, and Hussey 1998; Potter 1991). Cancer and
homicide rates are also important factors in the African American mortality differential (Keith and Smith 1988).
Especially disturbing is the fact that life expectancy for African Americans ac- tually declined between 1984 and
1988 and again between 1990 and 1991, but by 1995 it was only back to where it had been in 1984. This was
particularly noticeable for males and was apparently caused by an increase in deaths from HIV/AIDS and by a rise
in the already high homicide rates. For example, in 1990 the life expectancy for white males in the United States
was 72.7 years. In that same year, in the Central Harlem section of New York City, an African American male had a
life expectancy of 53.8 years (about the same as Bangladesh at the time) (Findley and Ford 1993). This was due
especially to the effect of AIDS, compounded by homicide, suicide, and the spread of infectious diseases in a
poverty- and crime-ridden area.

The gap in mortality in the United States between whites and African Americans could be closed completely with
increased standards of living and improved lifestyle, according to a study by Rogers (1992). His analysis of data
from the 1986 National Health Interview Survey suggests that sociodemographic factors such as age, sex, marital
status, family size, and income account for most of the racial differences in life expectancy. In general, the data
suggest that socioeconomic status is more im- portant than lifestyle factors in explaining the racial difference in
mortality (Hay- ward et al. 2000). An important part of socioeconomic status is wealth, not just income. Low
income increases your risk of health problems, but low levels of wealth lowers your resilience—your ability to
recover from illness and its social and eco- nomic ramifications—even if you have a reasonable income. Thus, Huie
and associ- ates (Huie et al. 2003) found that the much lower level of assets among blacks, compared to whites,
negatively affects their health, even when controlling for educa- tion and income.

This is generally consistent with the pattern for other racial/ethnic groups. For example, over time, the income and
social status gap has narrowed between “Ang- los” (non-Hispanic whites) and the Mexican-origin population in the
United States. As this happened, differences in death rates between the groups disappeared and more recently have
crossed over, so that age-adjusted death rates among both males and females are lower for Hispanics in the United
States than for non-Hispanic whites (Hoyert et al. 2006). Some of this difference may be due to differences in the
way Hispanic identity is coded in the vital statistics data (the numerator of the death rate) and how it is coded in the
census (the denominator of the rate). Smith and Brad- shaw (2005) think that similar coding would eliminate the
“Hispanic Paradox,” but other research using data sets that were not affected by the coding of Hispanic iden- tity do
consistently show this lower mortality for Hispanics, so it cannot yet be dis- missed (Peak and Weeks 2002;
Rumbaut and Weeks 1996). In all events, even if Hispanic mortality were simply the same as that for non-Hispanic
whites, it still highlights the tremendous disparity between blacks and others in the United States.

As immigrants have once again become more numerous in the United States, where you were born has reemerged as
a characteristic of importance. Hummer and his associates (1999) used data from the National Health Interview
Survey to calcu- late the probabilities of survival for different groups. They found that U.S.-born young adult blacks
had the highest odds of dying after controlling for socioeco- nomic status, whereas older foreign-born blacks and
Asians had the lowest likeli- hood of dying in comparison to other groups—Americanization isn’t necessarily good
for your health!

The United States is, of course, not the only country with racial or ethnic groups that may experience inequalities in
mortality. For example, in the 1940s, before Pales- tine was partitioned to create the state of Israel, the death rate
among Muslims was two to three times that of the Jewish population, probably due to the higher economic status of
the Jews (United Nations 1953). The mortality gap between Jews and Mus- lims within the modern state of Israel
has narrowed considerably, but Jews continue to have a slightly higher life expectancy (Israel Central Bureau of
Statistics 2007).

Marital Status

It has long been observed that married people tend to live longer than unmarried people. This is true not only in the
United States but in other countries as well (Hu and Goldman 1990; Kaplan and Kronick 2006). A long-standing
explanation for this phenomenon is that marriage is selective of healthy people; that is, people who are physically
handicapped or in ill health may have both a lower chance of marry- ing and a higher risk of death. At least some of
the difference in mortality by marital status certainly is due to this (Kisker and Goldman 1987).

Another explanation is that marriage is good for your health: protective, not just selective. In 1973, Gove examined
this issue, looking at cause-of-death data for the United States in 1959–61. His analysis indicated that the differences
in mortality be- tween married and unmarried people were “particularly marked among those types of mortality
where one’s psychological state would appear to affect one’s life chances” (Gove 1973:65). As examples, Gove
noted that among men aged 25 to 64, suicide rates for single men were double those of married men. For women,
the dif- ferences were in the same direction, but they were not as large. Unmarried males and females also had
higher death rates from what Gove called “the use of socially ap- proved narcotics” such as alcohol and cigarettes.
Finally, Gove noted that for mortal- ity associated with diseases requiring “prolonged and methodical care,”
unmarried people are also at a disadvantage. In these cases, the most extreme rates were among divorced men, who
had death rates nine times higher than married men.

In general, Gove’s analysis suggested that married people, especially men, have lower levels of mortality than
unmarried people because their levels of social and psychological adjustment are higher. Other researchers have
found that economic factors may also play a protective role. Married women are healthier than unmar- ried women
partly because they have higher incomes (Hahn 1993), and unmarried men are especially more likely to die than
married men if they are living below the poverty line (Smith and Waitzman 1994).

Does this mean that if you are currently single you should jump into a marriage just because you think it might
prolong your life? Not necessarily, but Lillard and Panis (1996) found evidence in the Panel Study of Income
Dynamics in the United States that relatively unhealthy men tend to marry early and to remain married longer,
presumably using marriage as a protective mechanism. The flip side of that is that international comparisons of data
suggest that it is the ending of a marriage that especially elevates the risk of death. Divorced males have a noticeably
higher death rate than people in any other marital category (Fenwick and Barresi 1981; Hu and Goldman 1990).

Summary and Conclusion

The control of disease and mortality has vastly improved the human condition and has, in fact, revolutionized life.
Yet, there are still wide variations between nations with respect to both the probabilities of dying and the causes of
those deaths. The differences between nations exist because countries are at different stages of the health and
mortality transition, the shift from high mortality (largely from infec- tious diseases, with most deaths occurring at
young ages) to low mortality (with most deaths occurring at older ages and largely caused by degenerative diseases).
The different timing is due to a complex combination of political, economic, and cultural factors. There are many
routes to low mortality, including genuine bumps in the road such as the HIV/AIDS pandemic that grips sub-
Saharan Africa. That dis- ease is so perverse that it has upset the usual pattern in which the very young and the very
old are more vulnerable to death than are young adults, and the pattern is even emerging that women are more at risk
than are men. In general, females have a sur- vival advantage over males at every age in most of the world, and a
gender gap in mortality that favors women seems to be a feature of the health and mortality tran- sition, at least in
the absence of a disease like HIV/AIDS.

We have been most successful at controlling communicable diseases, which are largely dealt with through public
health measures, but medical technology has be- come increasingly good at limiting disability and postponing death
from noncom- municable diseases, as well. This has helped to slow down the death rates at the older ages. It is
ironic, however, that our very success at creating a life that is rela- tively free of communicable disease and that is
built on a secure food supply, has produced in its wake a transition in our pattern of nutrition that threatens to in-
crease our risk of noncommunicable disease.

Differences in mortality within a society tend to be due to social status inequali- ties. As status and prestige (indexed
especially by education, occupation, income, and wealth) go up, death rates go down. The social and economic
disadvantages felt by minority groups, such as among blacks in the United States, often lead to lower life
expectancies. Marital status is also an important variable, with married people tending to live longer than unmarried
people.

Although mortality rates are low in the more developed nations and are declin- ing in most less developed nations,
diseases that can kill us still exist if we relax our vigilance. The explosion of HIV/AIDS onto the world stage was a
reminder of that, as was the emergence of SARS and now avian influenza. Worldwide efforts have been put into
malaria and tuberculosis control because those deadly diseases have also been making a resurgence in many regions
of the world, reminding us that death control cannot be achieved and then taken for granted, for as Zinsser so aptly
put it:

However secure and well-regulated civilized life may become, bacteria, protozoa, viruses, infected fleas, lice, ticks, mosquitoes,
and bedbugs will always lurk in the shad- ows ready to pounce when neglect, poverty, famine, or war lets down the defenses.
And even in normal times they prey on the weak, the very young, and the very old, living along with us, in mysterious obscurity
waiting their opportunities. (Zinsser 1935:13)

If the thought of those lurking diseases scares you to death, then I suppose that too is part of the health and mortality
transition. Also lurking around the corner is Chapter 6, in which we examine fertility concepts, measurements, and
trends.

Main Points

1. The changes over time in death rates and life expectancy are captured by the perspective of the health and
mortality transition.
2. Significant widespread improvements in the probability of survival date back only to the nineteenth century
and have been especially impressive since the end of World War II. The drop in mortality, of course,
precipitated the massive growth in the size of the human population.
3. The role played by public health preventive measures in bringing down death rates is exemplified by the
saying a century ago that the amount of soap used could be taken as an index of the degree of civilization of
a people.
4. World War II was a turning point in the transition because it led to new medi- cines and to a transfer of
public health and medical technology all over the world, creating rapid declines in the death rate.
5. The things that can kill us are broadly categorized as communicable diseases, noncommunicable
conditions, and injuries, whereas the most important “real” cause of death in the United States (and
increasingly in the world as a whole) is the use of tobacco.
6. Life span refers to the oldest age to which members of a species can survive, whereas longevity is the
ability to resist death from year to year.
7. Although biological factors affect each individual’s chance of survival, social factors are also important
overall determinants of longevity.
8. Among the important biological determinants of death are age and sex, with the very young and the very
old being at greatest risk, and with males generally hav- ing higher death rates than females.

9. Mortality is measured with tools such as the crude death rate, the age-specific death rate, and life
expectancy
10. Living in a city used to verge on being a form of latent suicide, but now cities tend to have lower death
rates than rural areas, and rich people live longer than poor people on average.
11.