Combining health and social protection measures to reach the ultra ...

Decision-makingGlobal and regional mortality in 2001Slightly more than 56 million people died in 2001, 10.5million, or nearly 20%, of whom were children younger thanfive. Of these child deaths, 99% occurred in low- and middleincomecountries. Those age 70 and over accounted for 70%of deaths in high-income countries, compared with 30% inother countries. Thus a key point is the comparatively largenumber of deaths among the young and the middle-aged inlow- and middle-income countries. In these countries, 30% ofall deaths occur at ages 15 to 59, compared with 15% inhigh-income countries. The causes of death at these ages, aswell as in childhood, are thus important in assessing publichealth priorities.Trends in mortality levelsThe 1990s were characterized by significant economic gainsin most regions, with growth in gross national product percapita ranging from 18% in South Asia and sub-SaharanAfrica to more than 100% in East Asia and the Pacific andthe Middle East and North Africa. Overall, gross nationalproduct per capita grew by about 33% in low- and middleincomecountries during the decade. One would expect thisto have led to a significant improvement in life expectancy,and this indeed occurred in most regions with the notableexception of Europe and Central Asia and, in particular, sub-Saharan Africa (Table 1a and 1b). In the former region, lifeexpectancy was largely unchanged at around 72.5 years overthe decade, primarily because of the massive rise in adultmortality in countries such as Russia and its neighboursduring the first part of the decade, which negated the declinesin child mortality. Much of this extraordinary increase in adultmortality, which rose by about 50% between 1987 and1994, has been attributed to alcohol abuse, particularlyamong men (Leon et al. 1997).Economic development and better coverage of thepopulation with essential child health services have ensuredcontinued declines in levels of child mortality, as measured bythe risk of death from birth to age five, in all regions. Thenotable exception is sub-Saharan Africa, where childmortality among girls remained unchanged at around 165per 1000, with only a modest decline (5%) in the risk ofdeath for boys. The absence of significant declines in childmortality in the 1990s in sub-Saharan Africa is most likelylargely due to the impact of HIV/AIDS. Overall, the risk ofchild death declined from 90 per 1000 in 1990 to 80 per1000 in 2001, with the risk being remarkably similar formales and females (Table 1a and 1b); however, the differentialin child mortality between the world’s richest and poorestpopulations is stark, with a newborn in sub-Saharan Africafacing 25 times the risk of death before the age of five than anewborn in a high-income country.Despite the much greater uncertainty in relation to levels ofadult mortality compared with those for children, theestimates shown in Table 1a and 1b nonetheless indicatesubstantially different trends in adult mortality across differentregions between 1990 and 2001. For most regions, the riskof death between ages 15 and 60 fell by about 10 to 17%over the decade. This was not the case in Europe and CentralAsia, where policy shifts, particularly in relation to alcohol,together with broader social change, have largely beenresponsible for the 15% rise in adult male mortality and the6% increase in the risk of death for women. Note that theseestimates mask the large cyclical fluctuations in adultmortality in Russia, in particular, that characterized theregion’s mortality trends in the 1990s.Table 1 also reveals the large increase in adult mortality insub-Saharan Africa, which was due primarily to the unfoldingof the HIV/AIDS epidemic in southern Africa. Notwithstandingthe substantial uncertainty surrounding these estimates, theepidemic appears to have been of proportionately greaterconsequence for women, with the rise in their risk of death(67%) being twice that of males, among whom other causesof death such as violence were more common. If theseestimates are correct, then 52% of African males reachingage 15 and 44% of females will die before their 60thbirthdays, compared with, for instance, 6.5% of women inhigh-income countries, who despite their already low riskenjoyed a further 11% decline in mortality during the 1990s.These reversals in mortality decline have effectively negatedgains elsewhere, with the results that the global risk of adultdeath has remained essentially unchanged for males, andmay even have risen slightly for females.Taken together, the probability of death up to the age of fiveand between the ages of 15 and 60 are a better reflection ofthe risk of premature death than either alone, although bothhave particular public health implications. Some argue thathealth policy should be equally concerned with keepingadults alive into old age as it is with keeping children aliveinto adulthood. A convenient metric to measure this is the riskof death between birth and age 60 (Table 1a and 1b). Inhigh-income countries, given 2001 mortality rates, onlyabout 7% of females and 13% of males would be dead byage 60, compared with 55 to 62% in sub-Saharan Africa.Significant improvements in this summary measure ofpremature death can be observed in all regions except Europeand Central Asia and sub-Saharan Africa. Worldwide, theindex appears to have changed slightly for males and not atall for females.Other features of global mortality summarized in Table 1aand 1b are worth highlighting. First is the impressiveevidence of a continued decline in mortality among older agegroups in high-income countries that began in the early1970s. The risk of a 60-year-old dying before age 80declined by about 15% for both men and women in highincomecountries so that at 2001 rates, fewer than 33% ofwomen who reach age 60 will be dead by age 80, as will lessthan 50% of men. Second, crude death rates in East Asia andthe Pacific, Latin America and the Caribbean, and the MiddleEast and North African region are lower than in high-incomecountries, reflecting the impact of the older age structure ofrich countries, and are particularly low in Latin America andthe Caribbean. Third, the proportion of deaths that occurbelow age five, while declining in all regions, variesenormously across them, from just over 1% in high-incomecountries to 44% in sub-Saharan Africa. In some low- andmiddle-income regions, particularly East Asia and the Pacific,166 ✜ Global Forum Update on Research for Health Volume 4