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MORTALITY

The development of mortality in the Czech Republic since the second world war can be divided into three distinct periods. In the first period, from 1946 to 1960, as in other developed countries there was a general improvement in people's state of health leading to a marked fall in the level of mortality in all age groups except the oldest, where the fall was not so significant. Life expectancy at birth rose by about 10 years for both sexes during this period, bringing it to 67.9 years for men and 73.4 years for women in 1960, which was one of the highest levels of life expectancy at birth in the world. The most significant element in this change was the dramatic fall in the level of mortality among infants and children. In analysing the reasons for the positive development of mortality in the Czech population in the first fifteen years after the end of World War II we must stress the high quality of organised state health care which allowed the mass introduction of certain preventive measures (vaccination) and forms of treatment (widespread use of antibiotics).

The second period in the development of mortality (1960-1987) was characterised by a stagnation of life expectancy at birth at 66-68 years for men and 73-75 years for women. A comparison of the intensity and structure of mortality at the beginning and end of this period provides an insight into the basic tendencies in the development of mortality during these years. Life expectancy at birth for men was virtually the same in 1960 and in 1987 (67.9 years), but there were significant differences in its structure. In 1987 mortality up to the age of 40 was lower, largely as a result of the fall in infant mortality, but mortality at higher ages had worsened. Among women, life expectancy rose by 1.7 years during this period (from 73.4 to 75.1 years), with a reduction in the mortality rate for all age groups, again mainly thanks to a fall in mortality in the first year of life. As mortality developed differently for the two sexes, excess male mortality increased, with the difference in life expectancy at birth rising from 5.5 years in 1960 to 7.2 years in 1987. The slow long-term improvement or indeed worsening in the indices of mortality meant that the Czech Republic began to lag behind other developed countries, in which life expectancy at birth at the end of the 1980s was on average 4-6 years higher and male mortality in particular was much more positive. This can be illustrated by a comparison of mortality in the Czech Republic and France, which was virtually the same for both sexes at the beginning of the 1960s and a similar structure of mortality by age. In 1987 the Czech Republic was lagging behind France in terms of life expectancy by 4.5 years for men and 5.2 years for women due to a very different structure of mortality, particularly the higher intensity of mortality in middle and old age. The causes of this long-term stagnation of mortality under the communist regime are well known.

The most important factor was the poor life style of the majority of the population with poor nutrition combined with a lack of exercise, smoking, a high consumption of alcohol and a lack of concern by people for their own state of health. The health care system did not have the resources to invest in new technology or the wide-spread introduction of new drugs, and the lack of demand from individuals also affected the efficacy of health education. There was a long–term worsening of the environment due to harmful industrial practices and the equipment used in industry resulted in a hazardous working environment especially for men. Last but not least, there was a high level of social-psychological frustration due to the lack of individual or social prospects for a large part of the population.

The beginning of the third period of the development of mortality in the Czech Republic can be set at 1987, when the stagnation or even worsening of the indices of mortality that was typical of the 1960s and 1970s in particular was replaced by a rapid improvement. These changes have not been consistent over time but accelerated after 1990 with the deep-reaching social and economic changes in society. In 1997 112,700 deaths were registered and in 1998 only 109,500, which was 17,700 fewer than in 1987. The crude death rate for 1998 was 10.6%o, 1.7%o less than in 1987. The fall in this index does not however show the full reduction in the overall mortality level as it is deformed by the continuing ageing of the population. If this is eliminated by adjusting figures to the standard 1987 age structure, the fall in the crude death rate between 1987 and 1998 is 2.6%o, to 9.7%o.

In 1998 life expectancy at birth as a synthetic index of the intensity of mortality reached 71.1 years for men and 78.1 years for women, representing an average lengthening of life expectancy by 3.2 and 3.0 years respectively since 1987. The average annual increase in this index of 0.25 years puts the Czech Republic among those countries with an already high life expectancy where the level of mortality is falling fastest. Together with Slovakia, Poland and Slovenia it forms a group of post-communist countries where the general state of health is improving and the level of mortality falling with the relatively successful social transformation. In Slovakia, for example, life expectancy rose by 2.2 years for men and 1.3 years for women between 1990 and 1997, in Poland the rise was 1.8 and 0.7 years and in Slovenia it was about 1.5 years for both sexes. Mortality rates in these countries can be expected to gradually move towards those in developed countries. At the same time certain post-Soviet countries (the Russian Federation, Ukraine, Moldova) have seen a definite worsening of mortality (a fall in life expectancy of 2-3 years for men and 1-2 years for women) which can be attributed to the economic and political upheavals, the decline in the standard of living, social instability, the collapse of the health care system and cuts in expenditure on health, the deterioration of the social environment accompanied with the traumas of unsuccessful social transformation, etc.

The improvement in the general state of health and the level of mortality in the Czech Republic since 1987 and particularly during the continuing process of profound social change since 1990 can be attributed to a combined effect of many factors. The most important of these are as follows:

• people are taking an increasingly active role in caring for their own health;
• there are clear changes in the style of life and particularly in nutrition habits, partly due to the wider range of foods available;
• liberalisation and demonopolisation of the health care system together with a considerable increase in resources invested have resulted in a wider offer of services, the introduction of modern technology and methods, a rapid spread of the most up-to-date drugs, as well as a major increase in the standard of health care (e.g. the cases of invasive heart surgery have quadrupled since 1990).
• environmental pollution has been reduced, particularly with considerable cuts in emissions of dust and SO₂;
• conditions in the work environment have improved, reducing risk levels;
• the social transformation to date has been bearable (a low level of poverty, long-term unemployment under 10% of the work force).

The development of probabilities of dying by age and sex shows that the fall in mortality levels has affected all age groups. The comparative index of mortality by age and sex shows that the greatest reduction between 1987 and 1997 was among infants of both sexes - falling to approximately 50% of the 1987 level. For both sexes the quotient of infant mortality plummeted from 12‰ in 1987 to 5.9‰ in 1997 and 5.2‰ in 1998, bringing the Czech Republic close to the values in developed western European countries. The positive development of mortality among children in the first year of life was due primarily to the fall in mortality in the first four weeks of life, with the quotient of neonatal mortality (the number of infants dying in the first 27 days of life per 1,000 live births) dropping from 8.3%o to 3.2%o for both sexes, i.e. by over 60%. The drop in the quotient of postneonatal mortality (infants dying between 28 days and 11 months per 1,000 live births) was slower - from 3.7%o in 1987 to 2.0%o in 1998.

In other age groups the major factor in the increase in life expectancy at birth was the fall in mortality of men over 30 and women over 40. Between 1987 and 1998 the probabilities of dying for these groups fell by 10-20% and similarly in the 55-69 age group for both sexes. The stability of the annual reduction in the mortality rate shows clearly that this is not just a short-term fall but rather a permanent improvement in the mortality of these age groups. The small number of deaths involved calls for great care when assessing the change in childhood mortality (to the age of 15), as is shown by the unevenness of changes of probabilities of dying by age and sex (with dramatic changes from one year to the next). The average values of these indices changed little over several years and indeed showed a long-term downward trend, even though they still lag behind the standards of developed European countries. In other groups the development of mortality for men aged 15 to 29 and women aged 15 to 39 is very uneven, sometimes remaining unchanged (e.g. with women aged 30-39 and men aged 20-24), sometimes showing a fall in the mortality rate (for both sexes aged 15-19 and women aged 25-29), but again with certain possibly random deviations which make the overall trend in mortality unclear.

In general it is possible to say that the probabilities of dying by age and sex confirm the long-term positive trend in mortality in the Czech Republic, which, apart from infants, is occurring particularly in middle and old age. This is primarily a result of the considerable lag in these age groups in comparison with those countries with the lowest levels of mortality. From an analytic point of view it is interesting to compare the historically lowest probabilities of dying in this country since the war with the probabilities of dying over the last years studied. For both sexes and in almost all age groups,the historically lowest mortality level was reached in 1997 for men and 1996-1997 for women. The only important exception was for men aged 40-54, where for individual five-year age groups the historical minimum was at the end of the 1950s or beginning of the 1960s. This confirms the existing lag in the intensity of mortality of middle-aged Czech men, which is where the Czech Republic differs most from the structure of mortality standard among developed European populations.

In view of the changing mortality rates throughout the life span, no assessment of changes in age-specific mortality on the basis of comparative indexes of mortality by sex can in itself establish the importance of specific age groups in the changes in life expectancy between 1987 and 1997. For this purpose it is better to use the individual contributions of age groups to the change in life expectancy at birth. Of the total 2.6 year increase in male life expectancy, 1.7 years, i.e. 66%, can be attributed to the 45-84 age group. For women the situation was even more unambiguous as the fall in mortality between 50-89 years represented 1.8 years of the total 2.4-year increase in life expectancy, i.e. 75%. The greatest contribution to the drop in total mortality in this period was due to the reduction in infant mortality. For men this caused an increase in total life expectancy of 0.5 years (19%) and for women 0.4 years (16%). The very low levels of infant mortality mean that its contribution to any future rise in life expectancy will be minimal. Even a hypothetical elimination of mortality in the first year of life would only result in an insignificant increase of 0.44 years for men and 0.42 years for women. For other age groups, with the exception of men aged 40-54 and women aged 45-54, the change in probabilities of dying was only responsible for a marginal contribution to the increase in life expectancy at birth.

The great similarity of changes in the changing level and structure of sex-specific mortality means that excess male mortality has not changed in the late 1980s and 1990s. Excess male mortality measured as the difference in life expectancy at birth for men and for women fell only slightly between 1987 and 1997, from 7.3 to 7.0 years, which is the Europe-wide average. The curve of excess mortality by age typically shows the maximum excess male mortality of around 300% in the 20-29 age group as a result of excess male mortality from external causes. Only at the beginning (0-14 years) and the end (70+ years) of the life span probability of dying for men is less than double that for women. Among other age groups the comparative index of mortality is above 200%. The distribution of the contributions of different age groups to the difference in life expectancy at birth for women and men, which is influenced not only by excess mortality but also by the mortality at a given age, shows a typical single-peak distribution with the maximum in the 60-69 age group, in which excess male mortality cuts almost two years off average life expectancy at birth compared with that of women. In 1997, 85% (5.9 years) of the difference in life expectancy for both sexes was due to excess male mortality in the larger 40-84 age interval. The highest excess mortality in the 20-29 age group contributed only 5% (0.4 years) to the difference in life expectancy between the sexes, as the result of low intensity of mortality in this age group.

A significant improvement in mortality conditions in the period under observation was due mainly to the considerable fall in the intensity of mortality for the most important group of causes of death - diseases of the circulatory system. The standardised mortality rate for this group fell by 20% for both sexes, although it is still well above the average for developed countries. The greatest contribution to the fall in the intensity of mortality in this group was from the 40-50% reduction for both sexes in mortality from cerebrovascular disease and acute myocardial infarction (see Tables 9-11 in the Appendix). On the other hand, the mortality from atherosclerosis rose significantly (by 64% for men and 55% for women), primarily between 1996 and 1997, although this may be due to changes in coding methods. The standardised mortality rate for another major disease of the circulatory system, chronic ischaemic heart disease, changed only slightly, showing a slight downward trend.

Even if the mortality rate for the second largest group of causes of death, neoplasms, has displayed little change in the long term, varying rates of development were recorded within the group. The most significant change for both sexes was related to malignant neoplasm of stomach, where there was a reduction in the standardised mortality rate of around 30%. A positive development was also noted for men suffering from neoplasm of trachea, bronchus and lung, with a fall of 15%. An opposite trend was observed among women with the mortality rate rising by almost one third between 1987 and 1997. A negative trend was registered for certain forms of neoplasms, as with a 15% rise in the intensity of mortality of men due to malignant neoplasm of colon.

Three other important groups of causes of death - diseases of the respiratory system, diseases of the digestive system and external causes - made no significant contribution to the overall change in mortality due to their relatively low intensity (they represent only 15% of all deaths). Nevertheless there was a improvement in illnesses of the respiratory and digestive systems, where the mortality rate fell by 39% and 19% respectively for men and 23% and 17% for women. Among external causes a drop in the female mortality rate was largely due to the drop in suicides (by 37%) and other external causes (by 35%). The rise in male mortality due to traffic accidents (by 21%) meant that despite a 10-15% fall in the suicide rate, the standardised mortality rate for external causes did not change.

These variations in the development of the intensity of mortality for different groups of causes of death did not radically change the structure of mortality according to the cause of death. Between 1987 and 1997 deaths became more concentrated into the five most important groups of causes. The percentage of deaths in these groups represented 95% of all deaths in 1997, while over the long term the single most important group - diseases of the circulatory system - has accounted for 56-57% of all deaths. The second most important cause is neoplasms, responsible for a quarter of all deaths and this percentage rose by 3% in the period in question, a trend also recorded in developed countries. The relative proportions of deaths from external causes (7%), diseases of the respiratory and digestive systems (both almost 4%), have been stable over the long term. This trend in mortality was manifested in a fall of 14,500 in the total number of deaths. The largest contribution to this fall was from deaths from diseases of the circulatory system (6,700 persons), followed by deaths from diseases of the respiratory system (1,600 persons) and other unspecified causes (3,500 persons). The numbers of deaths from neoplasms and external causes did not change significantly.

The greatest contribution to the increased life expectancy between 1987 and 1997 (2.64 years for men and 2.34 for women) came from the major drop from diseases of the circulatory system due to their highest intensity and level of reduction, which accounted for 1.36 years life expectancy for men and 1.24 years for women (52% and 53% respectively). Virtually all this contribution appeared among people over the age of 35, with the fall being similar for men in the 35-64 and 65+ age groups, while for women the fall was greater in the older age group. With respect to the most frequent illnesses of the circulatory system, the rise in male life expectancy was primarily due to the drop in mortality from acute myocardial infarction (1.02 years) and from cerebrovascular disease (0.67 years). For women the largest contribution came from the drop in cerebrovascular disease (0.94 years) and then acute myocardial infarction (0.53 years). The second greatest contribution to the rise in life expectancy (0.73 years for men and 0.60 years for women, i.e. 28% and 26% respectively) came from the group of other causes and was primarily due to the drop in infant mortality. The contribution of other groups of causes of death was not very significant (around 20% for both sexes), either because of the very slight improvement in the mortality rate (neoplasms) or because although there was a significant drop the total number of deaths is small (diseases of the respiratory and digestive systems).

In all the groups of causes analysed there is a clear excess male mortality which, when expressed by a comparative index of excess mortality, was highest in 1987 for respiratory conditions (245%), and in 1997 in the external causes group (253%). The greatest contribution to the drop in the difference between life expectancy at birth for men and women (1987 - 7.32 years, 1997 - 7.02 years) came from the reduction in the difference between male and female mortality from diseases of the circulatory system. This fell from 3.19 years to 2.90 years, which represent 44% and 41% of the total difference. The reduction in excess mortality could also be seen in diseases of the respiratory system (from 0.45 of a year to 0.29 of a year, i.e. from 6% to 4%), and for other unspecified causes (from 0.51 to 0.25 of a year, i.e. from 7% to 4%). The contribution to excess male mortality from external causes, however, rose ( from 1.10 years to 1.41 years, i.e. from 15% to 20%), with a similar trend being recorded for deaths from neoplasms (from 1.65 years to 1.79 years, i.e. from 23% to 26%). For specific age groups the greatest difference in the male and female mortality rates at both the beginning and the end of the period studied was found in the 35-64 age group (1987 - 3.79 years, 1997 - 3.52 years, i.e. 52% and 50%), while there was a gradual rise in the excess male mortality in the over 65 age group (from 2.50 years to 2.71 years, i.e. from 34% to 39%).

The positive development in the intensity of mortality recorded in recent years could have been expected as the far-reaching change in the political and economic system opened the way for many factors which contributed to an improvement of the general state of health of Czech population and to a rise in the average life span. The rate of these changes was, however, surprising: life expectancy at birth for 1998 (men - 71.1 years, women - 78.1 years) reached the level predicted for the last year of this millennium. Nevertheless the large potential for improvement in mortality in the Czech Republic and the continuing long-term improvement of mortality in developed countries mean that we cannot realistically hope to reach the levels of those countries in less than the lifetime of one generation. It will first and foremost require an improvement in the mortality rates of people in middle and old age, particularly from diseases of the circulatory system and neoplasms, which are the areas where there is the greatest lag behind the levels in developed countries. The rise in life expectancy, as a very positive result of the profound changes in demographic reproduction during the last ten years, does paradoxically bring certain problems - primarily the further increase in the process of demographic ageing with all its economic and social implications, including a gradual but considerable increase in the resources needed to maintain the quality of the health care system.

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