NUR 508 Discussion Major Causes of U.S. Mortality

NUR 508 Discussion Major Causes of U.S. Mortality

NUR 508 Discussion Major Causes of U.S. Mortality

What were the major causes of U.S. mortality in the last 100 years, and what public health measures most contributed to improvements in the health of the nation? Include at least two source citations from the readings and/or additional sources to support your answer

The United States has enjoyed more than a century of nearly uninterrupted declines in mortality and rising longevity. In 1900, one in 40 Americans died annually. By 2013, that rate was roughly one in 140, a cumulative improvement of more than two thirds. As shown in Figure 1, life expectancy at birth rose by more than 30 years over this period, from 47 to 79.

While the overall pace of mortality decline has been fairly steady, its causes have varied over time. In the early part of the twentieth century, public health measures and improved nutrition led to rapid reductions in mortality caused by infectious diseases. As a result, cardiovascular disease and cancer accounted for nearly three quarters of all deaths by 1950. Beginning in the 1960s medical advances and changes in people’s behavior turned the tide on these diseases, and mortality improvements since then have been driven primarily by better treatment and disease management.

Despite the steady decline in overall mortality, differences persist between demographic and socioeconomic groups. Women live longer than men, while whites and Hispanics live longer than blacks. But the largest disparities in life expectancy reflect differences in educational attainment: On average, individuals with a college or advanced degree live more than 10 years longer than those without a high school degree. Moreover, while gaps in life expectancy between men and women and between racial groups have narrowed in recent decades, differences by educational attainment have grown larger.

NUR 508 Discussion Major Causes of U.S. MortalityAlthough rising life expectancy is clearly beneficial to individuals, it has led to higher costs for federal programs such as Social Security and Medicare. Increases in longevity raise both the number of individuals collecting federal retirement benefits and the length of time during which they receive those benefits. Consequently, the outlook for mortality is a key input into federal budget projections. While most forecasters expect mortality to continue declining at roughly the pace observed in recent decades, the Social Security Trustees project a substantial slowdown in the rate of improvement. This more pessimistic outlook for life expectancy results in a significantly more optimistic view of Social Security’s finances.

Epidemiological Drivers of Declining Mortality, 1900-2013

The United States experienced an unprecedented decline in mortality during the twentieth century. Life expectancy at birth rose by more than 30 years between 1900 and 2013 as the overall death rate fell at a relatively constant rate of about 1 percent per year. But the stability of this overall trend masks dramatic changes in the underlying causes of mortality.

At the start of the twentieth century, infectious diseases were the leading cause of mortality, accounting for nearly a third of all deaths. Rapid urbanization and increasing population density during the preceding decades created ideal conditions for the spread of bacteria, leading to high rates of mortality from tuberculosis, influenza, and waterborne diseases. Over the first few decades of the 1900s, public health measures, improved nutrition, and new medical technologies dramatically reduced the number of deaths from infectious disease. This decline was initially driven by urban sanitation measures such as the introduction of water filtration and chlorination systems in major cities, as well increased resistance to infection from better nutrition. Following the development of antibiotics in the mid-1930s, the rate of improvement accelerated sharply. Altogether, the death rate from infectious disease fell by 90 percent from 1900 to 1950, accounting for nearly two thirds of the overall reduction in mortality during that period.

As deaths from infectious diseases declined in importance, chronic diseases emerged as the leading killers. Driven in part by the steady rise in smoking rates, mortality from cardiovascular disease and cancer rose more than 50 percent from 1900 to 1950, together accounting for more than three quarters of all deaths by the middle of the century.

Cardiovascular mortality peaked in 1950 and began to decline rapidly by the mid-1960s, falling roughly by half from 1960 to 1990 (Figure 2). Medical advances during this period produced more effective treatments for cardiovascular disease and especially for acute heart disease, including specialized coronary care units, new pharmaceuticals, and advanced surgical procedures such as bypass surgery and angioplasty. A more active approach to prevention and disease management, as well behavioral changes such as reduced smoking rates and improved diet, further reduced the likelihood of severe heart disease and the associated mortality risk. Aggregate mortality fell by one-third from 1950 to 1990, with nearly all of that decline attributable to cardiovascular diseases and more than half to heart disease alone.

NUR 508 Discussion Major Causes of U.S. MortalityWhile cancer deaths continued to rise at a gradual pace throughout this period, mortality from cancers peaked in 1990 and then began to fall steadily. Some of this decline is attributable to the reduced prevalence of smoking, and many credit this trend to successful public health campaigns and the imposition of tobacco control. However, medical innovation likely played a greater role, as declines in mortality from specific types of cancer were systematically related to the quality of pharmaceuticals, imaging technology, and surgical procedures used in the treatment of that particular cancer. By one estimate, new drug treatments and medical technologies explain more than three quarters of the decline in cancer deaths since 2000.

The Distribution of Gains in Mortality

Age

As the epidemiological drivers of declining mortality have shifted over time, so too has the age distribution of mortality. During the early part of the 20th century, mortality was concentrated among the young. Infants and children — who are especially vulnerable to infectious diseases because of their developing immune systems — accounted for nearly half of all deaths in 1900, while those over 65 accounted for fewer than one fifth. As infectious disease mortality declined and deaths from cardiovascular disease and cancer rose over the course of the century, the age distribution of mortality shifted dramatically: By 2013, the infant and child share of deaths was around 1 percent, while the elderly share was nearly three quarters.

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Socioeconomic Status

Despite substantial gains in overall mortality and life expectancy, disparities persist between demographic and socioeconomic groups. In 2012, life expectancy at birth for non-Hispanic whites was 78.8 years, compared with 75.5 years for non-Hispanic blacks. Hispanics had the highest life expectancy, at 81.6 years. Within racial groups, women tend to live longer than men: On average, women’s life expectancy exceeds that of men of the same race by about five years, with a somewhat larger difference between black women and black men.

NUR 508 Discussion Major Causes of U.S. MortalityHowever, the most significant driver of disparities in mortality is education, a principal component of socioeconomic status. As shown in Figure 4, differences in life expectancy by educational attainment dominate differences by race or gender. For instance, the life expectancy gap between the most and least educated black males in 2008 was 10 years, while the largest difference between whites and blacks with the same level of education was four years. Moreover, even as differences in life expectancy by race and gender have narrowed over the past few decades, disparities by education have widened. Among whites, the difference in life expectancy between the most and least educated rose by more than eight years from 1990 to 2008; among blacks, the difference rose by about four years.

The relationship between mortality and educational attainment is not well understood. One possible explanation is that better educated (and usually wealthier) individuals have access to better medical care. This account appears particularly plausible for the U.S., where a large share of the population has historically lacked health insurance and many of those with low socioeconomic status have little access to health care of any quality.

However, differential access to health care does not provide a complete explanation for these gaps in life expectancy. Evidence from the introduction of Medicare in the U.S. suggests that access to health care has only minor effects on the mortality of the elderly and the incidence of many health conditions is higher among the less-educated, suggesting that inequalities exist before the health care system becomes involved. Moreover, international experience is not consistent with the view that health care access is key. For instance, both Canada and the United Kingdom provide universal health insurance and equal access to care, but mortality disparities have risen in the U.K and fallen in Canada.
Alternatively, differences in health related behaviors may explain the gap. Individuals with higher education are substantially less likely to smoke, and that difference has been growing over time. In addition, the rapid rise in obesity in recent decades has been concentrated among the less-educated. Yet while these factors explain some of the gap in life expectancy, differences in mortality persist even after they are taken into account.
Another possibility is greater use of preventative care and better adherence to treatment regimes and therapies among the better-educated. Self-management of disease has likely grown more important over time, as it matters most for the chronic illnesses that cause many deaths today. Better education may also provide general human capital that allows more knowledgeable individuals to improve their overall health. For example, the better-educated are more likely to make use of newer and higher quality medical technologies.
Projections of Mortality

Nearly half of all federal outlays are for transfer programs to retirees, primarily Social Security and Medicare. Because these programs guarantee benefits until death, declining rates of mortality mean more beneficiaries collecting benefits for longer. Future changes in mortality and life expectancy are therefore an important determinant of these programs’ costs and the overall budgetary outlook.

NUR 508 Discussion Major Causes of U.S. MortalityForecasts of mortality are highly uncertain. As discussed above, recent gains in mortality have largely been driven by medical advances, but the development of new drugs, devices, or treatments cannot easily be predicted. In addition, projections of mortality must contend with a more fundamental uncertainty: Is there a biological limit on the human lifespan, and if so, are we approaching it?

As a result of this uncertainty, most forecasters base their projections of mortality on extrapolation of past trends. While the historical stability of the overall rate mortality reduction supports this approach, past declines were driven by idiosyncratic trends in the underlying causes of death, and those trends have not been stable over time. As a result, trends in mortality within particular age groups have changed considerably since the early twentieth century: While the rate of improvement has slowed for the young, it has accelerated for the elderly. This suggests that the historical stability of the overall rate of decline may be a coincidence rather than an intrinsic trend.

Conclusion

The dramatic decline in mortality over the last century is one of the most striking features of recent U.S. (and world) history. Knowledge, science, and technology have propelled a steady extension of Americans’ lifespans and improvements in the quality of their lives even at older ages. Advances in the understanding of infectious diseases and investments in sanitation, water purification, and other public health improvements eliminated infectious disease as a major cause of death. Scientific innovations of new drugs, treatments, and medical devices together with improved health behaviors related to smoking, nutrition, and obesity further reduced mortality from cancer and cardiac diseases.

Nevertheless, not all Americans have shared equally in the benefits of health-enhancing knowledge and innovation. While differences in life expectancy by gender and race are narrowing, those with less education have fallen further behind. Differences in income and corresponding inequalities in access to health care may play some role in this divergence, but the evidence suggests that other factors are also important. Education exerts a direct effect on reducing mortality and morbidity through the adoption of healthier lifestyles, more effective management of chronic diseases, and more frequent and appropriate use of advanced treatment opportunities.

Looking forward, there is little reason to expect the development of life saving ideas and technologies to slow. While this is welcoming news for humanity, it also means higher costs for the federal government from two sources. Seniors will receive more expensive health care benefits and they will collect all federal retiree benefits for longer periods. This uncertainty implies greater risk of substantial increases in federal elder-support expenditures and budget deficits.

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