Elsevier

The Lancet

Volume 363, Issue 9415, 3 April 2004, Pages 1155-1159
The Lancet

Public Health
Mortality trends and setbacks: global convergence or divergence?

https://doi.org/10.1016/S0140-6736(04)15902-3Get rights and content

Summary

Health trends over much of the past century have been generally, and notably, positive throughout the world. In several regions, however, life expectancy has declined over the past 1–2 decades. This trend suggests that the expectation that emerged in the 1960s and 1970s of worldwide gains and convergence in population health status is not guaranteed by a general deterministic process. National populations can now be clearly grouped into those that have achieved rapid gains in life expectancy; those whose gains are slower or are perhaps plateauing; and those in which the trends have reversed. Over the past two centuries, outside times of war and famine, such reversals have been rare. Exploration of these varied population health trends elucidates better the close relation between population health and the processes of economic, social, and technological change. Such analysis has shown that the health status of human populations should be a guiding criterion in the debate on sustainable development.

Section snippets

Trends in life expectancy

The figure shows three groupings of national life expectancy trends over the past half-century, with data from the UN World Population Prospects, 2002.22 The three groupings are those suggested by Caselli and colleagues,23 and refer to national populations that have undergone, respectively, rapid gains in life expectancy; slower, perhaps plateauing gains; and frank reversals. The countries shown are representative of each of those three contrasting trends. Chile, Mexico and Tunisia have

Differences within countries

The above analysis has examined inter-country differences. Increasing within-population mortality differentials have also emerged in many developed and developing countries. A central target of WHO's Health for All strategy for Europe, from 1985, was to reduce differences in health status within countries by at least 25% by improving the health of disadvantaged groups. However, socioeconomic gradients in mortality have increased in most developed countries that provide data—at least in a

Technological solutions?

Technological progress will not necessarily narrow these gaps. Such progress has brought great benefits, but has also brought various unintended consequences. For example, the between country gap in life expectancy caused by unequal access to health-care advances has widened. The discovery of insulin in 1921 transformed type 1 diabetes from a rapidly fatal childhood disease to a survivable disorder—but only for those with access to treatment. Other new treatments have meant that more people die

Transient aberrations or continuing divergence?

Are these divergences in population health mere transient aberrations? Or might a worldwide convergence of health indices be less achievable than previously thought? Part of the answer might lie in the fact that, at global and regional scales, major changes are occurring to social and environmental living conditions. These unprecedented global changes will both enhance and impair population health. For example, the global spread of mass schooling, in combination with radios and television,

Conclusion

Globally, life expectancy has been on a long uptrend. However, the emerging picture of variable mortality trends and regional setbacks indicates that future health gains are not guaranteed by any general deterministic process of convergence. Rather, there is an increased heterogeneity between countries, here summarised as those achieving rapid gains, those achieving slower or plateauing gains, and those having frank reversals.

From these varied population health trends, we can understand better

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