Seminar “ Statistica demografică în România: unde suntem, către ce ne îndreptăm?”, Institutul Național de Statistică, 11 ianuarie 2016

1. Mortality divergence and causes of death
MODICOD: an AXA project
France Meslé and Jacques Vallin
Demographic statistics in Romania: where are we, what are we moving towards?
11 January 2016, National Institute of Statistics, Bucharest

2. A basic idea
• Cause-of-death analysis is necessary to
understand mortality trends and forecast
their future
• However this is a complex analysis which
requires heavy data processes to insure
comparability in time and space.
• Especially it is important to deal with
disruptions introduced by the revisions of
the International Classification of Diseases
(ICD)

3. • A method developed at INED
• Two international research projects:
→ Modicod: one transition for many countries (incl.
Romania) from ICD-9 to ICD-10
→ Dimocha: several transitions for selected
countries (from ICD-6 to ICD-10)
• Over 30 collaborators in Europe, and also in
the US and in Japan
Reconstructing coherent series of
deaths by cause
3

4. Modicod countries
4

5. Dimocha countries
5

6. The situation when Modicod started
6
50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 0 1 2 3 4 5 6 7 8 9 10
Belarus
Estonia
Latvia
Lithuania
Moldavia
Ukraine
Czech Republic
Romania
France
Russia
Poland
W. Germany
East Germany
Spain
USA
England & Wales
Japan
ICD6 and ICD7 ICD8 ICD9 1988 Soviet Class. ICD10 ICD10 abridged

7. Where we go with Modicod
7
50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 0 1 2 3 4 5 6 7 8 9 10
Belarus
Estonia
Latvia
Lithuania
Moldavia
Ukraine
Czech Republic
Romania
France
Russia
Poland
W. Germany
East Germany
Spain
USA
England & Wales
Japan
ICD6 and ICD7 ICD8 ICD9 1988 Soviet Class. ICD10 ICD10 abridged

8. Where we go with Dimocha
8
50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 0 1 2 3 4 5 6 7 8 9 10
Belarus
Estonia
Latvia
Lithuania
Moldavia
Ukraine
Czech Republic
Romania
France
Russia
Poland
W. Germany
East Germany
Spain
USA
England & Wales
Japan
ICD6 and ICD7 ICD8 ICD9 1988 Soviet Class. ICD10 ICD10 abridged

9. A solid basis for analysing the east-
west mortality divergence
lundi 11 janvier 2016 9

10. The starting point

11. From 1965, an impressive divergence
11

12. • More severe in countries of the former USSR
than in Central Europe
• More serious for males than for females
• Particularly marked at adult working ages
A general health crisis in Central and
Eastern Europe
12
From 1965 to 1985, Russian men lost 1.6 years in life
expectancy at birth, and 2.3 years in life expectancy at
age 15

13. 30 years later

14. Since the 1990s, a starting convergence
14

15. • After the fall of the Berlin Wall and the breakdown of
the USSR, life expectancy in Central Europe began to
progress again, one country after another
• Republics of the former USSR entered a very chaotic
period with huge fluctuations due to Gorbachev’s
anti-alcohol campaign, its subsequent loosening and
the transition to a market economy
• Finally, in the 2000s, late-runners started catching up
In the early 1990s, diverging trends
between Central and Eastern Europe
15

16. 16
East Germany
Czech R.
Poland.
Slovakia
Hungary
Romania
Bulgaria
Russia
Belarus
Ukraine
Estonia
Latvia
Lithuania
MALES
FEMALES
FEMALES
MALES

17. A dramatic male mortality increase at working ages,
followed by a reduction over a wider range of ages
17

18. Changes in male life expectancy: circulatory diseases
and external causes are the main contributors
18

19. Notable progress at old ages for females
19

20. Annual trends in mortality from
circulatory diseases
0.000
0.002
0.004
0.006
0.008
0.010
0.012
0.014
1955 1965 1975 1985 1995 2005
Standardized death rate
Russia
Lithuania
Latvia
Estonia
Poland
France
MALES
0.000
0.002
0.004
0.006
0.008
0.010
0.012
0.014
1955 1965 1975 1985 1995 2005
Standardized death rate
Russia
Latvia
Estonia
Lithuania
Poland
France
FEMALES

21. • When divergence started in the mid-1960s, all
European countries were completing their
epidemiologic transition, as defined by Omran.
• They had entered the 3rd age of man-made and
degenerative diseases.
• Western European countries were very rapidly able to
control and reduce those diseases, especially
circulatory diseases.
• Central and Eastern European countries, in contrast,
did not succeed.
Do these trends fit with the health
transition theory?
21

22. • A 4th age of the epidemiologic transition:
→ “Age of delayed degenerative diseases”
(Olshansky and Ault, 1986)
→ “The hybristic stage”, the age of diseases related
to behaviour and lifestyle (Rogers and
Hackenberg, 1987)
• Rethinking the whole perspective:
→ The health transition (Frenk et al., 1991)
→ A succession of divergence and convergence
processes (Vallin and Meslé, 2004)
Explaining the cardiovascular revolution
22

23. The succession of divergence/convergence
processes
• Any major factor of improvement in life expectancy results
in a phase of divergence. After some time “laggers” catch
up with the pioneers in a convergence phase.
• In the case of the cardiovascular revolution, factors of
improvement were complex :
→ Medical factors: prevention, systematic screening, new drugs, new
surgery, emergency services, …
→ Economic factors: curing chronic diseases costs a lot and requires a
new organisation of the health system, …
→ Social and behavioral factors: decrease in alcohol and tobacco
consumption, improving diet quality, …
• It took Central and Eastern European countries much more
time to enter this stage than most Western European
countries, but the convergence is now occurring.

24. •“Divergence-convergence” theory:
→ Sub-national trends may follow the same rule
→ New improvements cause new processes of
divergence/convergence
→ A new process can start even if the previous one
has not ended
•Two remaining issues:
→ Differences between males and females
→ Mortality at old ages
What will be the future challenges?
24

25. A narrowing gap between males and females …

26. But differences are still huge
26

27. Life expectancy at age 60 is steadily increasing, …

28. 28
But at 75+, the gap
with the most
advanced countries is
increasing

29. The story continues …
29

30. • This work was supported by INED, the MPIDR and two
research grants:
→ Modicod: "Le projet AXA Mortality Divergence and Causes of
Death"
→ Dimocha: "Project ANR-12-FRAL-0003-01 DIMOCHA"
• Many thanks to the « Modicod-Dimocha » team:
Evgeny Andreev, Magali Barbieri, Simon Bourdieu, Giancarlo Camarda, Inna
Danilova, Géraldine Duthé, Sarah Fabre, Aina Faus, Agnieszka Fihel, Sigrid
Gellers-Barkmann, Pavel Grigoriev, Andoria Ionita, Futoshi Ishii, Domantas
Jasilionis, Dmitri Jdanov, Yu Korekawa, Juris Krumins, Hernan Manzelli, Yui
Ohtsu, Nadine Ouellette, Marketa Pechholdova, Olga Penina, Svitlana
Poniakina, Roland Rau, Rosa Gomez Redondo, Luule Sakkeus, Pavlo
Shevshuk, Vladimir Shkolnikov, Vlada Stankuniene, Jacques Vallin, Alyson
van Raalte
Acknowledgements
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