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Patterns of mortality across 44 countries among men and women aged 15–44 years
Original article
Patterns of mortality across 44 countries among men and women aged 15–44 years Keywords Gender differences Young men Mortality Risky lifestyles
Alan White and Mike Holmes Abstract Background: This epidemiological study is the first to explore patterns of mortality in young men and women (aged 15–44 years) worldwide. Its purpose was to chart differing national/regional patterns to illuminate causal factors of death in young men. Methods: Data from the new World Health Organisation Statistical Information Services Mortality Database was analysed for patterns of premature death in men and women aged 15–44 years across 44 countries. Rates of death from all causes were compared between men and women and the number of deaths calculated as a proportion of total deaths for each country. The study focused on six potentially avoidable categories of death: Accidents and Adverse Effects, Suicide, Malignant Neoplasms, Diseases of the Circulatory System, Homicide and Injury Purposely Inflicted by Other Persons, and Chronic Liver Disease & Cirrhosis. Results: Rates of death varied between countries and between men and women. The causes of death for both men and women differed markedly between the age groups 15–34 years and 35–44 years. Men’s higher rates of deaths for Accidents and Adverse Effects persisted across all the age groups but deaths resulting from disease processes rose rapidly in the age group 35–44 years. Conclusions: Every country has an excess of male deaths due to potentially avoidable causes. The main causes of death are those that are more or less directly attributable to lifestyle and risk taking. More research is required but policy makers and health practitioners should already start to use the available data to develop better-targeted healthcare services for young men. ß 2006 WPMH GmbH. Published by Elsevier Ireland Ltd.
Introduction Alan White, PhD, RN Leeds Metropolitan University, UK Mike Holmes, PhD Centre for Men’s Health, Leeds Metropolitan University, UK Corresponding author E-mail: [email protected]
Online 1 June 2006
Over the last 10 years awareness of the health of men has rapidly expanded and studies have started to analyse data from the male population [1–5]. Exploring mortality and morbidity data with a specific male focus has enabled a clearer picture of the health challenges facing men to emerge. All studies have found young men relative to their female peers to be vulnerable to premature death across the countries surveyed. This has usually been attributed to risky lifestyles such as smoking, high alcohol intake and involvement in accidents [6]. Sui-
ß 2006 WPMH GmbH. Published by Elsevier Ireland Ltd.
cide has also been reported to be a significant cause of death in young men [2,3]. What is not clear is how these causes relate to other causes of death and whether country by country variation reflects the relative importance of specific causes of death. Such an analysis of mortality patterns should help to identify contributory factors and, in turn, enable more effective targeting of health promotion interventions. Publication of the new mortality database by the World Health Organisation Statistical Information Service (WHOSIS) [7] provides an opportunity for a scoping exercise on the state
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Original article of young men’s health between countries across the globe as well as between young men and women in these countries.
countries. These countries were retained in the study but the degree to which their data can be compared to the other countries is limited.
Methods
Numbers of deaths in the age group 15–44 years as a proportion of total deaths
This study investigates countries on the WHOSIS database to determine patterns of premature death among young men and women aged between 15 and 44 years. The database does not cover all countries and there are some notable omissions, e.g. Cyprus, India, Pakistan, China and most African countries. Selection for inclusion of countries from the database in this study depended on whether the data was sufficiently recent and complete to permit a valid comparison, e.g. South Africa, Malta, Iceland and Luxembourg provide data for the number of deaths but not for the rate of deaths, which is necessary for direct comparison between countries. The countries included in the study are drawn from five continents and also represent the range of economic development. The final list of 44 countries (with year of data in brackets) included in the study were: Argentina (2001), Armenia (2002), Australia (2001), Austria (2002), Belgium (1997), Brazil (2000), Bulgaria (2002), Canada (2000), Chile (2001), China/Hong Kong (2000), Czech Republic (2002), Denmark (1999), Egypt (2000), Estonia (2002), Finland (2002), France (2000), Germany (2001), Greece (2001), Hungary (2002), Ireland (2001), Israel (1999), Italy (2001), Japan (2002), Kazakhstan (2002), Latvia (2002), Lithuania (2002), Netherlands (2003), New Zealand (2000), Norway (2001), Philippines (1998), Poland (2002), Portugal (2002), Romania (2002), Russian Federation (2002), Singapore (2001), Slovakia (2000), Slovenia (2002), Spain (2001), Sweden (2001), Switzerland (2000), Thailand (2000), Ukraine (2002), UK (2002) and USA (2000). Data from six of these countries (Bulgaria, Ireland, Kazakhstan, Philippines, Singapore and Ukraine) were based on the International Classification System (ICD) 9. Data from the rest of the countries were based on ICD 10. Switzerland and the Russian Federation use ICD 10 but with different groupings or terms, i.e. Neoplasms (C00–D48) and ‘Intentional Self Harm’ (X60–X84) as opposed to Malignant Neoplasms (C00–D97) and ‘Suicide and Self Inflicted Injury’ (X60–X84) used by the other
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Deaths within the age group 15–44 years were calculated as a percentage of all deaths for each country (Fig. 1). Some countries had a large burden of premature death in both their male and female population. The median percentage across the 44 countries of total deaths in this age group for men was 7.4% and for women 3.1%, reflecting the higher risk of death for men in this age group. For Thailand 35% of the total male deaths were within this
Figure 1
Percentage of deaths in the age group 15–44 years (with year of data in brackets) compared with total deaths for men and women for the 44 countries.
Original article age group (for women it was also high at 19.5%). For Brazil (23.1%), Kazakhstan (22.2%) and the Philippines (21.5%) total male deaths in this age group were also over 20%. At the other end of the scale relatively few deaths were reported for this age group in Sweden (3.5%), Japan (4.2%), the Netherlands (4.4%), Italy (4.8%), and the UK (4.9%). Relatively low as these proportions of male deaths were, the corresponding rates for women were consistently lower. For example, less than 1.5% of Swedish female deaths were in the age group 15–44 years.
Rates of death for men and women in the age group 15–44 years The ratio of the rate of death across each age group for men and women was calculated. Across all the age ranges under investigation in this study there was a higher ratio of male deaths to female deaths (Fig. 2). The ratio for men was twice or more than that of women at all ages between 15 and 65 years. The highest ratios of death in men compared with women was within the age range 15–24 years (median ratio 2.8) and 25–43 years (median ratio 2.6), with the ratios decreasing with increasing age. Marked inter-country variations were found within Estonia and Latvia where the rate in men was over four and a half times that in women in the age groups 15–24 and 25–34 years. For Egypt, the Netherlands and Hong Kong male deaths were less than twice that of female deaths in these age groups.
Figure 2
Median ratio between men and women for the 44 countries for rates of death from all causes by age.
The three age ranges 15–24, 25–34 and 35– 44 years that constitute ‘young men’ were further analysed. The numbers of deaths for each ICD classification group were totalled for these three age groups and ranked by size for the 44 countries to reveal the main causes of death for men in each country. Accidents & Adverse Effects (and the equivalent group in the old External Causes of Morbidity & Mortality ICD classification) were the most frequently reported cause of death in 36 of the 44 countries. Deaths due to Suicide and Self Inflicted Injury (or Intentional Self Harm) were within the top five causes of death in 38 and within the top three causes of death in 25 of the 44 countries. Also prominent were deaths due to Malignant Neoplasm (or Neoplasm) and Diseases of the Circulatory System. After these four causes of death a number of other causes stood out for different countries, for instance Mental Disorders (which includes deaths due to substance misuse) was the principal cause of death in Norway. Infectious and Parasitic diseases (which includes HIV) was important in Portugal, the Philippines, Thailand and the Ukraine, amongst others. In the eight countries where Accidents were not the most frequent reported cause of death the principal causes of death for these age groups were: Malignant Neoplasms in Hong Kong, the Netherlands, Singapore Diseases of the Cardiovascular System in Egypt, the Philippines Homicide in Brazil Suicide in Japan Mental Disorders in Norway Signs, Symptoms and other Ill-Defined Causes in Thailand To develop the analysis further the rates of death were compared among the 36 countries (hereafter referred to as the 36 countries which excluded Bulgaria, Ireland, Kazakhstan, the Philippines, Singapore, Switzerland, the Russian Federation and the Ukraine) that were on the new ICD classification system for ‘Accidents and Adverse Effects’ (V01–X59; Y40– Y86; Y88), ‘Suicide and Self-Inflicted Injury’ (X60–X84), ‘Diseases of the Cardiovascular System’ (I00–I99), and ‘Malignant Neoplasms’ (C00–C97). In the light of concern over alcohol abuse in young men, deaths due to ‘Chronic
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Original article Liver Disease and Cirrhosis (K70;K73–K74;K76) were included in the analysis along with deaths due to ‘Homicide and Injury Purposely Inflicted by Other Persons’ (X85–Y09) to reflect the number of men dying violently.
Accidents and Adverse effects The Accidents and Adverse Effects category includes deaths due to road traffic accidents,
work-related deaths, accidental poisoning, accidents at home and deaths such as accidental drowning (Table 1). This category accounts for the greatest number of young men’s deaths in the 36 countries. The median death rate per 100,000 population was 41.5 deaths for men aged 15–24 years and 42.0 for men aged 25–34 years. The rate declined slightly over the age of 35 years but although in most countries its place as the principal cause of death was replaced by other causes it still accounted
Table 1 Rate of death by age group due to Accidents & Adverse Effects for the 36 countriesa Country
Argentina Armenia Australia Austria Belgium Brazil Canada Chile Czech Rep Denmark Egypt Estonia Finland France Germany Greece Hong Kong Hungary Israel Italy Japan Latvia Lithuania Netherlands New Zealand Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Thailand UK USA Median a
142
Year
15 to 24 years
25 to 34 years
35 to 44 years
(per 100,000 population)
Male
Female
Male
Female
Male
Female
2001 2002 2001 2002 1997 2000 2000 2001 2002 1999 2000 2002 2002 2000 2001 2001 2000 2002 1999 2001 2002 2002 2002 2003 2000 2001 2002 2002 2002 2000 2002 2001 2001 2000 2002 2000
41.6 21.8 42.5 41.4 46.5 51.8 35.1 35.8 45.1 39.8 27.1 123.4 36.9 47.6 35.1 77.1 10.3 34.2 23.1 44 20.9 90.6 80.4 19.4 44.6 32.2 45.2 55.7 40.8 40.3 49.1 45.1 27.9 76.2 24 52.2 41.5
11.4 4.1 10.6 12.7 14.9 9.8 13.3 6.9 12.9 7.1 5 19 8.5 13.8 10.8 17.1 3.3 9.4 5.8 10.5 6 25.1 19.3 6.8 14.2 7.9 11.4 10.2 12.2 12.2 11 10.5 7.4 13.2 5.7 19.2 10.7
41 26.6 38.7 27.2 45.1 62.2 30.2 55.7 47.6 36 24 150.9 36.1 42 22.4 67.5 14 41.9 20.7 39.3 16.6 145.5 121.1 18.4 44.4 23.7 54.4 61.7 56.9 56.3 47.3 48.2 22.5 78 22.2 45.3 42.0
9.2 4.9 8.4 5.7 10.7 8.9 8.4 9.1 11.3 9.4 4.3 24.6 8.3 9.1 5 13 2.7 9.6 5.7 7.6 3.8 23.1 19.7 3.2 12.7 6 8.9 9.5 11.4 5.9 9.8 9.7 5.1 13.9 4.3 13.9 9.0
41.8 32.8 28.9 30.9 38.7 66.2 29.5 62.2 53.8 34.6 22.5 181.2 57.3 37.9 22 45.7 17.4 71.5 24.2 28.6 16.6 198.2 190.1 15.7 34.7 24.8 72.7 60.8 90.4 71.7 46.3 44.2 27.1 74.9 19.7 51.3 40.3
8.5 6.3 9.4 8.7 9.5 10.1 9.2 7.5 12.9 12.7 5.3 43.8 13.8 10.5 6.3 12.4 2.6 13.5 7.6 6.9 4.4 39.4 32.5 3.7 8.1 5.9 12 8.7 20.3 14 3.9 8.1 5.8 16.9 5.3 17.8 9.0
Data compiled from WHOSIS Mortality Database.
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Original article for 40.3 deaths per 100,000 population in the age group 35–44 years (over four times the rate for women in this age group). Inter-country rates of deaths from Accidents and Adverse Effects varied greatly with Eastern European countries, Estonia, Latvia and Lithuania, having particularly high levels of death in this category. In Estonia the rate rose to nearly 200 deaths per 100,000 population in the age range 35–44 years, with death rates climbing steeply with the increasing ages in the three groups. At the other end of the scale Hong Kong, Singapore, the Netherlands and Japan had rates that barely rose above the 20 per 100,000 mark. Of the eight countries that were not directly comparable with the 36 countries due to the differences in the classification system, Russia had very high rates of death due to ‘External Causes of Morbidity and Mortality’ (V01–Y89) with levels reaching 539 deaths per 100,000 population in the age group 35–44 years. Kazakhstan had rates of 204 deaths per 100,000 population in the ‘Accidents’ category (E47–E52) and the Ukraine 229 deaths per 100,000 population from ‘Accidents and Adverse Effects’ (E47–E53). These former Soviet Union countries, along with the Baltic countries, stood out even from other East European countries in having more than twice the rate of such deaths in the age group 35–44 years of any other country. When the individual countries were considered in more detail, although Accidents and Adverse Effects were seen as the main cause of death for most countries, the specific nature of the accidents and adverse effects varied. In the Russian Federation deaths resulting from ‘‘Accidental Poisoning by and Exposure to Noxious Substances’’ (which includes deaths due to alcoholic poisoning) were more than those from ‘‘Transport Accidents’’. In Kazakhstan ‘Accidental Poisoning’ was ranked third behind ‘‘Accidents’’ and ‘‘Diseases of the Circulatory system’’, whereas in the majority of the Western European countries transport accidents made up the most significant cause of death within this category.
Suicide and Self Inflicted Injury The Suicide and Self Inflicted Injury category includes deaths that are directly attributed to
suicide and self inflicted injury (X60–X84) (Table 2). For a significant number of countries suicide was among the top three causes of death for young men but in others it was hardly evident at all; Egypt for example had a rate of less than 0.2 deaths per 100,000 population across the three age groups. Regional differences were also noted with Southern European countries having a lower level of suicide than Northern European countries. But, again, the Eastern European countries stood out, with Lithuania having rates of 59.4 per 100,000 population in the age range 15–24 years rising to 117.9 per 100,000 population in the age group 35–44 years. Russia had a rate of 91.8 deaths per 100,000 population in the Intentional Self Harm (X60–X84) category for the age range 35–44 years. In most countries a trend of increasing death rates with increasing age through the three age groups was evident, and was reflected in the median death rates per 100,000 population of 14.1 in the group 15– 24 years, 21.7 in the group 25–34 years and 23.8 in the group 35–44 years. For women the median death rate was approximately four times lower across all the age groups (per 100,000 population 3.6, 4.6 and 6.5, respectively). But, when the total deaths for women were ranked for each country, suicide, despite the lower rate, was still within the top three causes of death for young women in many of the countries in this study. Belgium was the country with the highest rate of death due to suicide of the 36 countries, with a rate of 14.2 per 100,000 population in the age range 35–44 years, but still less than an eighth of that for men in Lithuania in the same age group.
Diseases of the Circulatory System Deaths as a result of cardiovascular disease among men increased from the age group 15–24 years (median 3.9 per100,000 population), to the age group 25–34 years (11.2 per 100,000 population), followed by a near fourfold increase in the median death rate in the age group 35–44 years (39.2 per 100,000 population) (Table 3). A similar pattern was seen among women from the 36 countries with the median death rate increasing from 2.1 to 4.6 to 16.0 per 100,000 population across the increasing age ranges.
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Original article Table 2 Rates of death by age group due to Suicide for the 36 countriesa Country
Argentina Armenia Australia Austria Belgium Brazil Canada Chile Czech Rep Denmark Egypt Estonia Finland France Germany Greece Hong Kong Hungary Israel Italy Japan Latvia Lithuania Netherlands New Zealand Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Thailand UK USA Median a
Year
15 to 24 years
25 to 34 years
35 to 44 years
(per 100,000 population)
Male
Female
Male
Female
Male
Female
2001 2002 2001 2002 1997 2000 2000 2001 2002 1999 2000 2002 2002 2000 2001 2001 2000 2002 1999 2001 2002 2002 2002 2003 2000 2001 2002 2002 2002 2000 2002 2001 2001 2000 2002 2000
15.3 1.7 20.7 20.1 19.2 6 20.2 19.9 12.2 12.5 0.2 32.8 29.1 12.1 12.4 3 7.5 17 11.4 6.6 14.7 29.8 59.4 6.9 30.4 22.1 19.7 7 11.4 14.1 17.3 6.7 11.2 16.4 8.2 17 14.4
5 0.3 4.8 3.6 5.4 2 5.5 4.9 3.6 2.3 0 4 7.2 3.6 2.7 0.3 5.5 3.6 1.3 1.3 6.3 4.1 5.9 3.1 5.7 7.6 2.7 1.4 2.3 2 2.2 1.4 3.6 4.3 2.4 3 3.6
13.7 5.8 34.2 27 34.9 8.7 21.7 24.4 22 22.3 0.2 57.1 37.6 26 16.8 5.7 20.3 29.5 11.4 10.3 26 44 84.6 14.3 38.8 22.2 26.8 14.7 20 20.6 30.6 11.8 16.9 23.6 17.3 19.6 21.9
3 0.4 7.5 5.2 10.7 1.9 5.5 4.4 3.8 5.3 0 6.4 9.5 6.9 4 0.6 11.3 5.4 2.7 2.3 11 8.7 11.5 4.2 7.2 5.4 2.6 3.5 3.2 1.8 5.6 2.8 4.9 4.7 4 4.3 4.6
13.6 5.7 29.6 32.4 43 9.8 27.4 25.6 30.3 26.5 0.1 64.8 45.2 40.3 22.8 7.3 16 69.9 14 10.2 36.8 74.1 117.9 18.1 22.1 22.4 38.5 18.8 35.4 30.1 48.9 12.9 23.8 19.3 17.9 22.8 24.7
3.9 1.1 8 9.5 14.2 2.2 7.3 4.7 7 7.7 0.1 6.1 12.7 11.8 6.1 1.4 7.9 13.8 1 3.3 10.9 9.7 11.3 6.5 5.5 8.7 6.4 3.6 5 7.8 11.1 3.9 8 6 4.1 6.4 6.5
Data compiled from WHOSIS Mortality Database.
Striking inter-country differences existed among men: per 100,000 population Hong Kong and Sweden had less than 21 deaths whereas Latvia had 169.9 deaths in the age group 35–44 years. Egypt and the Philippines stood out as having relatively high rates in the age range 15–24 years (30.9 and 16.6 per 100,000 population, respectively). Russia, the Ukraine and Kazakhstan all had rates above 200 per 100,000 population for deaths due to cardiovascular disease in the age group 35–44
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years with Russia having 292.2 deaths per 100,000 population. When the causes of death within the classification group ‘Cardiovascular Diseases’ were analysed more closely, in many countries the deaths that stood out as the principal reported causes of death in men aged 15–34 years were from ‘Diseases of Pulmonary Circulation and Other Forms of Heart Disease’ (I26–I51), which includes deaths due to pulmonary embolism, heart failure, rhythm disorders, alcoholic
Original article Table 3 Rates of death by age group due to Cardiovascular Disease for the 36 countriesa Country
Argentina Armenia Australia Austria Belgium Brazil Canada Chile Czech Rep Denmark Egypt Estonia Finland France Germany Greece Hong Kong Hungary Israel Italy Japan Latvia Lithuania Netherlands New Zealand Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Thailand UK USA Median a
Year
15 to 24 years
25 to 34 years
35 to 44 years
(per 100,000 population)
Male
Female
Male
Female
Male
Female
2001 2002 2001 2002 1997 2000 2000 2001 2002 1999 2000 2002 2002 2000 2001 2001 2000 2002 1999 2001 2002 2002 2002 2003 2000 2001 2002 2002 2002 2000 2002 2001 2001 2000 2002 2000
4.6 4.8 2.4 4.1 3.6 5.7 2.4 3.7 3.5 3.8 30.9 7.7 2.7 2.8 3.2 4.7 2.6 5 3.3 4.1 4.2 10.1 5.3 3.2 3 1.8 3.9 5.9 4.4 6.2 2.8 3.4 2.5 8.8 3.1 4 3.9
4.2 3.4 1.2 2.1 1.6 4.6 1.9 1.7 2.9 2.3 20 4 2.2 1.4 2.5 1.9 0.8 1.4 1.3 2 2 4.1 1.6 2.6 1.1 0.8 2.1 3 1.7 1.8 2.9 1.2 1.2 4.9 2.4 2.9 2.1
13.7 17.9 9.4 8.3 7.3 18.3 5.6 10.1 9.6 12 50.6 29.1 6.1 6.1 8.2 13.9 5.2 18 6.6 10.7 10.7 47.7 25.7 7.1 13.7 4.4 13.9 11.7 20.4 11.7 13.3 8.2 6 28.6 8.9 12.1 11.2
8.3 6.3 4.2 4.7 4.1 12.4 3.3 5.2 2.9 3.1 32 4.3 3.5 4.1 4.4 6.6 2.8 6.3 2.7 4.3 4.3 8.1 8.2 5.4 7.6 3 5.4 5.8 9.4 4.6 1.4 3.6 1.9 12.6 4.6 7.5 4.6
51.3 100.5 27.3 31.5 39.2 65.7 25.3 26.3 44.5 36.9 117.6 139.5 39.8 30.7 34.9 49.8 18.9 106.1 22.5 29.5 33.3 169.9 114.1 30.9 39.1 24.5 76.5 46 121.2 67.2 38.1 30.8 20.3 53.1 36 50.3 39.2
27.5 17.8 12.4 12.2 18.3 45.3 9.8 15 14.2 16.4 63.1 34.6 17 10.3 14.6 13.6 5.4 43.2 7.6 10.8 11.4 48 21.6 18.2 16.5 10.6 21.5 15.6 36.5 20.1 15 10.4 8.3 21.6 14.9 24.9 16.0
Data compiled from WHOSIS Mortality Database.
cardiomyopathy and sudden cardiac death. Deaths due to myocardial infarction became more prevalent in the age group 35–44 years and above. Deaths from cardiovascular disease in women followed a similar pattern with women in Egypt, the Philippines and Latvia having the highest rates for this reported cause of death, and Hong Kong and Sweden mirroring the low rates of death in men in these countries (5.4 and 8.3 per 100,000 popu-
lation, respectively in the age range 35–44 years).
Malignant Neoplasm Unsurprisingly, rates of death for malignant neoplasms were low for both men and women in the two lower age groups and tightly clustered across the 36 countries: per 100,000 population for men 6.0 and 10.5 and for
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Original article Table 4 Rates of death by age group due to Malignant Neoplasms for the 36 countriesa Country
Argentina Armenia Australia Austria Belgium Brazil Canada Chile Czech Rep Denmark Egypt Estonia Finland France Germany Greece Hong Kong Hungary Israel Italy Japan Latvia Lithuania Netherlands New Zealand Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Thailand UK USA Median a
Year
15 to 24 years
25 to 34 years
35 to 44 years
(per 100,000 population)
Male
Female
Male
Female
Male
Female
2001 2002 2001 2002 1997 2000 2000 2001 2002 1999 2000 2002 2002 2000 2001 2001 2000 2002 1999 2001 2002 2002 2002 2003 2000 2001 2002 2002 2002 2000 2002 2001 2001 2000 2002 2000
7.6 7.8 5.1 3.9 6.2 6.6 5.6 8.8 5.6 8.5 5.4 7.7 4.2 5.6 4.3 5.0 4.0 6.5 4.2 6.3 4.0 8.4 8.8 5.0 6.4 3.6 6.0 6.7 7.9 6.0 9.7 5.5 4.7 6.5 6.1 5.1 6.0
4.5 9.5 3.6 2.5 4.3 4.5 3.7 4.0 4.2 4.9 4.0 2.0 4.1 3.3 3.3 3.2 2.9 3.3 2.3 4.3 2.9 4.7 3.2 3.3 5.7 3.4 4.1 7.1 5.6 3.5 3.7 3.8 2.6 6.0 3.8 3.6 3.8
11.1 18.9 9.3 8.6 9.2 9.3 8.4 10.6 11.2 13.2 9.0 8.6 11.2 10.3 7.8 10.9 11.5 11.3 11.4 9.3 7.6 16.7 10.8 9.5 10.0 7.9 10.8 10.9 16.4 14.6 11.3 10.0 7.6 34.9 9.4 9.2 10.5
14.8 17.5 9.2 7.8 10.4 11.7 10.2 13.5 12.1 14.8 8.1 9.6 7.0 9.7 9.1 9.9 9.8 15.1 14.6 10.1 9.0 11.8 15.2 12.0 13.8 11.2 10.0 11.0 17.3 13.3 10.5 10.3 7.6 23.1 11.9 10.4 10.8
35.0 52.1 29.9 29.2 38.8 30.4 27.6 25.9 41.3 34.6 20.7 57.1 20.4 51.1 31.4 32.7 50.9 98.1 31.3 30.9 25.5 49.4 47.6 28.3 29.9 29.8 46.4 57.1 68.5 53.9 38.1 42.7 21.4 62.4 28.0 32.7 33.7
53.3 64.4 37.5 36.3 44.3 39.7 40.3 44.3 42.2 47.6 21.9 43.8 30.5 45.0 37.7 32.8 36.5 74.5 45.5 37.5 32.8 53.1 54.8 43.5 47.6 39.0 50.7 45.5 67.7 52.2 39.8 39.7 30.2 48.2 39.1 40.4 42.9
Data compiled from WHOSIS Mortality Database.
women 3.8 and 10.8 (Table 4). No country exceeded a rate of 10 per 100,000 population in the age range 15–24 years. Only Thailand exceeded a rate of 20 per 100,000 population in the age range 25–34 years (for both men and women). The median rate of death for men in the age range 35–44 years was 33.7 per 100,000 population. Hungary stood out with a rate of 98.1 deaths per 100,000 population in the age group 35–44 years. Lung cancer and cancer of the lip, oral cavity and pharynx, which
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accounted for nearly 50% of the cancer-related deaths, predominated in this age group. The lowest rates of death from neoplasms were in Egypt and Sweden (20.7 and 21.4 deaths per 100,000 population in the age range 35–44 years, respectively). For women a similar pattern was evident with the median at 35–44 years of age higher than for men (42.9 deaths per 100,000 population). Hungary again had the highest rate at 74.5 per 100,000 population among the age group
Original article 35–44 years. When the total number of deaths were considered breast cancer and cancer of the cervix and uterus appeared to be the principal cause of this increase.
Chronic Liver Disease & Cirrhosis Death resulting from liver disease are of interest because of increasing concern over
the rising levels of alcohol consumption (Table 5). For men, death from chronic liver disease was uncommon in the age group 15–24 years across all the countries (with a median death rate of 0.0 per 100,000 population). This increased in the age group 25–34 years (median 1.9 per 100,000 population with a high of 15.35 per 100,000 population in Estonia), and increased more markedly in the age group 35–
Table 5 Rates of death (per 100,000) by age group due to Chronic Liver Disease for the 36 countries less onea,b Country
Argentina Australia Austria Belgium Brazil Canada Chile Czech Rep Denmark Egypt Estonia Finland France Germany Greece Hong Kong Hungary Israel Italy Japan Latvia Lithuania Netherlands New Zealand Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Thailand UK USA Median a b
Year
2001 2001 2002 1997 2000 2000 2001 2002 1999 2000 2002 2002 2000 2001 2001 2000 2002 1999 2001 2002 2002 2002 2003 2000 2001 2002 2002 2002 2000 2002 2001 2001 2000 2002 2000
15 to 24 years
25 to 34 years
35 to 44 years
Male
Female
Male
Female
Male
Female
0.1 0 0.2 0 0.8 0 0.2 0.1 0 2.7 0 0 0 0.1 0 0 0.6 0 0 0 0 0 0.1 0 0 0.2 0.1 1.6 0.2 0 0.1 0 0.2 0.1 0.1 0
0.2 0.1 0.2 0 0.4 0.1 0.3 0 0 1.9 0 0 0.1 0.1 0 0 0.3 0.2 0.1 0 1.2 0.4 0 0 0 0.2 0.3 0.7 0.2 0 0.1 0 0.2 0 0.1 0.1
1 0.4 1.9 1.3 8.1 0.4 4 2.3 0.7 7.3 15.1 2.4 1 2.2 0.4 0.4 9.1 1.1 1.7 0.8 6.2 10.4 0.8 0 0 3.5 3.9 8.2 5.7 2 1.3 0 5.2 3.4 1.6 1.9
0.3 0.5 1.2 0.4 1.4 0.1 1 1 0.8 4.1 5.4 1.3 0.7 0.9 0.9 0 2.4 0 0.6 0.4 1.9 2.1 0.3 0 0 1.2 2 2.6 1 0.7 0.7 0.3 1.1 1.5 0.8 0.9
7.7 5.3 15.3 13.1 28.3 4.1 23.1 18.4 16.3 36.8 36.2 14.1 11.6 16.4 4.6 4.2 84.2 2.2 8.9 6.8 19.9 32.6 3.1 1.4 3.9 19.5 20.2 55 37.8 24.1 11.1 2.1 17.8 15.6 11.4 15.3
1.2 1.9 6.2 7.5 4.4 2 5.4 6.1 10.3 13.1 15.3 5.4 5.3 7.2 0.3 0.7 23.9 1 2.7 1.8 10.3 7.7 1.3 0.6 0.6 3.6 7.8 17.3 9.3 9.8 2.7 1.2 3.7 8.2 5.1 5.3
Data not available for Armenia. Data compiled from WHOSIS Mortality Database.
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Original article 44 years (median death 15.3 per 100,000 population). Hungary had the highest rate at 84 deaths per 100,000 population followed by Romania with 55 deaths per 100,000 population and Estonia, Egypt, Slovakia and Lithuania, all of which had more than 30 deaths per 100,000 population in the age group 35–44 years. New Zealand, Sweden and Singapore were notable for having low levels of deaths for this category in all these age ranges. For the year
2000 New Zealand reported no young man aged 15–34 years dying due to liver disease, and a rate of 1.4 deaths per 100,000 population in the age group 35–44 years. For women there was a similar increase in the death rate after the age of 35 years but not as marked as for men, with the median for all 36 countries being 5.3 per 100,000 population in the age group 35–44 years. Once again, Hungary had the highest rates at 24 per 100,000 population followed by Romania and Estonia.
Table 6 Rates of death by age group due to Homicide for the 36 countriesa Country
Argentina Armenia Australia Austria Belgium Brazil Canada Chile Czech Rep Denmark Egypt Estonia Finland France Germany Greece Hong Kong Hungary Israel Italy Japan Latvia Lithuania Netherlands New Zealand Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Thailand UK USA Median a
148
Year
15 to 24 years
25 to 34 years
35 to 44 years
(per 100,000 population)
Male
Female
Male
Female
Male
Female
2001 2002 2001 2002 1997 2000 2000 2001 2002 1999 2000 2002 2002 2000 2001 2001 2000 2002 1999 2001 2002 2002 2002 2003 2000 2001 2002 2002 2002 2000 2002 2001 2001 2000 2002 2000
22.1 2.7 2.2 0.4 2.8 94.3 3.2 17 1.3 1.6 0.2 8.7 2.4 1 0.8 1.5 7.5 0.7 11.4 2 14.7 12.9 7.2 1.9 2.6 1.8 1.5 2.7 11.4 1.7 2.8 1.4 1.7 8.2 1.7 17 2.5
2.2 0.7 1.4 1.3 1.3 6.9 1.1 1.4 0.7 1 0 3 2.5 0.5 0.6 0 0.8 1.2 0.6 0.4 0.2 3.5 2 0.4 1.1 0.4 0.8 0.6 1.1 0.9 2.2 0.5 0.8 1.1 0.7 3.8 1.0
20.2 6.8 3.1 0.9 2.7 89.1 3.6 17.4 1.5 2.7 0.2 20.5 6.7 1.4 0.8 2 20.3 3 11.4 2.6 26 19.2 16.6 2.3 3.3 1.8 3 4.8 20 6.2 2 2.9 1.3 12.9 2.3 19.6 3.2
2.7 0.9 1.5 1.4 2.1 6.3 0.9 1.3 1.3 1.5 0 3.2 1 0.5 0.4 0.1 1.3 1.2 0.2 0.5 0.3 6.9 3.7 1.8 1.7 1.5 0.8 2.4 1.4 0.8 0 0.6 1 2.3 0.6 4.1 1.3
14.4 6.2 3.4 0.7 3.6 55.7 3.2 13.8 3.2 1.3 0.1 39.5 5 1.6 1.1 1.7 16 6 14 2.1 36.8 24.1 20.7 1.8 2.4 1.2 3.8 4.3 35.4 4.4 2.5 2.3 1.4 18.6 1.8 22.8 3.7
2.3 1.8 1.6 0.9 3 5.7 1.3 1.4 1.5 2.6 0.1 7.1 1.6 0.8 0.8 0.5 0.6 4.3 1.8 0.6 0.3 5.7 4.8 1.6 0.6 1.6 1.5 1.6 3 0.8 2 0.5 0.3 3.4 0.7 3.9 1.6
Data compiled from WHOSIS Mortality Database.
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Original article Homicide and Injury Purposely Inflicted by Other Persons The relatively low median death rates per 100,000 population as a result of homicide among men (2.5 at ages 15–24 years, 3.2 at ages 25–34 years, and 3.5 at ages 35–44 years) indicated that in most countries this cause was not a significant contributor to men’s high mortality figures (Table 6). From the 36 countries 24 reported less than 7 deaths per 100,000 population across the three age groups and 13 of these reported less than three deaths per 100,000 population. Brazil stood out as having startlingly higher numbers of deaths as a result of homicide with over 95 per 100,000 population in the age group 15–24 years. Estonia, Japan and Romania all had steeply rising rates of death with increasing age among men. Rates exceeded the upper 30s per 100,000 population by the age of 35–44 years. The USA along with Latvia and Lithuania also displayed a similar pattern of rising death rates into the 20s per 100,000 population by the age of 35–44 years. Russia
Figure 3
recorded deaths per 100,000 population within the ‘Assault’ (X85–Y09) classification group of 32.9, 67.5 and 75.7 corresponding with the three age groups of increasing years. Comparing the death rates from homicide for men and women showed that many more men died violently. Even in Brazil the figures for women (per 100,000 population 6.9, 6.3 and 5.7, respectively across age groups of increasing years) were over ten times less than for men, and these were the highest figures for women across the 36 countries. The median death rates for women per 100,000 population across the three age ranges were: 1, 1.3 and 1.6, respectively. Russian women had higher rates in the ‘Assault’ category of 10.2, 17.4 and 17.7, respectively across the three age groups of increasing years.
Comparison of median death rates The median death rates of all the 36 countries (Fig. 3) showed that the higher rate of deaths for Accidents and Adverse Effects persisted
Median death rates (per 100,000 population) across the 36 countries for men and women by age.
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Original article across all the age ranges whereas the rate of death for the other causes of death increased with age, with the disease-based conditions all having far higher rates of death in the age group 35–44 years.
Discussion The intention of the study, in line with previous work [2,3], was to raise issues and pose questions of why different patterns exist between countries and between men and women. Although in a study of this nature it is not possible to investigate underlying causes directly, the recorded patterns do support the finding of the World Health Report 2002 on Risk Taking [6] in that men’s lifestyle seems to be a major factor in their rates of premature death. The nature of the risks that men face can be interpreted in many ways, from the physical risk associated with road traffic accidents to the personal lifestyle risk associated with smoking, poor diet and alcohol consumption. What is also apparent, however, is that differences between countries in premature mortality are consistent with prevailing socio-economic circumstances, with the countries of Eastern Europe having the highest rates of death overall. Throughout the world the developing countries or those in transition have the highest rates of death among the age group 15–44 years. Social upheaval and uncertainty could play a part in the very high rates among the young who are perhaps more vulnerable than others to insecurity and threat or more affected by the opportunities such change creates. Notably men seem harder hit by these influences, in terms of premature death, than women. The rate of death for women in this age group is much lower than that for men and varies less between countries, an observation also noted in an analysis of health inequalities in Europe [8]. Nevertheless, albeit at a lower level, the country rankings in rates of premature death and causes are similar for women and men. What emerges from the analysis is that there are definite differences between the health problems men face in the age group 15–34 years and in the age group 35–44 years. Death primarily results from accidents and suicide in the early years and disease processes
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in the later years. The seeds of death from degenerative conditions are probably sown in life styles established earlier. There is a need for substantial work to be done with young men to try and prevent premature loss of life at an early age. Although in some countries the total loss of life as a percentage of overall deaths seems small the effect of the number of years of life lost is greater. A young man’s death has a marked effect on families, employers and ultimately on the economy. Even though the high rates of death as a result of ‘‘Accidents and Adverse Effects’’ might not be surprising, the variation from country to country in causes of death within this category is noteworthy. In some countries road transport accidents are the principal risk and in others accidental poisoning is a more significant risk. These levels of accidental poisoning are attributable to alcoholic poisoning [9] and are a particular concern in young men across Eastern Europe. The number of deaths due to malignant neoplasms, cardiovascular disease and chronic liver disease also show the importance of lifestyle factors such as smoking and alcohol intake, which are known to increase risk for these diseases [4]. Therefore although deaths from cardiovascular disease are decreasing in many countries, the reported specific causes of death within this classification point strongly to men’s lifestyle factors contributing to these figures. Deaths resulting from pulmonary circulatory problems and other forms of heart disease reinforce the concern that binge drinking is increasing the number of sudden cardiac deaths and other alcohol-related cardiomyopathy [10]. Types of cancer leading to the most significant numbers of male and female deaths were analysed. Women are primarily affected by sexspecific cancers, with breast cancer being the most important. Discounting female deaths attributable to cancers of the breast, cervix and uterus emphasises the greater incidence of mortality among young men from cancers that might be anticipated to affect men and women similarly (sex-specific cancers are rare among men in the age group 15–44 years). A significant proportion of cancer deaths have been suggested to result from nine behavioural and environmental factors with smoking and alcohol, along with diet, being important in the increased risk in men [11].
Original article Homicide is seen as a big problem in some, but not all, of the countries with Brazil standing out from all the other countries. The prevailing street culture in many countries leads many young men into violence against both men and women [12,13]. Differences in suicide rates pose questions about how suicide is seen within the countries. The very high levels in Eastern Europe support the suggestion that young men are at a much higher risk in countries in transition [14,15]. The high rates in Japan may also reflect social change as well as a cultural acceptance of suicide. In Southern European countries and Egypt suicide is still a taboo for either religious or legal reasons. The low incidence of reported deaths from suicide in these countries may be attributable in part or whole to under-reporting. In conclusion this study has highlighted the importance of recognising the extent of loss of life in young men. Although the death of a young man can be looked at in numbers or rates of death, the data can also be seen as potential years of life lost. For each individual death at an early age there is a significant number of years that person could have expected to live and contribute had he reached the average life expectancy for the country
(which itself should be higher if fewer premature deaths occurred). This highlights the loss to the individual men, their families and to society. In every country there is an excess of male deaths due to potentially avoidable reasons. The main causes of death are those that are more or less directly attributable to lifestyle and risk taking. This raises questions as to whether policy makers and health practitioners can influence how young men live their lives and exercise choice, and whether they can intervene in a social environment where young men’s increased risk taking has become the norm. More disturbing questions are also raised about why young men turn to suicide in such large numbers. There are many limitations to this study, not least the restricted number of countries that could be included (the sub-Saharan countries and the Indian Sub-continent being the most obvious omissions) and the lack of more localised data from within the countries included. National average life expectancy figures can mask huge variations within a country. Nevertheless it is hoped that this broad scoping exercise prompts questions and points to further more detailed analysis and debate.
References [1] Christov V, Zdravko K, Todorova M, Ivanov L, Tzurakova F. A report on the demographic characteristics and the state of men’s health in Bulgaria. J Men’s Health Gend 2004;1(3):191–6. [2] White AK, Cash K. The state of men’s health in Western Europe. J Men’s Health Gend 2004;1:60–6. [3] White AK, Cash K. The state of men’s health across 17 European Countries. Brussels: The European Men’s Health Forum; 2003, ISBN 1-898883-94-7. [4] McKee M, Shkolnikov V. Understanding the toll of premature death among men in Eastern Europe. BMJ 2001;323(7320): 1051–5. [5] Ogah G. Men’s Health in Africa. Conference presentation at The 1st World Congress on Men’s Health: Sex & Gender Matter – From Boys to Men: The Future of Men’s Health, Vienna; 2001. [6] World Health Organization, The World Health Report 2002: Reducing Risks,
[7]
[8]
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Promoting Healthy Life. Geneva: The World Health Organization; 2002. The World Health Organization, The World Health Organization Statistical Information Service Mortality Database;, 2005 http:// www3 .who.int/whosis/menu.cfm?path= whosis&language=english. Mackenbach JP. Health Inequalities: Europe in Profile. Expert report commissioned by, and published under the auspices of, the UK Presidency of the EU, London, 2005. Mesle´ F. Mortality in Central and Eastern Europe: long-term trends and recent upturns. Demographic Research, Special Collection 2, Article 3, http://www. demographic-research.org/special/2/3/s2-3. pdf accessed Dec 2005. Britton A, McKee M. The relation between alcohol and cardiovascular disease in Eastern Europe: explaining the paradox. J Epidemiol Community Health 2000;54(5): 328–32.
[11] Danaei G, Hoorn, SV Lopez AD, Murray CJL, Ezzati M, and the Comparative Risk Assessment collaborating group (Cancers). Causes of cancer in the world: comparative risk assessment of nine behavioural and environmental risk factors. The Lancet, 2005; 366:1784–94. [12] Barker GT. Dying to be men: youth masculinity and social exclusion. Abingdon: Routledge; 2005. [13] Mercy JA, Butchart A, Farrington D, Cerda´ M. Youth Violence. In: Krug ET, Dahlber LL, Mercy JA, Zwi AB, Lozano R, editors. World Report on violence and health. Geneva: World Health Organization; 2002. [14] Rutz W. Mental health in Europe: problems, advances and challenges. Acta Psychiatrica Scandinavica 2001;104(s410):15. [15] Schmidtke A, Bille-Brahe U, Kerkhof AJF, De Leo D, editors. Suicidal Behaviour in Europe: Results from the WHO/EURO Multicentre Study on Suicidal Behaviour. Go¨ttingen: Hogrefe & Huber; 2001.
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Patterns of mortality across 44 countries among men and women aged 15–44 years Keywords Gender differences Young men Mortality Risky lifestyles
Alan White and Mike Holmes Abstract Background: This epidemiological study is the first to explore patterns of mortality in young men and women (aged 15–44 years) worldwide. Its purpose was to chart differing national/regional patterns to illuminate causal factors of death in young men. Methods: Data from the new World Health Organisation Statistical Information Services Mortality Database was analysed for patterns of premature death in men and women aged 15–44 years across 44 countries. Rates of death from all causes were compared between men and women and the number of deaths calculated as a proportion of total deaths for each country. The study focused on six potentially avoidable categories of death: Accidents and Adverse Effects, Suicide, Malignant Neoplasms, Diseases of the Circulatory System, Homicide and Injury Purposely Inflicted by Other Persons, and Chronic Liver Disease & Cirrhosis. Results: Rates of death varied between countries and between men and women. The causes of death for both men and women differed markedly between the age groups 15–34 years and 35–44 years. Men’s higher rates of deaths for Accidents and Adverse Effects persisted across all the age groups but deaths resulting from disease processes rose rapidly in the age group 35–44 years. Conclusions: Every country has an excess of male deaths due to potentially avoidable causes. The main causes of death are those that are more or less directly attributable to lifestyle and risk taking. More research is required but policy makers and health practitioners should already start to use the available data to develop better-targeted healthcare services for young men. ß 2006 WPMH GmbH. Published by Elsevier Ireland Ltd.
Introduction Alan White, PhD, RN Leeds Metropolitan University, UK Mike Holmes, PhD Centre for Men’s Health, Leeds Metropolitan University, UK Corresponding author E-mail: [email protected]
Online 1 June 2006
Over the last 10 years awareness of the health of men has rapidly expanded and studies have started to analyse data from the male population [1–5]. Exploring mortality and morbidity data with a specific male focus has enabled a clearer picture of the health challenges facing men to emerge. All studies have found young men relative to their female peers to be vulnerable to premature death across the countries surveyed. This has usually been attributed to risky lifestyles such as smoking, high alcohol intake and involvement in accidents [6]. Sui-
ß 2006 WPMH GmbH. Published by Elsevier Ireland Ltd.
cide has also been reported to be a significant cause of death in young men [2,3]. What is not clear is how these causes relate to other causes of death and whether country by country variation reflects the relative importance of specific causes of death. Such an analysis of mortality patterns should help to identify contributory factors and, in turn, enable more effective targeting of health promotion interventions. Publication of the new mortality database by the World Health Organisation Statistical Information Service (WHOSIS) [7] provides an opportunity for a scoping exercise on the state
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Original article of young men’s health between countries across the globe as well as between young men and women in these countries.
countries. These countries were retained in the study but the degree to which their data can be compared to the other countries is limited.
Methods
Numbers of deaths in the age group 15–44 years as a proportion of total deaths
This study investigates countries on the WHOSIS database to determine patterns of premature death among young men and women aged between 15 and 44 years. The database does not cover all countries and there are some notable omissions, e.g. Cyprus, India, Pakistan, China and most African countries. Selection for inclusion of countries from the database in this study depended on whether the data was sufficiently recent and complete to permit a valid comparison, e.g. South Africa, Malta, Iceland and Luxembourg provide data for the number of deaths but not for the rate of deaths, which is necessary for direct comparison between countries. The countries included in the study are drawn from five continents and also represent the range of economic development. The final list of 44 countries (with year of data in brackets) included in the study were: Argentina (2001), Armenia (2002), Australia (2001), Austria (2002), Belgium (1997), Brazil (2000), Bulgaria (2002), Canada (2000), Chile (2001), China/Hong Kong (2000), Czech Republic (2002), Denmark (1999), Egypt (2000), Estonia (2002), Finland (2002), France (2000), Germany (2001), Greece (2001), Hungary (2002), Ireland (2001), Israel (1999), Italy (2001), Japan (2002), Kazakhstan (2002), Latvia (2002), Lithuania (2002), Netherlands (2003), New Zealand (2000), Norway (2001), Philippines (1998), Poland (2002), Portugal (2002), Romania (2002), Russian Federation (2002), Singapore (2001), Slovakia (2000), Slovenia (2002), Spain (2001), Sweden (2001), Switzerland (2000), Thailand (2000), Ukraine (2002), UK (2002) and USA (2000). Data from six of these countries (Bulgaria, Ireland, Kazakhstan, Philippines, Singapore and Ukraine) were based on the International Classification System (ICD) 9. Data from the rest of the countries were based on ICD 10. Switzerland and the Russian Federation use ICD 10 but with different groupings or terms, i.e. Neoplasms (C00–D48) and ‘Intentional Self Harm’ (X60–X84) as opposed to Malignant Neoplasms (C00–D97) and ‘Suicide and Self Inflicted Injury’ (X60–X84) used by the other
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Deaths within the age group 15–44 years were calculated as a percentage of all deaths for each country (Fig. 1). Some countries had a large burden of premature death in both their male and female population. The median percentage across the 44 countries of total deaths in this age group for men was 7.4% and for women 3.1%, reflecting the higher risk of death for men in this age group. For Thailand 35% of the total male deaths were within this
Figure 1
Percentage of deaths in the age group 15–44 years (with year of data in brackets) compared with total deaths for men and women for the 44 countries.
Original article age group (for women it was also high at 19.5%). For Brazil (23.1%), Kazakhstan (22.2%) and the Philippines (21.5%) total male deaths in this age group were also over 20%. At the other end of the scale relatively few deaths were reported for this age group in Sweden (3.5%), Japan (4.2%), the Netherlands (4.4%), Italy (4.8%), and the UK (4.9%). Relatively low as these proportions of male deaths were, the corresponding rates for women were consistently lower. For example, less than 1.5% of Swedish female deaths were in the age group 15–44 years.
Rates of death for men and women in the age group 15–44 years The ratio of the rate of death across each age group for men and women was calculated. Across all the age ranges under investigation in this study there was a higher ratio of male deaths to female deaths (Fig. 2). The ratio for men was twice or more than that of women at all ages between 15 and 65 years. The highest ratios of death in men compared with women was within the age range 15–24 years (median ratio 2.8) and 25–43 years (median ratio 2.6), with the ratios decreasing with increasing age. Marked inter-country variations were found within Estonia and Latvia where the rate in men was over four and a half times that in women in the age groups 15–24 and 25–34 years. For Egypt, the Netherlands and Hong Kong male deaths were less than twice that of female deaths in these age groups.
Figure 2
Median ratio between men and women for the 44 countries for rates of death from all causes by age.
The three age ranges 15–24, 25–34 and 35– 44 years that constitute ‘young men’ were further analysed. The numbers of deaths for each ICD classification group were totalled for these three age groups and ranked by size for the 44 countries to reveal the main causes of death for men in each country. Accidents & Adverse Effects (and the equivalent group in the old External Causes of Morbidity & Mortality ICD classification) were the most frequently reported cause of death in 36 of the 44 countries. Deaths due to Suicide and Self Inflicted Injury (or Intentional Self Harm) were within the top five causes of death in 38 and within the top three causes of death in 25 of the 44 countries. Also prominent were deaths due to Malignant Neoplasm (or Neoplasm) and Diseases of the Circulatory System. After these four causes of death a number of other causes stood out for different countries, for instance Mental Disorders (which includes deaths due to substance misuse) was the principal cause of death in Norway. Infectious and Parasitic diseases (which includes HIV) was important in Portugal, the Philippines, Thailand and the Ukraine, amongst others. In the eight countries where Accidents were not the most frequent reported cause of death the principal causes of death for these age groups were: Malignant Neoplasms in Hong Kong, the Netherlands, Singapore Diseases of the Cardiovascular System in Egypt, the Philippines Homicide in Brazil Suicide in Japan Mental Disorders in Norway Signs, Symptoms and other Ill-Defined Causes in Thailand To develop the analysis further the rates of death were compared among the 36 countries (hereafter referred to as the 36 countries which excluded Bulgaria, Ireland, Kazakhstan, the Philippines, Singapore, Switzerland, the Russian Federation and the Ukraine) that were on the new ICD classification system for ‘Accidents and Adverse Effects’ (V01–X59; Y40– Y86; Y88), ‘Suicide and Self-Inflicted Injury’ (X60–X84), ‘Diseases of the Cardiovascular System’ (I00–I99), and ‘Malignant Neoplasms’ (C00–C97). In the light of concern over alcohol abuse in young men, deaths due to ‘Chronic
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Original article Liver Disease and Cirrhosis (K70;K73–K74;K76) were included in the analysis along with deaths due to ‘Homicide and Injury Purposely Inflicted by Other Persons’ (X85–Y09) to reflect the number of men dying violently.
Accidents and Adverse effects The Accidents and Adverse Effects category includes deaths due to road traffic accidents,
work-related deaths, accidental poisoning, accidents at home and deaths such as accidental drowning (Table 1). This category accounts for the greatest number of young men’s deaths in the 36 countries. The median death rate per 100,000 population was 41.5 deaths for men aged 15–24 years and 42.0 for men aged 25–34 years. The rate declined slightly over the age of 35 years but although in most countries its place as the principal cause of death was replaced by other causes it still accounted
Table 1 Rate of death by age group due to Accidents & Adverse Effects for the 36 countriesa Country
Argentina Armenia Australia Austria Belgium Brazil Canada Chile Czech Rep Denmark Egypt Estonia Finland France Germany Greece Hong Kong Hungary Israel Italy Japan Latvia Lithuania Netherlands New Zealand Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Thailand UK USA Median a
142
Year
15 to 24 years
25 to 34 years
35 to 44 years
(per 100,000 population)
Male
Female
Male
Female
Male
Female
2001 2002 2001 2002 1997 2000 2000 2001 2002 1999 2000 2002 2002 2000 2001 2001 2000 2002 1999 2001 2002 2002 2002 2003 2000 2001 2002 2002 2002 2000 2002 2001 2001 2000 2002 2000
41.6 21.8 42.5 41.4 46.5 51.8 35.1 35.8 45.1 39.8 27.1 123.4 36.9 47.6 35.1 77.1 10.3 34.2 23.1 44 20.9 90.6 80.4 19.4 44.6 32.2 45.2 55.7 40.8 40.3 49.1 45.1 27.9 76.2 24 52.2 41.5
11.4 4.1 10.6 12.7 14.9 9.8 13.3 6.9 12.9 7.1 5 19 8.5 13.8 10.8 17.1 3.3 9.4 5.8 10.5 6 25.1 19.3 6.8 14.2 7.9 11.4 10.2 12.2 12.2 11 10.5 7.4 13.2 5.7 19.2 10.7
41 26.6 38.7 27.2 45.1 62.2 30.2 55.7 47.6 36 24 150.9 36.1 42 22.4 67.5 14 41.9 20.7 39.3 16.6 145.5 121.1 18.4 44.4 23.7 54.4 61.7 56.9 56.3 47.3 48.2 22.5 78 22.2 45.3 42.0
9.2 4.9 8.4 5.7 10.7 8.9 8.4 9.1 11.3 9.4 4.3 24.6 8.3 9.1 5 13 2.7 9.6 5.7 7.6 3.8 23.1 19.7 3.2 12.7 6 8.9 9.5 11.4 5.9 9.8 9.7 5.1 13.9 4.3 13.9 9.0
41.8 32.8 28.9 30.9 38.7 66.2 29.5 62.2 53.8 34.6 22.5 181.2 57.3 37.9 22 45.7 17.4 71.5 24.2 28.6 16.6 198.2 190.1 15.7 34.7 24.8 72.7 60.8 90.4 71.7 46.3 44.2 27.1 74.9 19.7 51.3 40.3
8.5 6.3 9.4 8.7 9.5 10.1 9.2 7.5 12.9 12.7 5.3 43.8 13.8 10.5 6.3 12.4 2.6 13.5 7.6 6.9 4.4 39.4 32.5 3.7 8.1 5.9 12 8.7 20.3 14 3.9 8.1 5.8 16.9 5.3 17.8 9.0
Data compiled from WHOSIS Mortality Database.
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Original article for 40.3 deaths per 100,000 population in the age group 35–44 years (over four times the rate for women in this age group). Inter-country rates of deaths from Accidents and Adverse Effects varied greatly with Eastern European countries, Estonia, Latvia and Lithuania, having particularly high levels of death in this category. In Estonia the rate rose to nearly 200 deaths per 100,000 population in the age range 35–44 years, with death rates climbing steeply with the increasing ages in the three groups. At the other end of the scale Hong Kong, Singapore, the Netherlands and Japan had rates that barely rose above the 20 per 100,000 mark. Of the eight countries that were not directly comparable with the 36 countries due to the differences in the classification system, Russia had very high rates of death due to ‘External Causes of Morbidity and Mortality’ (V01–Y89) with levels reaching 539 deaths per 100,000 population in the age group 35–44 years. Kazakhstan had rates of 204 deaths per 100,000 population in the ‘Accidents’ category (E47–E52) and the Ukraine 229 deaths per 100,000 population from ‘Accidents and Adverse Effects’ (E47–E53). These former Soviet Union countries, along with the Baltic countries, stood out even from other East European countries in having more than twice the rate of such deaths in the age group 35–44 years of any other country. When the individual countries were considered in more detail, although Accidents and Adverse Effects were seen as the main cause of death for most countries, the specific nature of the accidents and adverse effects varied. In the Russian Federation deaths resulting from ‘‘Accidental Poisoning by and Exposure to Noxious Substances’’ (which includes deaths due to alcoholic poisoning) were more than those from ‘‘Transport Accidents’’. In Kazakhstan ‘Accidental Poisoning’ was ranked third behind ‘‘Accidents’’ and ‘‘Diseases of the Circulatory system’’, whereas in the majority of the Western European countries transport accidents made up the most significant cause of death within this category.
Suicide and Self Inflicted Injury The Suicide and Self Inflicted Injury category includes deaths that are directly attributed to
suicide and self inflicted injury (X60–X84) (Table 2). For a significant number of countries suicide was among the top three causes of death for young men but in others it was hardly evident at all; Egypt for example had a rate of less than 0.2 deaths per 100,000 population across the three age groups. Regional differences were also noted with Southern European countries having a lower level of suicide than Northern European countries. But, again, the Eastern European countries stood out, with Lithuania having rates of 59.4 per 100,000 population in the age range 15–24 years rising to 117.9 per 100,000 population in the age group 35–44 years. Russia had a rate of 91.8 deaths per 100,000 population in the Intentional Self Harm (X60–X84) category for the age range 35–44 years. In most countries a trend of increasing death rates with increasing age through the three age groups was evident, and was reflected in the median death rates per 100,000 population of 14.1 in the group 15– 24 years, 21.7 in the group 25–34 years and 23.8 in the group 35–44 years. For women the median death rate was approximately four times lower across all the age groups (per 100,000 population 3.6, 4.6 and 6.5, respectively). But, when the total deaths for women were ranked for each country, suicide, despite the lower rate, was still within the top three causes of death for young women in many of the countries in this study. Belgium was the country with the highest rate of death due to suicide of the 36 countries, with a rate of 14.2 per 100,000 population in the age range 35–44 years, but still less than an eighth of that for men in Lithuania in the same age group.
Diseases of the Circulatory System Deaths as a result of cardiovascular disease among men increased from the age group 15–24 years (median 3.9 per100,000 population), to the age group 25–34 years (11.2 per 100,000 population), followed by a near fourfold increase in the median death rate in the age group 35–44 years (39.2 per 100,000 population) (Table 3). A similar pattern was seen among women from the 36 countries with the median death rate increasing from 2.1 to 4.6 to 16.0 per 100,000 population across the increasing age ranges.
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Original article Table 2 Rates of death by age group due to Suicide for the 36 countriesa Country
Argentina Armenia Australia Austria Belgium Brazil Canada Chile Czech Rep Denmark Egypt Estonia Finland France Germany Greece Hong Kong Hungary Israel Italy Japan Latvia Lithuania Netherlands New Zealand Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Thailand UK USA Median a
Year
15 to 24 years
25 to 34 years
35 to 44 years
(per 100,000 population)
Male
Female
Male
Female
Male
Female
2001 2002 2001 2002 1997 2000 2000 2001 2002 1999 2000 2002 2002 2000 2001 2001 2000 2002 1999 2001 2002 2002 2002 2003 2000 2001 2002 2002 2002 2000 2002 2001 2001 2000 2002 2000
15.3 1.7 20.7 20.1 19.2 6 20.2 19.9 12.2 12.5 0.2 32.8 29.1 12.1 12.4 3 7.5 17 11.4 6.6 14.7 29.8 59.4 6.9 30.4 22.1 19.7 7 11.4 14.1 17.3 6.7 11.2 16.4 8.2 17 14.4
5 0.3 4.8 3.6 5.4 2 5.5 4.9 3.6 2.3 0 4 7.2 3.6 2.7 0.3 5.5 3.6 1.3 1.3 6.3 4.1 5.9 3.1 5.7 7.6 2.7 1.4 2.3 2 2.2 1.4 3.6 4.3 2.4 3 3.6
13.7 5.8 34.2 27 34.9 8.7 21.7 24.4 22 22.3 0.2 57.1 37.6 26 16.8 5.7 20.3 29.5 11.4 10.3 26 44 84.6 14.3 38.8 22.2 26.8 14.7 20 20.6 30.6 11.8 16.9 23.6 17.3 19.6 21.9
3 0.4 7.5 5.2 10.7 1.9 5.5 4.4 3.8 5.3 0 6.4 9.5 6.9 4 0.6 11.3 5.4 2.7 2.3 11 8.7 11.5 4.2 7.2 5.4 2.6 3.5 3.2 1.8 5.6 2.8 4.9 4.7 4 4.3 4.6
13.6 5.7 29.6 32.4 43 9.8 27.4 25.6 30.3 26.5 0.1 64.8 45.2 40.3 22.8 7.3 16 69.9 14 10.2 36.8 74.1 117.9 18.1 22.1 22.4 38.5 18.8 35.4 30.1 48.9 12.9 23.8 19.3 17.9 22.8 24.7
3.9 1.1 8 9.5 14.2 2.2 7.3 4.7 7 7.7 0.1 6.1 12.7 11.8 6.1 1.4 7.9 13.8 1 3.3 10.9 9.7 11.3 6.5 5.5 8.7 6.4 3.6 5 7.8 11.1 3.9 8 6 4.1 6.4 6.5
Data compiled from WHOSIS Mortality Database.
Striking inter-country differences existed among men: per 100,000 population Hong Kong and Sweden had less than 21 deaths whereas Latvia had 169.9 deaths in the age group 35–44 years. Egypt and the Philippines stood out as having relatively high rates in the age range 15–24 years (30.9 and 16.6 per 100,000 population, respectively). Russia, the Ukraine and Kazakhstan all had rates above 200 per 100,000 population for deaths due to cardiovascular disease in the age group 35–44
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years with Russia having 292.2 deaths per 100,000 population. When the causes of death within the classification group ‘Cardiovascular Diseases’ were analysed more closely, in many countries the deaths that stood out as the principal reported causes of death in men aged 15–34 years were from ‘Diseases of Pulmonary Circulation and Other Forms of Heart Disease’ (I26–I51), which includes deaths due to pulmonary embolism, heart failure, rhythm disorders, alcoholic
Original article Table 3 Rates of death by age group due to Cardiovascular Disease for the 36 countriesa Country
Argentina Armenia Australia Austria Belgium Brazil Canada Chile Czech Rep Denmark Egypt Estonia Finland France Germany Greece Hong Kong Hungary Israel Italy Japan Latvia Lithuania Netherlands New Zealand Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Thailand UK USA Median a
Year
15 to 24 years
25 to 34 years
35 to 44 years
(per 100,000 population)
Male
Female
Male
Female
Male
Female
2001 2002 2001 2002 1997 2000 2000 2001 2002 1999 2000 2002 2002 2000 2001 2001 2000 2002 1999 2001 2002 2002 2002 2003 2000 2001 2002 2002 2002 2000 2002 2001 2001 2000 2002 2000
4.6 4.8 2.4 4.1 3.6 5.7 2.4 3.7 3.5 3.8 30.9 7.7 2.7 2.8 3.2 4.7 2.6 5 3.3 4.1 4.2 10.1 5.3 3.2 3 1.8 3.9 5.9 4.4 6.2 2.8 3.4 2.5 8.8 3.1 4 3.9
4.2 3.4 1.2 2.1 1.6 4.6 1.9 1.7 2.9 2.3 20 4 2.2 1.4 2.5 1.9 0.8 1.4 1.3 2 2 4.1 1.6 2.6 1.1 0.8 2.1 3 1.7 1.8 2.9 1.2 1.2 4.9 2.4 2.9 2.1
13.7 17.9 9.4 8.3 7.3 18.3 5.6 10.1 9.6 12 50.6 29.1 6.1 6.1 8.2 13.9 5.2 18 6.6 10.7 10.7 47.7 25.7 7.1 13.7 4.4 13.9 11.7 20.4 11.7 13.3 8.2 6 28.6 8.9 12.1 11.2
8.3 6.3 4.2 4.7 4.1 12.4 3.3 5.2 2.9 3.1 32 4.3 3.5 4.1 4.4 6.6 2.8 6.3 2.7 4.3 4.3 8.1 8.2 5.4 7.6 3 5.4 5.8 9.4 4.6 1.4 3.6 1.9 12.6 4.6 7.5 4.6
51.3 100.5 27.3 31.5 39.2 65.7 25.3 26.3 44.5 36.9 117.6 139.5 39.8 30.7 34.9 49.8 18.9 106.1 22.5 29.5 33.3 169.9 114.1 30.9 39.1 24.5 76.5 46 121.2 67.2 38.1 30.8 20.3 53.1 36 50.3 39.2
27.5 17.8 12.4 12.2 18.3 45.3 9.8 15 14.2 16.4 63.1 34.6 17 10.3 14.6 13.6 5.4 43.2 7.6 10.8 11.4 48 21.6 18.2 16.5 10.6 21.5 15.6 36.5 20.1 15 10.4 8.3 21.6 14.9 24.9 16.0
Data compiled from WHOSIS Mortality Database.
cardiomyopathy and sudden cardiac death. Deaths due to myocardial infarction became more prevalent in the age group 35–44 years and above. Deaths from cardiovascular disease in women followed a similar pattern with women in Egypt, the Philippines and Latvia having the highest rates for this reported cause of death, and Hong Kong and Sweden mirroring the low rates of death in men in these countries (5.4 and 8.3 per 100,000 popu-
lation, respectively in the age range 35–44 years).
Malignant Neoplasm Unsurprisingly, rates of death for malignant neoplasms were low for both men and women in the two lower age groups and tightly clustered across the 36 countries: per 100,000 population for men 6.0 and 10.5 and for
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Original article Table 4 Rates of death by age group due to Malignant Neoplasms for the 36 countriesa Country
Argentina Armenia Australia Austria Belgium Brazil Canada Chile Czech Rep Denmark Egypt Estonia Finland France Germany Greece Hong Kong Hungary Israel Italy Japan Latvia Lithuania Netherlands New Zealand Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Thailand UK USA Median a
Year
15 to 24 years
25 to 34 years
35 to 44 years
(per 100,000 population)
Male
Female
Male
Female
Male
Female
2001 2002 2001 2002 1997 2000 2000 2001 2002 1999 2000 2002 2002 2000 2001 2001 2000 2002 1999 2001 2002 2002 2002 2003 2000 2001 2002 2002 2002 2000 2002 2001 2001 2000 2002 2000
7.6 7.8 5.1 3.9 6.2 6.6 5.6 8.8 5.6 8.5 5.4 7.7 4.2 5.6 4.3 5.0 4.0 6.5 4.2 6.3 4.0 8.4 8.8 5.0 6.4 3.6 6.0 6.7 7.9 6.0 9.7 5.5 4.7 6.5 6.1 5.1 6.0
4.5 9.5 3.6 2.5 4.3 4.5 3.7 4.0 4.2 4.9 4.0 2.0 4.1 3.3 3.3 3.2 2.9 3.3 2.3 4.3 2.9 4.7 3.2 3.3 5.7 3.4 4.1 7.1 5.6 3.5 3.7 3.8 2.6 6.0 3.8 3.6 3.8
11.1 18.9 9.3 8.6 9.2 9.3 8.4 10.6 11.2 13.2 9.0 8.6 11.2 10.3 7.8 10.9 11.5 11.3 11.4 9.3 7.6 16.7 10.8 9.5 10.0 7.9 10.8 10.9 16.4 14.6 11.3 10.0 7.6 34.9 9.4 9.2 10.5
14.8 17.5 9.2 7.8 10.4 11.7 10.2 13.5 12.1 14.8 8.1 9.6 7.0 9.7 9.1 9.9 9.8 15.1 14.6 10.1 9.0 11.8 15.2 12.0 13.8 11.2 10.0 11.0 17.3 13.3 10.5 10.3 7.6 23.1 11.9 10.4 10.8
35.0 52.1 29.9 29.2 38.8 30.4 27.6 25.9 41.3 34.6 20.7 57.1 20.4 51.1 31.4 32.7 50.9 98.1 31.3 30.9 25.5 49.4 47.6 28.3 29.9 29.8 46.4 57.1 68.5 53.9 38.1 42.7 21.4 62.4 28.0 32.7 33.7
53.3 64.4 37.5 36.3 44.3 39.7 40.3 44.3 42.2 47.6 21.9 43.8 30.5 45.0 37.7 32.8 36.5 74.5 45.5 37.5 32.8 53.1 54.8 43.5 47.6 39.0 50.7 45.5 67.7 52.2 39.8 39.7 30.2 48.2 39.1 40.4 42.9
Data compiled from WHOSIS Mortality Database.
women 3.8 and 10.8 (Table 4). No country exceeded a rate of 10 per 100,000 population in the age range 15–24 years. Only Thailand exceeded a rate of 20 per 100,000 population in the age range 25–34 years (for both men and women). The median rate of death for men in the age range 35–44 years was 33.7 per 100,000 population. Hungary stood out with a rate of 98.1 deaths per 100,000 population in the age group 35–44 years. Lung cancer and cancer of the lip, oral cavity and pharynx, which
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accounted for nearly 50% of the cancer-related deaths, predominated in this age group. The lowest rates of death from neoplasms were in Egypt and Sweden (20.7 and 21.4 deaths per 100,000 population in the age range 35–44 years, respectively). For women a similar pattern was evident with the median at 35–44 years of age higher than for men (42.9 deaths per 100,000 population). Hungary again had the highest rate at 74.5 per 100,000 population among the age group
Original article 35–44 years. When the total number of deaths were considered breast cancer and cancer of the cervix and uterus appeared to be the principal cause of this increase.
Chronic Liver Disease & Cirrhosis Death resulting from liver disease are of interest because of increasing concern over
the rising levels of alcohol consumption (Table 5). For men, death from chronic liver disease was uncommon in the age group 15–24 years across all the countries (with a median death rate of 0.0 per 100,000 population). This increased in the age group 25–34 years (median 1.9 per 100,000 population with a high of 15.35 per 100,000 population in Estonia), and increased more markedly in the age group 35–
Table 5 Rates of death (per 100,000) by age group due to Chronic Liver Disease for the 36 countries less onea,b Country
Argentina Australia Austria Belgium Brazil Canada Chile Czech Rep Denmark Egypt Estonia Finland France Germany Greece Hong Kong Hungary Israel Italy Japan Latvia Lithuania Netherlands New Zealand Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Thailand UK USA Median a b
Year
2001 2001 2002 1997 2000 2000 2001 2002 1999 2000 2002 2002 2000 2001 2001 2000 2002 1999 2001 2002 2002 2002 2003 2000 2001 2002 2002 2002 2000 2002 2001 2001 2000 2002 2000
15 to 24 years
25 to 34 years
35 to 44 years
Male
Female
Male
Female
Male
Female
0.1 0 0.2 0 0.8 0 0.2 0.1 0 2.7 0 0 0 0.1 0 0 0.6 0 0 0 0 0 0.1 0 0 0.2 0.1 1.6 0.2 0 0.1 0 0.2 0.1 0.1 0
0.2 0.1 0.2 0 0.4 0.1 0.3 0 0 1.9 0 0 0.1 0.1 0 0 0.3 0.2 0.1 0 1.2 0.4 0 0 0 0.2 0.3 0.7 0.2 0 0.1 0 0.2 0 0.1 0.1
1 0.4 1.9 1.3 8.1 0.4 4 2.3 0.7 7.3 15.1 2.4 1 2.2 0.4 0.4 9.1 1.1 1.7 0.8 6.2 10.4 0.8 0 0 3.5 3.9 8.2 5.7 2 1.3 0 5.2 3.4 1.6 1.9
0.3 0.5 1.2 0.4 1.4 0.1 1 1 0.8 4.1 5.4 1.3 0.7 0.9 0.9 0 2.4 0 0.6 0.4 1.9 2.1 0.3 0 0 1.2 2 2.6 1 0.7 0.7 0.3 1.1 1.5 0.8 0.9
7.7 5.3 15.3 13.1 28.3 4.1 23.1 18.4 16.3 36.8 36.2 14.1 11.6 16.4 4.6 4.2 84.2 2.2 8.9 6.8 19.9 32.6 3.1 1.4 3.9 19.5 20.2 55 37.8 24.1 11.1 2.1 17.8 15.6 11.4 15.3
1.2 1.9 6.2 7.5 4.4 2 5.4 6.1 10.3 13.1 15.3 5.4 5.3 7.2 0.3 0.7 23.9 1 2.7 1.8 10.3 7.7 1.3 0.6 0.6 3.6 7.8 17.3 9.3 9.8 2.7 1.2 3.7 8.2 5.1 5.3
Data not available for Armenia. Data compiled from WHOSIS Mortality Database.
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Original article 44 years (median death 15.3 per 100,000 population). Hungary had the highest rate at 84 deaths per 100,000 population followed by Romania with 55 deaths per 100,000 population and Estonia, Egypt, Slovakia and Lithuania, all of which had more than 30 deaths per 100,000 population in the age group 35–44 years. New Zealand, Sweden and Singapore were notable for having low levels of deaths for this category in all these age ranges. For the year
2000 New Zealand reported no young man aged 15–34 years dying due to liver disease, and a rate of 1.4 deaths per 100,000 population in the age group 35–44 years. For women there was a similar increase in the death rate after the age of 35 years but not as marked as for men, with the median for all 36 countries being 5.3 per 100,000 population in the age group 35–44 years. Once again, Hungary had the highest rates at 24 per 100,000 population followed by Romania and Estonia.
Table 6 Rates of death by age group due to Homicide for the 36 countriesa Country
Argentina Armenia Australia Austria Belgium Brazil Canada Chile Czech Rep Denmark Egypt Estonia Finland France Germany Greece Hong Kong Hungary Israel Italy Japan Latvia Lithuania Netherlands New Zealand Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Thailand UK USA Median a
148
Year
15 to 24 years
25 to 34 years
35 to 44 years
(per 100,000 population)
Male
Female
Male
Female
Male
Female
2001 2002 2001 2002 1997 2000 2000 2001 2002 1999 2000 2002 2002 2000 2001 2001 2000 2002 1999 2001 2002 2002 2002 2003 2000 2001 2002 2002 2002 2000 2002 2001 2001 2000 2002 2000
22.1 2.7 2.2 0.4 2.8 94.3 3.2 17 1.3 1.6 0.2 8.7 2.4 1 0.8 1.5 7.5 0.7 11.4 2 14.7 12.9 7.2 1.9 2.6 1.8 1.5 2.7 11.4 1.7 2.8 1.4 1.7 8.2 1.7 17 2.5
2.2 0.7 1.4 1.3 1.3 6.9 1.1 1.4 0.7 1 0 3 2.5 0.5 0.6 0 0.8 1.2 0.6 0.4 0.2 3.5 2 0.4 1.1 0.4 0.8 0.6 1.1 0.9 2.2 0.5 0.8 1.1 0.7 3.8 1.0
20.2 6.8 3.1 0.9 2.7 89.1 3.6 17.4 1.5 2.7 0.2 20.5 6.7 1.4 0.8 2 20.3 3 11.4 2.6 26 19.2 16.6 2.3 3.3 1.8 3 4.8 20 6.2 2 2.9 1.3 12.9 2.3 19.6 3.2
2.7 0.9 1.5 1.4 2.1 6.3 0.9 1.3 1.3 1.5 0 3.2 1 0.5 0.4 0.1 1.3 1.2 0.2 0.5 0.3 6.9 3.7 1.8 1.7 1.5 0.8 2.4 1.4 0.8 0 0.6 1 2.3 0.6 4.1 1.3
14.4 6.2 3.4 0.7 3.6 55.7 3.2 13.8 3.2 1.3 0.1 39.5 5 1.6 1.1 1.7 16 6 14 2.1 36.8 24.1 20.7 1.8 2.4 1.2 3.8 4.3 35.4 4.4 2.5 2.3 1.4 18.6 1.8 22.8 3.7
2.3 1.8 1.6 0.9 3 5.7 1.3 1.4 1.5 2.6 0.1 7.1 1.6 0.8 0.8 0.5 0.6 4.3 1.8 0.6 0.3 5.7 4.8 1.6 0.6 1.6 1.5 1.6 3 0.8 2 0.5 0.3 3.4 0.7 3.9 1.6
Data compiled from WHOSIS Mortality Database.
Vol. 3, No. 2, pp. 139–151, June 2006
Original article Homicide and Injury Purposely Inflicted by Other Persons The relatively low median death rates per 100,000 population as a result of homicide among men (2.5 at ages 15–24 years, 3.2 at ages 25–34 years, and 3.5 at ages 35–44 years) indicated that in most countries this cause was not a significant contributor to men’s high mortality figures (Table 6). From the 36 countries 24 reported less than 7 deaths per 100,000 population across the three age groups and 13 of these reported less than three deaths per 100,000 population. Brazil stood out as having startlingly higher numbers of deaths as a result of homicide with over 95 per 100,000 population in the age group 15–24 years. Estonia, Japan and Romania all had steeply rising rates of death with increasing age among men. Rates exceeded the upper 30s per 100,000 population by the age of 35–44 years. The USA along with Latvia and Lithuania also displayed a similar pattern of rising death rates into the 20s per 100,000 population by the age of 35–44 years. Russia
Figure 3
recorded deaths per 100,000 population within the ‘Assault’ (X85–Y09) classification group of 32.9, 67.5 and 75.7 corresponding with the three age groups of increasing years. Comparing the death rates from homicide for men and women showed that many more men died violently. Even in Brazil the figures for women (per 100,000 population 6.9, 6.3 and 5.7, respectively across age groups of increasing years) were over ten times less than for men, and these were the highest figures for women across the 36 countries. The median death rates for women per 100,000 population across the three age ranges were: 1, 1.3 and 1.6, respectively. Russian women had higher rates in the ‘Assault’ category of 10.2, 17.4 and 17.7, respectively across the three age groups of increasing years.
Comparison of median death rates The median death rates of all the 36 countries (Fig. 3) showed that the higher rate of deaths for Accidents and Adverse Effects persisted
Median death rates (per 100,000 population) across the 36 countries for men and women by age.
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149
Original article across all the age ranges whereas the rate of death for the other causes of death increased with age, with the disease-based conditions all having far higher rates of death in the age group 35–44 years.
Discussion The intention of the study, in line with previous work [2,3], was to raise issues and pose questions of why different patterns exist between countries and between men and women. Although in a study of this nature it is not possible to investigate underlying causes directly, the recorded patterns do support the finding of the World Health Report 2002 on Risk Taking [6] in that men’s lifestyle seems to be a major factor in their rates of premature death. The nature of the risks that men face can be interpreted in many ways, from the physical risk associated with road traffic accidents to the personal lifestyle risk associated with smoking, poor diet and alcohol consumption. What is also apparent, however, is that differences between countries in premature mortality are consistent with prevailing socio-economic circumstances, with the countries of Eastern Europe having the highest rates of death overall. Throughout the world the developing countries or those in transition have the highest rates of death among the age group 15–44 years. Social upheaval and uncertainty could play a part in the very high rates among the young who are perhaps more vulnerable than others to insecurity and threat or more affected by the opportunities such change creates. Notably men seem harder hit by these influences, in terms of premature death, than women. The rate of death for women in this age group is much lower than that for men and varies less between countries, an observation also noted in an analysis of health inequalities in Europe [8]. Nevertheless, albeit at a lower level, the country rankings in rates of premature death and causes are similar for women and men. What emerges from the analysis is that there are definite differences between the health problems men face in the age group 15–34 years and in the age group 35–44 years. Death primarily results from accidents and suicide in the early years and disease processes
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in the later years. The seeds of death from degenerative conditions are probably sown in life styles established earlier. There is a need for substantial work to be done with young men to try and prevent premature loss of life at an early age. Although in some countries the total loss of life as a percentage of overall deaths seems small the effect of the number of years of life lost is greater. A young man’s death has a marked effect on families, employers and ultimately on the economy. Even though the high rates of death as a result of ‘‘Accidents and Adverse Effects’’ might not be surprising, the variation from country to country in causes of death within this category is noteworthy. In some countries road transport accidents are the principal risk and in others accidental poisoning is a more significant risk. These levels of accidental poisoning are attributable to alcoholic poisoning [9] and are a particular concern in young men across Eastern Europe. The number of deaths due to malignant neoplasms, cardiovascular disease and chronic liver disease also show the importance of lifestyle factors such as smoking and alcohol intake, which are known to increase risk for these diseases [4]. Therefore although deaths from cardiovascular disease are decreasing in many countries, the reported specific causes of death within this classification point strongly to men’s lifestyle factors contributing to these figures. Deaths resulting from pulmonary circulatory problems and other forms of heart disease reinforce the concern that binge drinking is increasing the number of sudden cardiac deaths and other alcohol-related cardiomyopathy [10]. Types of cancer leading to the most significant numbers of male and female deaths were analysed. Women are primarily affected by sexspecific cancers, with breast cancer being the most important. Discounting female deaths attributable to cancers of the breast, cervix and uterus emphasises the greater incidence of mortality among young men from cancers that might be anticipated to affect men and women similarly (sex-specific cancers are rare among men in the age group 15–44 years). A significant proportion of cancer deaths have been suggested to result from nine behavioural and environmental factors with smoking and alcohol, along with diet, being important in the increased risk in men [11].
Original article Homicide is seen as a big problem in some, but not all, of the countries with Brazil standing out from all the other countries. The prevailing street culture in many countries leads many young men into violence against both men and women [12,13]. Differences in suicide rates pose questions about how suicide is seen within the countries. The very high levels in Eastern Europe support the suggestion that young men are at a much higher risk in countries in transition [14,15]. The high rates in Japan may also reflect social change as well as a cultural acceptance of suicide. In Southern European countries and Egypt suicide is still a taboo for either religious or legal reasons. The low incidence of reported deaths from suicide in these countries may be attributable in part or whole to under-reporting. In conclusion this study has highlighted the importance of recognising the extent of loss of life in young men. Although the death of a young man can be looked at in numbers or rates of death, the data can also be seen as potential years of life lost. For each individual death at an early age there is a significant number of years that person could have expected to live and contribute had he reached the average life expectancy for the country
(which itself should be higher if fewer premature deaths occurred). This highlights the loss to the individual men, their families and to society. In every country there is an excess of male deaths due to potentially avoidable reasons. The main causes of death are those that are more or less directly attributable to lifestyle and risk taking. This raises questions as to whether policy makers and health practitioners can influence how young men live their lives and exercise choice, and whether they can intervene in a social environment where young men’s increased risk taking has become the norm. More disturbing questions are also raised about why young men turn to suicide in such large numbers. There are many limitations to this study, not least the restricted number of countries that could be included (the sub-Saharan countries and the Indian Sub-continent being the most obvious omissions) and the lack of more localised data from within the countries included. National average life expectancy figures can mask huge variations within a country. Nevertheless it is hoped that this broad scoping exercise prompts questions and points to further more detailed analysis and debate.
References [1] Christov V, Zdravko K, Todorova M, Ivanov L, Tzurakova F. A report on the demographic characteristics and the state of men’s health in Bulgaria. J Men’s Health Gend 2004;1(3):191–6. [2] White AK, Cash K. The state of men’s health in Western Europe. J Men’s Health Gend 2004;1:60–6. [3] White AK, Cash K. The state of men’s health across 17 European Countries. Brussels: The European Men’s Health Forum; 2003, ISBN 1-898883-94-7. [4] McKee M, Shkolnikov V. Understanding the toll of premature death among men in Eastern Europe. BMJ 2001;323(7320): 1051–5. [5] Ogah G. Men’s Health in Africa. Conference presentation at The 1st World Congress on Men’s Health: Sex & Gender Matter – From Boys to Men: The Future of Men’s Health, Vienna; 2001. [6] World Health Organization, The World Health Report 2002: Reducing Risks,
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