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Regional mortality differences in Western Europe: A review of the situation in the seventies
REGIONAL MORTALITY DIFFERENCES IN WESTERN EUROPE: A REVIEW OF THE SITUATION IN THE SEVENTIES* FRANS W. Netherlands
Interuniversity
A. VAN POPPEL
Demographic
Institute.
Voorburg.
The Netherlands
Abstract-A comparison of data from nearly 260 regions in Western Europe during the period from 1969 to 1977 reveals regional differences of 11.0 years in life expectation at birth for males as well as females (from 73.6 to 62.6 years for males and from 79.2 to 68.5 years for females). The causes of these differences are still inadequately explored: however, it appears that male mortality is often relatively higher in the regions that are most highly urbanized and where mining and heavy industry or dockyards are concentrated. In contrast. the populations of predominantly agricultural regions appear to enjoy a . . higher life expectation.
INTRODUCTION
While maintaining a system of private enterprise and parliamentary democracy, the governments of a large number of Western European countriest have tried to put an end to the worst forms of inequality by guaranteeing every citizen a home, a minimum wage and access to health and educational facilities [l]. This pursuit of greater social and economic equality began quite recently in some European countries (for example Spain and Portugal), whereas in others (for example the Netherlands, England and Sweden), the process had already begun before the Second World War. We can reasonably expect that these policies, especially in the latter group of countries, would have brought to an end the most dramatic form of inequality that we know, that of “the ability to survive-duration of life itself’ [Z]. After all, a large number of government policies were directed towards those forms of social inequality that had a negative influence on the life expectancy of the least privileged groups. Recent research in Norway, England and France has shown however, that this policy of lowering the level of social and economic inequality did not mean the end of inequality in life chances between the least privileged and the most privileged groups (in terms of education, income and professional status) in society. Information on social inequality with respect to death is not available for all Western European countries. I would nonetheless like to attempt a rough answer to the question of whether social equality in the duration of life has been achieved in Western Europe as a whole. This answer will be based on data referring to regional differences in the mean duration of life in the countries of Western Europe. *This article is an enlarged and updated version of a paper. presented to a WHO/UN meeting on socioeconomic determinants and consequences of mortality. held in Mexico City in June 1979. t For the purpose of this article. Western Europe comprises the Common Market countries, Scandanavia. the Iberian peninsula. Austria and Switzerland 341
Inequality in the expectation of life between regions in a country can be seen as an indication of the existence of social inequality with respect to death. As such, we can assume that, if there is a difference in mortality between two regions, then the variables responsible for the level of mortality (style of living, accessibility to and availability of various social, economic and health facilities, motivations for using these facilities, etc.) will have different values in the one region than in the other. If considerable differences in regional mortality levels are found, then our conclusion can be that complete equality with respect to the social factors relevant to the mortality risks of the individual does not yet exist in Western European society. I deliberately stress social factors because in the Western European context, little real importance can be attached to genetic differences between population groups or differences in the physical geography of regions within countries. Furthermore, social factors not only include ihose circumstances beyond the control of the individual that negatively influence his or her probability of survival by denying certain things essential to health status. It can also be argued that certain patterns of behaviour at an individual level, for which there is a certain amount of personal choice involved (smoking, drinking, driving manners, nutrition), are also social factors, because the frequency at which they occur differs from region to region. One must doubt however, whether the influence of the causes of these differences can be fitted into the framework of a policy of greater equality. An exact answer to the question as to whether the pursuit of more social and economic equality has been successful or not is made even more difficult by the fact that where these policies have had a positive result, new forces may have been put into practice that have led to a reduction of the life chances of the formerly less privileged groups, for example a higher mortality resulting from the ability to buy a private car. Due to all these circumstances, the usefulness of our data remains limited. As a general indication of the social inequality with respect to death however. they remain. in my opinion, useful.
342
FRAN
w.
A. VAN
ACTUAL DATA USED
The comparison of regional mortality levels involved 18 countries: Italy, Austria, Switzerland, Finland. Norway, Sweden, Belgium, the Netherlands, Luxemburg, France, the Federal Republic of Germany, England and Wales, Scotland, Northern Ireland, the Irish Republic, Denmark, Spain and Portugal. For 16 of the 18 selected countries, data on the regional expectation of life have been studied; there is no regional data available for Northern Ireland and Luxemburg: each country is considered as one region. The methods used for calculating the expectation of life and the life table are not the same in every country. Essentially three methods have been used; Reed and Merrell’s. Keyfitz and Flieger’s, and one based on a theoretically derived relation between mortality rates and probabilities. Although the age grouping differs from country to country, calculations for the Netherlands have shown us that this has little effect on the value of the expectation of life. The regions in the European countries involved vary quite clearly in terms of size, population and internal homogeneity. In most cases, owing to the lack of statistical data. there is quite simply no other choice than the one made here. We are therefore compelled to compare a variety of different administrative units such as the Austrian and German Bundeslander, the Grand Duchy of Luxemburg, the Swiss ‘cantons’, and the Belgian. Dutch. Italian and Spanish provinces. We had data at our disposal for varying periods between 1 January 1969 and I January 1978. The values of the expectation of life in the different regions are presented in Figs l-8. For both males and females, these values are divided up into 6 groups. These 6 groups are the same for every country. but the values are different for males and females. RESULTS
Spin
and Portugal
The expectation of life at birth for the period 1969-1972 for Spain and Portugal is given in Figs 1 and 2 [3]. For males (Fig. I) the three Portuguese regions (Norte, Centro and Sul) all have the same shading indicating that the expectation of life everywhere is lower than 66.0 years. None of the 50 Spanish provinces show this low expectation of life. Northern Portugal is characterized by a very low expectation of life-62.6 years. Central Portugal is 2.2 years higher at 64.8 years. The Spanish provinces bordering on Portugal have an expectation of life that bears no relation at all to that of Portugal. Only that western part of Galicia. bordering on Northern Portugal has a somewhat shorter expectation of life compared with the rest of Spain, but this is still 6.3 years higher than the neighbouring Portuguese region. * It has been suggested that the explanation for the favourable position of southern Italy lies partly in the method of calculating death rates. based on the number of deaths of the dejacro population in the numerator and the de jurv population in the denominator. This leads to an overestimation of the expectation of life in the emigrant regtons of the south.
POPPEL
In Spain. the large area extending down from the Pyrenees south-westwards to Madrid stands out as one of high expectation of life-varying between 70.5 years to 72.0 years. In one part of this area. Aragon and Castilla. life expectancy values even reach the European maximum. The least favourable expectation of life is to be found in two areas: first the area inland from the coastal area along the Bay of Biscay (Western Galicia, Old Leon and Old Castilia) in northwest Spain, and secondly in the far south between the Portuguese border via the Gulf of Cadiz to the Mediterranean. With regard to females (Fig. 2) Portugal’s regions again have the lowest expectation of life. No single region has values higher than 72.5 years. Again northern Portugal is the worst (68.5) while Sul (Lisboa. Sttubal) approaches the West European minimum with 71.8 years. If one looks at the separate Portuguese districts for which the expectation of life is given only for both sexes together, the differences are more extreme. Compared with lows of 63.4 in northern Vilareal. 64.8 in Porto and 64.7 in Braganca. one finds highs of 70.1 in the central area (Santarem) and 72.4 in Setubal. The difference is then 9.0 years instead of 2.2 or 3.1 years on a provincial basis. In Spain, there is not one province with an expectation of life lower than 72.5 years. while only two provinces have values less than 74.0 years. The southern part of Spain is characterized by a lower expectation of life. The situation is relatively favourable, although less so than for males. in the area southwest from the Pyrenees (Aragon, Castilla) and in the coastal area along the Bay of Biscay (including Asturia, Vizcaja). Nowhere do the values approach the European maximum. with Huesca again the exception. Austria,
Italy
and Switzerland
Figure 3 relates to Austria, Italy and Switzerland and shows the regional differences in life expectancy in the period 1970-1972 for Austria and Italy and the period 1969-71 for Switzerland [4]. So far as males are concerned. only 2 Austrian provinces (Nieder Gsterreich and Burgenland) have an expectation of life in the lowest category (66.0 years). Apart from these two provinces. there are 4 other provinces in eastern Austria with a low expectation of life. and a definite contrast between east and west can be ascertained. Not a single Austrian province, however. has an expectation of life higher than 68.5. A number of North Italian provinces correspond with the low life expectancy values in Austria. Lombardy, Trentino Alto,Adige and Friuli have an expectation of life of between 67.2 and 67.5 years, but even these northern provinces are above the level of most Austrian provinces. The highest expectation of life is found in the far south of Italy and in 7 provinces we find a life expectancy of between the 70.5 and 72.0 years*. Apart from the far south. we also come across these areas in Central Italy (Toscane, Umbria. Marche). The largest difference in life expectancy is 4.24 years (Friuli 67.19: Calabria 71.43 years). Two cantons in the extreme south of Switzerland. Ticino and Valais. have an expectation of life corresponding with the relatively low level in northern Italy. Together with these two cantons. Fribourg.
Regional
mortality
in
Western
343
Europe
4% Expectation
of life In years
-z 66.0 66.0-
Fig. I. Expectation
of life at birth for the period
Appenzell LRh. and Nidwalden also have a low average expectation of life. The most developed and industrialized parts of Switzerland-around Basle and Ziirich and along the edge of Lake Geneva-enjoy a relatively high average life expectancy, sometimes even exceeding 70.5 years. The maximum difference is 4.8 years, between Basel-Landschaft (71.63 years) and the tiny canton of Appenzell I.Rh. (66.83 years). Figure 4 shows us that the expectation of life of women in the 7 eastern provinces of Austria is less than 74.0 years, the second lowest category.
1969-72,
Spain and Portugal
~675
m
67.5-e69.0
m
69.0-470.5
/g
70.5-c72.0
n
32.0 (males).
Burgenland and Steiermark, both with 73.5 years, are some 1.55 years lower than the expectation of life in Vorarlberg, in the extreme west of the country. Again there is a clear contrast between east and west. In Italy, the highest life expectancy amongst women is to be found in the central area where the provinces Toscana, Umbria and Marche, as in the case of men, have the relatively high values of 76577.0. The situation is somewhat less favourable in Campania and Sicilia. No Italian province has a life expectancy value in the highest or the lowest category.
@a Expectation
of life in years
< 72.5
Fig. 2. Expectation
of life at birth for the period
1969-72.
Spain and Portugal
(females).
344
FRAY-6
w.
A.
VAN
POPPEL
Expectation d Iife in years m
4 66.0
m
66.0-c
67.5
@J
67.5-c
69.0
(IIID 69.0 - < 70.5 a
70.5-
0
2 72.0
< 72.0
Fig. 3. Expectation of life at birth for the period 1969-72. Austria. Italy and Switzerland (males). The same is true in Switzerland. where only Appenzell I.Rh., as was the case with men, has a life expectancy in the second to lowest category (73.17). Women in the canton of Geneva enjoy a particularly high life expectancy (77.12). while those around Basle and Zilrich and along the edge of Lake Geneva also have a relatively high expectation of life. The cantons of Uri. Obwalden. Nidwalden, Schwyz and Graubunden are characterized by a comparatively low expectation of life. Western Europe
Figures 5 and 6 show the situation in Western Europe. The data for the Netherlands are for the period 1971-75. those for England for the period 1974-75, Scotland for 1975-77. Northern Ireland for 1972-74, the Irish Republic for 1970-72, Belgium for 1970-71. France for 1974-76. Luxemburg for 1971-73. the Federal Republic of Germany for 1970-72 and Denmark for 1975-77 [5].
Taking the situation amongst males first (Fig. 5). we can see only 2 areas with a life expectancy in the very highest category of more than 72.0 years: the Dutch province of Zeeland and the 3 Danish provinces Viborg, Ringkebing and Bornholm. The situation in Northern Ireland and the French Nord-Pas de Calais region is, on the other hand, very unfavourable with an expectation of life lower than 66.0 years. The whole western part of the Federal Republic of Germany, Wallonia, parts of northern France (Alsace, Lorraine), Brittany, the northwestern parts of Scotland. is not much better. Looking at the situation by country. we get the following picture. The contrast between northern England and Wales on the one hand. and southern England on the other. is quite striking. The first of these areas has a far lower expectation of life. The situation is most unfavourable in the North West (which includes many old industrial towns such as Burnley. Bolton. Manchester and Oldham). with a value of 67.9 years. in the
Regional martality in Western Europe
34s
Exp+ctation of life in yaors
m
<72.5 72.5 - CI74.0 75.5 77.0 78.5
Fig. 4, Expectation of life at birth for the period 1969-72, Austria, ‘Italy and Switzerland (females).
North East (Newcastle and Sunderland) with 68.2 years and Mersey (Liverpool) with 68.3 years. The situation is much more favourable in the South West. East Anglia (Norfolk. Suffolk and Cambridgeshire) and Oxfordshire. where life expectancy is only just under the European maximum (71.3 years). The maximum difference in England is 3.4 years. We can conclude. but with some caution. that in England, the old urban and industrialized areas have a lower expectation of life than the less urban areas. The northwestern parts of Scotland-the Western Isles, the Highland Region and the Health Board Areas within the Strathclyde Region of Argyll and Clyde, Greater Glasgow and Lanarkshire-have a life expectancy of less than 67.5 years. The Orkney Islands and those Health Board Areas in Eastern Scotland have. on the other hand, a life expectancy of more than 69,Oyears. The values for Dumfries. Galloway’and the Border Regions are very close to those of the neighbouring English Northern Regional
Health Authority. The difference in life expectancy between Greater Glasgow (66.55) and the Border Regions (69.96 years) is 3.31 years. Northern Ireland is characterized by a very low expectation of life (65.0 years), whereas those provinces of the Irish Republic bordering onto Northern Ireland (Connacht, Part of Ulster) have a relatively high iife expectancy (more than 69.5 years). The situation is hardly better in the southern parts of the Irish Republic; Leinster with 68.26 years has the lowest life expectancy. In the Federal Republic of Germany, the highest life expectancy is to be found in Baden-Wiirtemberg, although the values are also high in Schieswig-Holstein. The whole of the western part of the country and West Berlin have a lower life expectancy, with Saarland having the lowest of all with 66.1 years. Again there is a general contrast between the more agricultural regions (Baden-Wiirtemberg. Bayern. Hessen. Schleswig-Holstein) and the more indus-
346
FRANS W. A. VAN POPPEL
Fig. 5. Expectation of life at birth for the period 1970-77. Western Europe (males).
urban regions of the western and northern parts of the Federal Republic. where the expectation of life is never higher than 67.2 years. Every Danish province. with the exception of Kobenhavn-Frederiksberg. is characterized by a high expectation of life. This exceeds 72.0 years in Bornhelm, Ringkebing and Viborg and is never lower than 71.0 in the remaining provinces, making the 68.19 years in Kobenhavn-Fredriksberg look ail the more exceptional. The southern Danish provinces compare very favourably with the federal German state of Schleswig-Holstein that borders on them. The regional contrasts in life expectancy in France are striking with a maximum difference of 5.0 years. Very low values are to be found in Brittany, in Nord and Pas de Calais, in Alsace and the Lorraine. The expectation of life here is never higher than 67.2 years. Normandy, Picardy and Champagne (all in the northern area) are also characterized by low values. The expectation of life in Poitou-Charente. in Miditrialized
Pyrim&es and in Languedoc-Roussillon and finally Paris is relatively high. Belgium (including Luxemburg) can also be divided into a northern and a southern zone. There is a distinct contrast between the’Flemish and the Wallonian provinces, the latter in the southern part of the country not having a life expectancy of more than 67.0 years. Limburg is the only Dutch province where the expectation of life is lower than 70.5 years. In all other provinces in the Netherlands it is higher. In general the expectation of life in the western and northern provinces is higher than in the southern provinces. The maximum regional difference is 2.3 year. We can see a similar regional pattern for females as for males in Fig. 6. Ail Dutch provinces (with the exception of the southern ones), parts of eastern and southern Denmark and central and southern France have an expectation of life between 77.0 and 78.5 years. A low
Regional
mortality
in Western
Europe
347
Expectation life in years m
( 72.5 72.5
L?zj
74.0-c
IlJm
75.5-
- < 74.0
I77.0-c 0
Fig. 6. EXI3ectation of life at birth for the period 1970-77,
expectation of life (between 72.5 and 74.0) can be found in-Ireland, the Strathclyde region in Scotland, Wallonia and the whole of the western part of the Federal Republic of Germany. Viewing the situation in the different countries, we start again with England. The north-south division found in the case of males, is even more obvious in the case of females although the differences are smaller. The North West (74.3) and North (74.4) have again the lowest values, while the highest are to be found in East Anglia and Oxford (76.9). The average life expectancy of women in Scotland is particularly low in the Strathclyde region. In Argyll and Clyde, Greater Glasgow, Lanarkshire and Ayrshire and Arran the expectation of life remains below 74.0 years. The situation with men was similar. The position of the eastern parts of Scotland is a little more favourable, with the Border Regions and Dumfries and Galloway enjoying a somewhat higher life expectancy than the neighbouring English regions. Finally, it is
W ‘est:ern
75.5 -z 77.0 78.5
378.5
Eiurope (females).
worth noting that the expectation of life in the Shetland Islands is very high (77.81 years), making the maximum difference in Scotland (between the Shetland Islands and Ayrshire and Arran) 4.37 years. The expectation of life in the 4 Irish provinces and Northern Ireland is in the second to lowest category, the lowest level being in Munster with 73.25 years. In the Federal Republic of Germany a pattern similar to that for men can also be seen. The more agricultural areas of Baden-Wiirtemberg, Hessen and Schleswig-Holstein again have the highest expectation of life, while West Berlin and Saarland again have the lowest. West Berlin has the lowest value in all of this part of Europe. Generally speaking, the contrast between west and southeast is dominant. The Danish provinces, again with the exception of Kobenhavn-Frederiksberg, are characterized by a relatively high life expectancy. In the southern provinces of Ribe, Fyn and Ssnderjylland and in Viborg and Roskilde, this reaches a level of 77.0 or more, a
FRANS W. A. VAN POPPEL
348
Expectatlan
of hfe
66.0
- -z 675
m
675
- ~69.0
am]
69.0
- c70.5
m
70.5
- <720
I
372.0
Fig. 7. Expectation of life at birth for the period 1971-77. Scandinavia (males).
maximum difference Frederiksberg.
of 2.17 years with
Kobenhavn-
The regional differences in France with regard to females are not as strong as was the case with males, although a regional pattern can clearly be seen. Again the central and southern regions contrast with Alsace, Lorraine, Picardy and Nord-Pas-de-Calais. Belgium and Luxemburg are again characterized by a distinction between Wallonia and Flanders. Brabant has the highest life expectancy (75.0) of all the Belgian provinces, a little higher than West Flanders (74.8). In the Netherlands, the southern provinces again have the lowest expectation of life, while the northern and south-western provinces have higher life expectancy. The maximum, in Zeeland, is 77.8 years. Scandinavia
The data for Scandinavia is given in Figs 7 and 8. The Norwegian data is for the period 1971-75, the Finnish data for the period 1975-77 and the Swedish data is for the period 1974-77 CC;].
With regard to males (Fig. 7), it is immediately obvious that a large part of Sweden belongs to the category with an expectation of life higher than 72.0 years, while almost the same situation predominates in Norway. Only the provinces in the extreme north of this country (Troms and Finnmark) and the Oslo region have an expectation of life under the 70.5. Finnmark has an expectation of life as low as 68.0 but this is still somewhat more favourable than a very large number of Finnish provinces. The whole northern part of Finland has, for example, a life expectancy of less than 66.0 years, while in another 4 provinces in the southeast of the country the level is never higher than 67.50 years. The sparsely populated Ahvenanmaa islands enjoy the highest life expectancy (68.63). some 3.48 years higher than Pohjois-Karjalan in the eastern part of Finland. In a large number of Swedish and Norwegian provinces, however, we find a life expectancy higher than 72.0 years, mainly in southern Sweden, a part of central Sweden and a large part of southern Norway except that area on the Skagerrak. The maximum expectation of life in Norway is 73.0
349
Regional mortality in Western Europe
Expectation of life in years
Fig. 8. Expectation
of life at birth for the period 1971-77, Scandinavia (females).
years, in Sweden 73.55 years, while the minima are respectively 68.0 and 71.0 years. With females (Fig. 8) there are only 3 provinces in Norway and Sweden where the expectation of life is less than 77.0 years. These are again Troms and Finnmark (respectively 76.8 and 76.2 years) in the extreme north of Norway, and Bstfold in the south. In complete contrast to this, only one of the 12 Finnish provinces exceeds 77.0 years, namely Ahvenanmaa with a notably high 78.90 years. Life expectancy in the central part of Finland is between 74.0 and 75.5 years, while in the southwest the levels are a little higher. The maximum difference in Finland is 4.20 years. Four Norwegian and 4 Swedish provinces have an expectation of life of 78.5 or more, again in southern Sweden and the west coast provinces of Norway. The maximum value in Sweden and Norway is 79.2, while the minima are respectively 77.3 and 76.2 years. This
*Sweden, because the improvement has been uninterrupted.
of life expectancy
indicates regional differences of respectively 3.0 years.
1.9 and
CONCLUSION
The data presented here shows quite clearly that the European countries internally exhibit a large degree of heterogeneity with regard to the mean length of life of its inhabitants. National borders however, are still of great importance to the level of mortality when they separate two adjoining regions whose internal structure is otherwise similar. One only has to look at the difference in the levels of life expectancy in the Spanish-Portuguese, the Dutch-German and the Finnish-Swedish border regions to realize this. We can demonstrate the internal heterogeneity of Europe most clearly by comparing the maximum and minimum regional life expectancy values of each country with the temporal development of life expectancy in Sweden.* This has been done in Figs 9 and 10. The continuous line shows the values registered in Sweden since 1900.
FRANS W. A. VAN POPPEL
350
66.0 66.0 64.0 52.0
62.0 60.0 58.0
56.0
56.0 540 1935
I945
1955
1965
1975
Year Fig. 9. Regional
dikrences
in the expectation expectation
of life compared with the temporal of life in Sweden (males).
We can see that some regions in Portugal are in a similar situation for males as Sweden as a whole was around 1930 and that others correspond with values in Sweden towards the end of the 1930s (Fig. 9) The French regions can be placed between the beginning of the ’40s and the beginning of the 1960s while the values for Italy correspond with the values for Sweden between the beginning of the 1940s and the middle ’60s. Some Dutch provinces have values corresponding with Sweden as a whole at the beginning of the 195Os, whereas other provinces have values above that of Sweden at the present time.
69.0
-
67.0
-
65.0
-
63.0
-
61.0
-
59.0
-
57.0
development
of the
In the case of women, we can see that the variance with respect to the development in Sweden as a whole is much smaller and that all countries occupy less of the graph compared to the males. Portugal again lags behind the other countries, with life expectancies corresponding with those in Sweden in the 1940s (Fig. 10). The values for the French regions compare to those in Sweden between the middle of the ’50s and the end of the ’70s. The different levels of the Dutch provinces lie between those for Sweden some 10 years ago and a
-
67.0
- 630
1 lSO5
I ISIS
I 1925
I 1935
1 1945
8 IS?+!3
I 1965
590
IS75
Year Fig. 10. Regional
differences
in the expectation of life compared with the temporal expectation of life in Sweden (females).
development
of the
Regional mortality in Western Europe
351
Table 1. Maximum and minimum life expectancy values 1969- 1977 Females
Males
Austria Belgium/Luxembourg Denmark England Federal Reoublic of Germanv Finland ’ France Irish Republic/Northern Ireland Italy Netherlands Norway Portugal Scotland Spain Sweden Switzerland
Maximum
Minimum
DilTerence
Maximum
Minimum
Difference
68.37 69.32 72.80 71.30 68.49 68.63 70.70 69.73 71.43 72.43 73.02 64.80
65.49 66.13 68.19 67.90 66.06 65.15 65.70 65.00
2.88 3.19 4.61 3.40 2.43 3.48 5.00 4.73 4.24 2.30 5.00 2.20 3.31 5.10 2.51 4.80
75.05 75.03 77.46 76.90 74.50 78.90 77.70 73.96 76.84 77.82 79.16 71.60 77.81 77.10 79.18 77.12
73.50 75.57 75.29 74.30 72.52 74.70 74.10 73.25 72.94 76.13 76.17 68.50 73.44 73.80 77.27 73.17
1.55 I .46 2.17 2.60 I .98 4.20 3.60 0.71 3.90 1.51 2.99 3.10 4.37 3.30 1.91 3.95
69.96
72.80 73.55 71.63
67.19
70.13 68.02 62.60 66.65 67.70 71.04 66.83
level of 77.8 years that Sweden as a whole has not yet reached. On the basis of our data, there is no relation to be found between the expectation of life on a national level and the existing internal inequality within a country. However, because data have been used on different levels and for different time periods, we must realise that a strict comparison is not possible. Sweden and the Netherlands have, for example, a high expectation of life with a low regional differentiation internally, but in strong contrast to this, Germany and Austria have a low life expectancy and a low regional differentiation, and Norway a high life expectancy and a high regional differentiation. The internal inequality is greater for males than for females in every country except Portugal, Finland and Scotland. In Sweden this is only just the case (0.60 years), and in the Netherlands (0.79). Germany (0.45), Italy (0.35) and England (0.80) the same is true. In Denmark, Austria, Belgium, Spain and Norway (respectively 2.44, 1.55, 1.73, 1.80 and 2.01), the regional differences are clearly greater for males than for females. This can be seen in Table 1. Even if the level of regional inequality
amongst men is greater than amongst women, this does not mean to say that there are not any similarities between the regional patterns of mortality for men and those for women. The most favourable and the least favourable regions are the same for men and women in almost every country. This comparison of 18 European countries gives the impression that the urban areas with mining, docks and declining heavy industry tend to have a relatively low expectation of life, while the more agricultural country regions enjoy a higher one. Examples exist in France, Belgium, Italy and the Federal Republic. The question could be asked whether it is justifiable paying so much attention to differences in the mean expectation of life of 2-3 years for men and l-2 years for women in different provinces (Sweden, Austria, the Federal Republic, the Netherlands). Even if one admits that inequality with respect to death would
continue to exist, it is still rather difficult to convince oneself that the extra number of years obtained is worth all the effort needed to eliminate this inequality. Many writers have pointed out however, that even though a difference in the expectation of life of 2-3 years can be called minimal, the total elimination of, for example, neoplasms in Western Europe would only increase life expectancy by a little more than this amount. The huge amount of effort put into this last aspect is out of all proportion to the effort put into detecting regional differences and doing something about them. Illustrating this point with Dutch statistics, an increase in the life expectancy of the Limburg male by 2.3 years to bring it up to the same level as exists in &eland would be equal to 70% of the possible increase in life expectancy resulting from the elimination of neoplasms and even 70% more than the increase in life expectancy which would occur if a11accidents were eliminated. These figures would be 50% and 114% respectively for the female population. This is evident enough of the relevance of research into regional differences in mortality. REFERENCES This is based on: Schuyt C. De sociale toekomst van de verzorigingsstaat. Beleid en Muurschoppij 2, 190, 1976. Kitagawa E. M. and Hauser P. M. Differential Martality in the United States: A Study in Socio-economic Epidemiology. Harvard Univ. Press, Cambridge, 1973. Data borrowed from respectively: -Centro de Estudos DemogrBficos/lnstituto National de Estatistica. Tgbuas abreviadas de mortalidade distritais e regionais 1959-1962 e 1969-1972. Caderno no. 4. Lisboa, 1976. -Ministerio de Economica/lnstituto National de Estadistica. Tablas de mortalidad provinciales (1969-1972). Ano 1970. Madrid, 1978. Data borrowed from respectively: -1stituto di Demografia. Tavole di mortalita ridotte per le regioni e le repartizioni italiane 1959-1961-1971. Roma, 1977. -&terreichischen Statistisches Zentralamt (unter
352
FRANS W. A. VAN POPPEL Mitwirkung des Gsterreichischen Bundesinstitutes fur Gesundheitswesen,). Regionale Unterschiede in der Sterblichkeit in Osterreich 1969-1973. Beitrage zur Osterreichischen Statistik. Heft 404. Wien. 1976. ~-Average life expectancy for the 25 Swiss Cantons IS calculated on the basis of mortality rates for the period 1969-71. These are determined on the basis of the average number of deaths per year in the age groups
(1) imo = 140 (2) (1 - 44,) = (1 - &/(I - iqo) in which 5qo is derived from sm,, with the aid of Reed and Merrell’s formula, and (3) 4ml = 491 (4 - 244i). The mortality rates for those ages of 20 years and upwards are converted into rates for quinquennial age groups by assuming that, within each decennial age group, the mortality rates for the quinquennial age groups would be in the same proportions as in Switzerland as a whole in 1971. and also by taking into consideration the age structure within the decennial groups as published in the last Census. The mortality rates obtained in this way are then converted into mortality probabilities, and a life table is compiled on the basis of the method set out in Cornpurer Proyramsfor Detnoyruphic Analysis. Arriage E. er al.. U.S. Bureau of the Census, Washmgton. 1976. 5. Data borrowed from respectively: -Gardner M. and Donnan S. Life expectancy: variations among regional health authorities. Pop. Trend.\ IO. IO. 1977. -Wattelar C. et Renaerts M. Tables de mortalite abregees des provinces beiges 1970-1971. Infor-Demo no. 9. Departement de Dtmographie. Universiti Catholique de Louvain, Louvain-La-Neuve, 1976. -Poppel F. W. A. van. Provinciale sterfteverschillen in Nederland in de periode 1971-1975. K.N.A.G. Geoyrafisch Tiidschrifi. Nieuwe Reeks 5. 406. 1978. -Statistisches Bundesamt. AIlgmeine Sterbetafil fir die Bundesrepublik Deutschland 1970/72. Bevolkerung und Kultur, Fachserie A, Reihe 2, Sonderbeitrag, Stuttgart, 1976. -Registrar General Scotland. Annual Report 1977, Part 1. Mortality Statistics. Edinburgh, HMSO. 1978. -The data for the Irish Republic are calculated on the basis of the mortality rates for the period 1970-72. These are then converted in the same way as the Swiss data into mortality probabilities and life tables. The mortality rates are determined on the basis of the average number of deaths in the age groups < 1, l-4. 5-9. etc. up to and including 80+ in 1970, 1971 and 1972 (published in An Roinn Slainte (Central Statistical
Office). Tuarascail ar Staidreamh Beatha (Report on Vital Statistics)). and the number of persons present at the time of the 1971 Census (Central Statistical Office. Crn.su.s of’ Popularion 01’ Ireland 1971. Vol Il. Ages und Conjugal Conditions Clu.wrfird hi, Area.\. Dublin. 1973). -The average life expectancy for Denmark is likewise calculated on the basis of the method published by the U.S. Bureau of the Census. Mortality rates for the period 1975-77 (published in. Danmarks Statistik. Befolkningrns Meddelelser
Berueyelsrr
Kebenhavn)
I975.
I976.
1977. Statistiske
form the basis of these calcu-
lations. These mortality rates relate to the age groups < I. l-29, 30-39 etc. up to and including 7&79 and 80 + Quinquennial mortality rates are derived from these on the basis firstly of the provincial data on the age structure within the age groups l-29. 3&39. etc. up to and including 7s-79 years. and secondly of the mutual relationship between the mortality rates for the age groups l-4. 5-9, l&-14. 15-19. 20-24, 25-29, 3&34. 35-39 etc. up to and including 75-79 years as ascertained for Denmark as a whole on average during the period in question. -Dr G. Desoianaues of the INSEE (Paris) made available the unpublished French data concerning the period 197476. of life in Norway has been calculated 6. The expectation with the help of data published in: -Statistik Sentralbyra. Dodeliqheren i Fvlkmr 1971-1975. (Morta/it)Y in Counties-i971-1975). Norges offisielle statistik A 948. Oslo. 1978. The 5-vearlv (UD to the age of 30) and IO-yearly (from 30 to 80) mortality rates published in these statistics have been converted into probabilities of death with the help of Reed and Merrell’s formulae. and then a life table made from these probabilities. Data for Sweden was derived from: -Statistiska Centralbyran. BeJo/kninysfdriindrinyur. Del 3. Hela riket och Ianen m m. 1974. 1975. 1976. 1977. Stockholm. The published mortality rates for quinquennial age groups (up to the age of 85) have been turned into an average rate for the period 1974-1977. The mortality rate for the age group &I (the number of deaths in the first year of life divided by the number of live births) has been calculated and turned into an average for the period 1974-78. The values of -Im, . have been calcuiated by making , m o = ,qo and by converting smO via Reed and Merrell to 5q0 and then applying (1 - sq,):(l - ,q,) = (1 - 4q,). Finally. the value of ma,,+ has been calculated by weighing the values of +tgr, and msSc against the age structure. -The data for Finland have been calculated as follows. From the mortality rates published for the Finnish provinces (see Ttilastokeskus (Central Statistical Office of Finland), Suomen virallinen tilasto (Official Statistics of Finland) and Vlestonmuutokset (Vital Statistics) 1972. 1973. 1974 and 1975). the average figure for each of the age groups O-4, 5-9, etc. up to and including 75-79, 80+ is calculated for the period 1972-1975 inclusive. The value of ,qO is then determined per province on the basis of the relationship established for the whole country between ,qO and sat,,, The value 4ql is calculated and the life table constructed, in the same way as for Switzerland.
Interuniversity
A. VAN POPPEL
Demographic
Institute.
Voorburg.
The Netherlands
Abstract-A comparison of data from nearly 260 regions in Western Europe during the period from 1969 to 1977 reveals regional differences of 11.0 years in life expectation at birth for males as well as females (from 73.6 to 62.6 years for males and from 79.2 to 68.5 years for females). The causes of these differences are still inadequately explored: however, it appears that male mortality is often relatively higher in the regions that are most highly urbanized and where mining and heavy industry or dockyards are concentrated. In contrast. the populations of predominantly agricultural regions appear to enjoy a . . higher life expectation.
INTRODUCTION
While maintaining a system of private enterprise and parliamentary democracy, the governments of a large number of Western European countriest have tried to put an end to the worst forms of inequality by guaranteeing every citizen a home, a minimum wage and access to health and educational facilities [l]. This pursuit of greater social and economic equality began quite recently in some European countries (for example Spain and Portugal), whereas in others (for example the Netherlands, England and Sweden), the process had already begun before the Second World War. We can reasonably expect that these policies, especially in the latter group of countries, would have brought to an end the most dramatic form of inequality that we know, that of “the ability to survive-duration of life itself’ [Z]. After all, a large number of government policies were directed towards those forms of social inequality that had a negative influence on the life expectancy of the least privileged groups. Recent research in Norway, England and France has shown however, that this policy of lowering the level of social and economic inequality did not mean the end of inequality in life chances between the least privileged and the most privileged groups (in terms of education, income and professional status) in society. Information on social inequality with respect to death is not available for all Western European countries. I would nonetheless like to attempt a rough answer to the question of whether social equality in the duration of life has been achieved in Western Europe as a whole. This answer will be based on data referring to regional differences in the mean duration of life in the countries of Western Europe. *This article is an enlarged and updated version of a paper. presented to a WHO/UN meeting on socioeconomic determinants and consequences of mortality. held in Mexico City in June 1979. t For the purpose of this article. Western Europe comprises the Common Market countries, Scandanavia. the Iberian peninsula. Austria and Switzerland 341
Inequality in the expectation of life between regions in a country can be seen as an indication of the existence of social inequality with respect to death. As such, we can assume that, if there is a difference in mortality between two regions, then the variables responsible for the level of mortality (style of living, accessibility to and availability of various social, economic and health facilities, motivations for using these facilities, etc.) will have different values in the one region than in the other. If considerable differences in regional mortality levels are found, then our conclusion can be that complete equality with respect to the social factors relevant to the mortality risks of the individual does not yet exist in Western European society. I deliberately stress social factors because in the Western European context, little real importance can be attached to genetic differences between population groups or differences in the physical geography of regions within countries. Furthermore, social factors not only include ihose circumstances beyond the control of the individual that negatively influence his or her probability of survival by denying certain things essential to health status. It can also be argued that certain patterns of behaviour at an individual level, for which there is a certain amount of personal choice involved (smoking, drinking, driving manners, nutrition), are also social factors, because the frequency at which they occur differs from region to region. One must doubt however, whether the influence of the causes of these differences can be fitted into the framework of a policy of greater equality. An exact answer to the question as to whether the pursuit of more social and economic equality has been successful or not is made even more difficult by the fact that where these policies have had a positive result, new forces may have been put into practice that have led to a reduction of the life chances of the formerly less privileged groups, for example a higher mortality resulting from the ability to buy a private car. Due to all these circumstances, the usefulness of our data remains limited. As a general indication of the social inequality with respect to death however. they remain. in my opinion, useful.
342
FRAN
w.
A. VAN
ACTUAL DATA USED
The comparison of regional mortality levels involved 18 countries: Italy, Austria, Switzerland, Finland. Norway, Sweden, Belgium, the Netherlands, Luxemburg, France, the Federal Republic of Germany, England and Wales, Scotland, Northern Ireland, the Irish Republic, Denmark, Spain and Portugal. For 16 of the 18 selected countries, data on the regional expectation of life have been studied; there is no regional data available for Northern Ireland and Luxemburg: each country is considered as one region. The methods used for calculating the expectation of life and the life table are not the same in every country. Essentially three methods have been used; Reed and Merrell’s. Keyfitz and Flieger’s, and one based on a theoretically derived relation between mortality rates and probabilities. Although the age grouping differs from country to country, calculations for the Netherlands have shown us that this has little effect on the value of the expectation of life. The regions in the European countries involved vary quite clearly in terms of size, population and internal homogeneity. In most cases, owing to the lack of statistical data. there is quite simply no other choice than the one made here. We are therefore compelled to compare a variety of different administrative units such as the Austrian and German Bundeslander, the Grand Duchy of Luxemburg, the Swiss ‘cantons’, and the Belgian. Dutch. Italian and Spanish provinces. We had data at our disposal for varying periods between 1 January 1969 and I January 1978. The values of the expectation of life in the different regions are presented in Figs l-8. For both males and females, these values are divided up into 6 groups. These 6 groups are the same for every country. but the values are different for males and females. RESULTS
Spin
and Portugal
The expectation of life at birth for the period 1969-1972 for Spain and Portugal is given in Figs 1 and 2 [3]. For males (Fig. I) the three Portuguese regions (Norte, Centro and Sul) all have the same shading indicating that the expectation of life everywhere is lower than 66.0 years. None of the 50 Spanish provinces show this low expectation of life. Northern Portugal is characterized by a very low expectation of life-62.6 years. Central Portugal is 2.2 years higher at 64.8 years. The Spanish provinces bordering on Portugal have an expectation of life that bears no relation at all to that of Portugal. Only that western part of Galicia. bordering on Northern Portugal has a somewhat shorter expectation of life compared with the rest of Spain, but this is still 6.3 years higher than the neighbouring Portuguese region. * It has been suggested that the explanation for the favourable position of southern Italy lies partly in the method of calculating death rates. based on the number of deaths of the dejacro population in the numerator and the de jurv population in the denominator. This leads to an overestimation of the expectation of life in the emigrant regtons of the south.
POPPEL
In Spain. the large area extending down from the Pyrenees south-westwards to Madrid stands out as one of high expectation of life-varying between 70.5 years to 72.0 years. In one part of this area. Aragon and Castilla. life expectancy values even reach the European maximum. The least favourable expectation of life is to be found in two areas: first the area inland from the coastal area along the Bay of Biscay (Western Galicia, Old Leon and Old Castilia) in northwest Spain, and secondly in the far south between the Portuguese border via the Gulf of Cadiz to the Mediterranean. With regard to females (Fig. 2) Portugal’s regions again have the lowest expectation of life. No single region has values higher than 72.5 years. Again northern Portugal is the worst (68.5) while Sul (Lisboa. Sttubal) approaches the West European minimum with 71.8 years. If one looks at the separate Portuguese districts for which the expectation of life is given only for both sexes together, the differences are more extreme. Compared with lows of 63.4 in northern Vilareal. 64.8 in Porto and 64.7 in Braganca. one finds highs of 70.1 in the central area (Santarem) and 72.4 in Setubal. The difference is then 9.0 years instead of 2.2 or 3.1 years on a provincial basis. In Spain, there is not one province with an expectation of life lower than 72.5 years. while only two provinces have values less than 74.0 years. The southern part of Spain is characterized by a lower expectation of life. The situation is relatively favourable, although less so than for males. in the area southwest from the Pyrenees (Aragon, Castilla) and in the coastal area along the Bay of Biscay (including Asturia, Vizcaja). Nowhere do the values approach the European maximum. with Huesca again the exception. Austria,
Italy
and Switzerland
Figure 3 relates to Austria, Italy and Switzerland and shows the regional differences in life expectancy in the period 1970-1972 for Austria and Italy and the period 1969-71 for Switzerland [4]. So far as males are concerned. only 2 Austrian provinces (Nieder Gsterreich and Burgenland) have an expectation of life in the lowest category (66.0 years). Apart from these two provinces. there are 4 other provinces in eastern Austria with a low expectation of life. and a definite contrast between east and west can be ascertained. Not a single Austrian province, however. has an expectation of life higher than 68.5. A number of North Italian provinces correspond with the low life expectancy values in Austria. Lombardy, Trentino Alto,Adige and Friuli have an expectation of life of between 67.2 and 67.5 years, but even these northern provinces are above the level of most Austrian provinces. The highest expectation of life is found in the far south of Italy and in 7 provinces we find a life expectancy of between the 70.5 and 72.0 years*. Apart from the far south. we also come across these areas in Central Italy (Toscane, Umbria. Marche). The largest difference in life expectancy is 4.24 years (Friuli 67.19: Calabria 71.43 years). Two cantons in the extreme south of Switzerland. Ticino and Valais. have an expectation of life corresponding with the relatively low level in northern Italy. Together with these two cantons. Fribourg.
Regional
mortality
in
Western
343
Europe
4% Expectation
of life In years
-z 66.0 66.0-
Fig. I. Expectation
of life at birth for the period
Appenzell LRh. and Nidwalden also have a low average expectation of life. The most developed and industrialized parts of Switzerland-around Basle and Ziirich and along the edge of Lake Geneva-enjoy a relatively high average life expectancy, sometimes even exceeding 70.5 years. The maximum difference is 4.8 years, between Basel-Landschaft (71.63 years) and the tiny canton of Appenzell I.Rh. (66.83 years). Figure 4 shows us that the expectation of life of women in the 7 eastern provinces of Austria is less than 74.0 years, the second lowest category.
1969-72,
Spain and Portugal
~675
m
67.5-e69.0
m
69.0-470.5
/g
70.5-c72.0
n
32.0 (males).
Burgenland and Steiermark, both with 73.5 years, are some 1.55 years lower than the expectation of life in Vorarlberg, in the extreme west of the country. Again there is a clear contrast between east and west. In Italy, the highest life expectancy amongst women is to be found in the central area where the provinces Toscana, Umbria and Marche, as in the case of men, have the relatively high values of 76577.0. The situation is somewhat less favourable in Campania and Sicilia. No Italian province has a life expectancy value in the highest or the lowest category.
@a Expectation
of life in years
< 72.5
Fig. 2. Expectation
of life at birth for the period
1969-72.
Spain and Portugal
(females).
344
FRAY-6
w.
A.
VAN
POPPEL
Expectation d Iife in years m
4 66.0
m
66.0-c
67.5
@J
67.5-c
69.0
(IIID 69.0 - < 70.5 a
70.5-
0
2 72.0
< 72.0
Fig. 3. Expectation of life at birth for the period 1969-72. Austria. Italy and Switzerland (males). The same is true in Switzerland. where only Appenzell I.Rh., as was the case with men, has a life expectancy in the second to lowest category (73.17). Women in the canton of Geneva enjoy a particularly high life expectancy (77.12). while those around Basle and Zilrich and along the edge of Lake Geneva also have a relatively high expectation of life. The cantons of Uri. Obwalden. Nidwalden, Schwyz and Graubunden are characterized by a comparatively low expectation of life. Western Europe
Figures 5 and 6 show the situation in Western Europe. The data for the Netherlands are for the period 1971-75. those for England for the period 1974-75, Scotland for 1975-77. Northern Ireland for 1972-74, the Irish Republic for 1970-72, Belgium for 1970-71. France for 1974-76. Luxemburg for 1971-73. the Federal Republic of Germany for 1970-72 and Denmark for 1975-77 [5].
Taking the situation amongst males first (Fig. 5). we can see only 2 areas with a life expectancy in the very highest category of more than 72.0 years: the Dutch province of Zeeland and the 3 Danish provinces Viborg, Ringkebing and Bornholm. The situation in Northern Ireland and the French Nord-Pas de Calais region is, on the other hand, very unfavourable with an expectation of life lower than 66.0 years. The whole western part of the Federal Republic of Germany, Wallonia, parts of northern France (Alsace, Lorraine), Brittany, the northwestern parts of Scotland. is not much better. Looking at the situation by country. we get the following picture. The contrast between northern England and Wales on the one hand. and southern England on the other. is quite striking. The first of these areas has a far lower expectation of life. The situation is most unfavourable in the North West (which includes many old industrial towns such as Burnley. Bolton. Manchester and Oldham). with a value of 67.9 years. in the
Regional martality in Western Europe
34s
Exp+ctation of life in yaors
m
<72.5 72.5 - CI74.0 75.5 77.0 78.5
Fig. 4, Expectation of life at birth for the period 1969-72, Austria, ‘Italy and Switzerland (females).
North East (Newcastle and Sunderland) with 68.2 years and Mersey (Liverpool) with 68.3 years. The situation is much more favourable in the South West. East Anglia (Norfolk. Suffolk and Cambridgeshire) and Oxfordshire. where life expectancy is only just under the European maximum (71.3 years). The maximum difference in England is 3.4 years. We can conclude. but with some caution. that in England, the old urban and industrialized areas have a lower expectation of life than the less urban areas. The northwestern parts of Scotland-the Western Isles, the Highland Region and the Health Board Areas within the Strathclyde Region of Argyll and Clyde, Greater Glasgow and Lanarkshire-have a life expectancy of less than 67.5 years. The Orkney Islands and those Health Board Areas in Eastern Scotland have. on the other hand, a life expectancy of more than 69,Oyears. The values for Dumfries. Galloway’and the Border Regions are very close to those of the neighbouring English Northern Regional
Health Authority. The difference in life expectancy between Greater Glasgow (66.55) and the Border Regions (69.96 years) is 3.31 years. Northern Ireland is characterized by a very low expectation of life (65.0 years), whereas those provinces of the Irish Republic bordering onto Northern Ireland (Connacht, Part of Ulster) have a relatively high iife expectancy (more than 69.5 years). The situation is hardly better in the southern parts of the Irish Republic; Leinster with 68.26 years has the lowest life expectancy. In the Federal Republic of Germany, the highest life expectancy is to be found in Baden-Wiirtemberg, although the values are also high in Schieswig-Holstein. The whole of the western part of the country and West Berlin have a lower life expectancy, with Saarland having the lowest of all with 66.1 years. Again there is a general contrast between the more agricultural regions (Baden-Wiirtemberg. Bayern. Hessen. Schleswig-Holstein) and the more indus-
346
FRANS W. A. VAN POPPEL
Fig. 5. Expectation of life at birth for the period 1970-77. Western Europe (males).
urban regions of the western and northern parts of the Federal Republic. where the expectation of life is never higher than 67.2 years. Every Danish province. with the exception of Kobenhavn-Frederiksberg. is characterized by a high expectation of life. This exceeds 72.0 years in Bornhelm, Ringkebing and Viborg and is never lower than 71.0 in the remaining provinces, making the 68.19 years in Kobenhavn-Fredriksberg look ail the more exceptional. The southern Danish provinces compare very favourably with the federal German state of Schleswig-Holstein that borders on them. The regional contrasts in life expectancy in France are striking with a maximum difference of 5.0 years. Very low values are to be found in Brittany, in Nord and Pas de Calais, in Alsace and the Lorraine. The expectation of life here is never higher than 67.2 years. Normandy, Picardy and Champagne (all in the northern area) are also characterized by low values. The expectation of life in Poitou-Charente. in Miditrialized
Pyrim&es and in Languedoc-Roussillon and finally Paris is relatively high. Belgium (including Luxemburg) can also be divided into a northern and a southern zone. There is a distinct contrast between the’Flemish and the Wallonian provinces, the latter in the southern part of the country not having a life expectancy of more than 67.0 years. Limburg is the only Dutch province where the expectation of life is lower than 70.5 years. In all other provinces in the Netherlands it is higher. In general the expectation of life in the western and northern provinces is higher than in the southern provinces. The maximum regional difference is 2.3 year. We can see a similar regional pattern for females as for males in Fig. 6. Ail Dutch provinces (with the exception of the southern ones), parts of eastern and southern Denmark and central and southern France have an expectation of life between 77.0 and 78.5 years. A low
Regional
mortality
in Western
Europe
347
Expectation life in years m
( 72.5 72.5
L?zj
74.0-c
IlJm
75.5-
- < 74.0
I77.0-c 0
Fig. 6. EXI3ectation of life at birth for the period 1970-77,
expectation of life (between 72.5 and 74.0) can be found in-Ireland, the Strathclyde region in Scotland, Wallonia and the whole of the western part of the Federal Republic of Germany. Viewing the situation in the different countries, we start again with England. The north-south division found in the case of males, is even more obvious in the case of females although the differences are smaller. The North West (74.3) and North (74.4) have again the lowest values, while the highest are to be found in East Anglia and Oxford (76.9). The average life expectancy of women in Scotland is particularly low in the Strathclyde region. In Argyll and Clyde, Greater Glasgow, Lanarkshire and Ayrshire and Arran the expectation of life remains below 74.0 years. The situation with men was similar. The position of the eastern parts of Scotland is a little more favourable, with the Border Regions and Dumfries and Galloway enjoying a somewhat higher life expectancy than the neighbouring English regions. Finally, it is
W ‘est:ern
75.5 -z 77.0 78.5
378.5
Eiurope (females).
worth noting that the expectation of life in the Shetland Islands is very high (77.81 years), making the maximum difference in Scotland (between the Shetland Islands and Ayrshire and Arran) 4.37 years. The expectation of life in the 4 Irish provinces and Northern Ireland is in the second to lowest category, the lowest level being in Munster with 73.25 years. In the Federal Republic of Germany a pattern similar to that for men can also be seen. The more agricultural areas of Baden-Wiirtemberg, Hessen and Schleswig-Holstein again have the highest expectation of life, while West Berlin and Saarland again have the lowest. West Berlin has the lowest value in all of this part of Europe. Generally speaking, the contrast between west and southeast is dominant. The Danish provinces, again with the exception of Kobenhavn-Frederiksberg, are characterized by a relatively high life expectancy. In the southern provinces of Ribe, Fyn and Ssnderjylland and in Viborg and Roskilde, this reaches a level of 77.0 or more, a
FRANS W. A. VAN POPPEL
348
Expectatlan
of hfe
66.0
- -z 675
m
675
- ~69.0
am]
69.0
- c70.5
m
70.5
- <720
I
372.0
Fig. 7. Expectation of life at birth for the period 1971-77. Scandinavia (males).
maximum difference Frederiksberg.
of 2.17 years with
Kobenhavn-
The regional differences in France with regard to females are not as strong as was the case with males, although a regional pattern can clearly be seen. Again the central and southern regions contrast with Alsace, Lorraine, Picardy and Nord-Pas-de-Calais. Belgium and Luxemburg are again characterized by a distinction between Wallonia and Flanders. Brabant has the highest life expectancy (75.0) of all the Belgian provinces, a little higher than West Flanders (74.8). In the Netherlands, the southern provinces again have the lowest expectation of life, while the northern and south-western provinces have higher life expectancy. The maximum, in Zeeland, is 77.8 years. Scandinavia
The data for Scandinavia is given in Figs 7 and 8. The Norwegian data is for the period 1971-75, the Finnish data for the period 1975-77 and the Swedish data is for the period 1974-77 CC;].
With regard to males (Fig. 7), it is immediately obvious that a large part of Sweden belongs to the category with an expectation of life higher than 72.0 years, while almost the same situation predominates in Norway. Only the provinces in the extreme north of this country (Troms and Finnmark) and the Oslo region have an expectation of life under the 70.5. Finnmark has an expectation of life as low as 68.0 but this is still somewhat more favourable than a very large number of Finnish provinces. The whole northern part of Finland has, for example, a life expectancy of less than 66.0 years, while in another 4 provinces in the southeast of the country the level is never higher than 67.50 years. The sparsely populated Ahvenanmaa islands enjoy the highest life expectancy (68.63). some 3.48 years higher than Pohjois-Karjalan in the eastern part of Finland. In a large number of Swedish and Norwegian provinces, however, we find a life expectancy higher than 72.0 years, mainly in southern Sweden, a part of central Sweden and a large part of southern Norway except that area on the Skagerrak. The maximum expectation of life in Norway is 73.0
349
Regional mortality in Western Europe
Expectation of life in years
Fig. 8. Expectation
of life at birth for the period 1971-77, Scandinavia (females).
years, in Sweden 73.55 years, while the minima are respectively 68.0 and 71.0 years. With females (Fig. 8) there are only 3 provinces in Norway and Sweden where the expectation of life is less than 77.0 years. These are again Troms and Finnmark (respectively 76.8 and 76.2 years) in the extreme north of Norway, and Bstfold in the south. In complete contrast to this, only one of the 12 Finnish provinces exceeds 77.0 years, namely Ahvenanmaa with a notably high 78.90 years. Life expectancy in the central part of Finland is between 74.0 and 75.5 years, while in the southwest the levels are a little higher. The maximum difference in Finland is 4.20 years. Four Norwegian and 4 Swedish provinces have an expectation of life of 78.5 or more, again in southern Sweden and the west coast provinces of Norway. The maximum value in Sweden and Norway is 79.2, while the minima are respectively 77.3 and 76.2 years. This
*Sweden, because the improvement has been uninterrupted.
of life expectancy
indicates regional differences of respectively 3.0 years.
1.9 and
CONCLUSION
The data presented here shows quite clearly that the European countries internally exhibit a large degree of heterogeneity with regard to the mean length of life of its inhabitants. National borders however, are still of great importance to the level of mortality when they separate two adjoining regions whose internal structure is otherwise similar. One only has to look at the difference in the levels of life expectancy in the Spanish-Portuguese, the Dutch-German and the Finnish-Swedish border regions to realize this. We can demonstrate the internal heterogeneity of Europe most clearly by comparing the maximum and minimum regional life expectancy values of each country with the temporal development of life expectancy in Sweden.* This has been done in Figs 9 and 10. The continuous line shows the values registered in Sweden since 1900.
FRANS W. A. VAN POPPEL
350
66.0 66.0 64.0 52.0
62.0 60.0 58.0
56.0
56.0 540 1935
I945
1955
1965
1975
Year Fig. 9. Regional
dikrences
in the expectation expectation
of life compared with the temporal of life in Sweden (males).
We can see that some regions in Portugal are in a similar situation for males as Sweden as a whole was around 1930 and that others correspond with values in Sweden towards the end of the 1930s (Fig. 9) The French regions can be placed between the beginning of the ’40s and the beginning of the 1960s while the values for Italy correspond with the values for Sweden between the beginning of the 1940s and the middle ’60s. Some Dutch provinces have values corresponding with Sweden as a whole at the beginning of the 195Os, whereas other provinces have values above that of Sweden at the present time.
69.0
-
67.0
-
65.0
-
63.0
-
61.0
-
59.0
-
57.0
development
of the
In the case of women, we can see that the variance with respect to the development in Sweden as a whole is much smaller and that all countries occupy less of the graph compared to the males. Portugal again lags behind the other countries, with life expectancies corresponding with those in Sweden in the 1940s (Fig. 10). The values for the French regions compare to those in Sweden between the middle of the ’50s and the end of the ’70s. The different levels of the Dutch provinces lie between those for Sweden some 10 years ago and a
-
67.0
- 630
1 lSO5
I ISIS
I 1925
I 1935
1 1945
8 IS?+!3
I 1965
590
IS75
Year Fig. 10. Regional
differences
in the expectation of life compared with the temporal expectation of life in Sweden (females).
development
of the
Regional mortality in Western Europe
351
Table 1. Maximum and minimum life expectancy values 1969- 1977 Females
Males
Austria Belgium/Luxembourg Denmark England Federal Reoublic of Germanv Finland ’ France Irish Republic/Northern Ireland Italy Netherlands Norway Portugal Scotland Spain Sweden Switzerland
Maximum
Minimum
DilTerence
Maximum
Minimum
Difference
68.37 69.32 72.80 71.30 68.49 68.63 70.70 69.73 71.43 72.43 73.02 64.80
65.49 66.13 68.19 67.90 66.06 65.15 65.70 65.00
2.88 3.19 4.61 3.40 2.43 3.48 5.00 4.73 4.24 2.30 5.00 2.20 3.31 5.10 2.51 4.80
75.05 75.03 77.46 76.90 74.50 78.90 77.70 73.96 76.84 77.82 79.16 71.60 77.81 77.10 79.18 77.12
73.50 75.57 75.29 74.30 72.52 74.70 74.10 73.25 72.94 76.13 76.17 68.50 73.44 73.80 77.27 73.17
1.55 I .46 2.17 2.60 I .98 4.20 3.60 0.71 3.90 1.51 2.99 3.10 4.37 3.30 1.91 3.95
69.96
72.80 73.55 71.63
67.19
70.13 68.02 62.60 66.65 67.70 71.04 66.83
level of 77.8 years that Sweden as a whole has not yet reached. On the basis of our data, there is no relation to be found between the expectation of life on a national level and the existing internal inequality within a country. However, because data have been used on different levels and for different time periods, we must realise that a strict comparison is not possible. Sweden and the Netherlands have, for example, a high expectation of life with a low regional differentiation internally, but in strong contrast to this, Germany and Austria have a low life expectancy and a low regional differentiation, and Norway a high life expectancy and a high regional differentiation. The internal inequality is greater for males than for females in every country except Portugal, Finland and Scotland. In Sweden this is only just the case (0.60 years), and in the Netherlands (0.79). Germany (0.45), Italy (0.35) and England (0.80) the same is true. In Denmark, Austria, Belgium, Spain and Norway (respectively 2.44, 1.55, 1.73, 1.80 and 2.01), the regional differences are clearly greater for males than for females. This can be seen in Table 1. Even if the level of regional inequality
amongst men is greater than amongst women, this does not mean to say that there are not any similarities between the regional patterns of mortality for men and those for women. The most favourable and the least favourable regions are the same for men and women in almost every country. This comparison of 18 European countries gives the impression that the urban areas with mining, docks and declining heavy industry tend to have a relatively low expectation of life, while the more agricultural country regions enjoy a higher one. Examples exist in France, Belgium, Italy and the Federal Republic. The question could be asked whether it is justifiable paying so much attention to differences in the mean expectation of life of 2-3 years for men and l-2 years for women in different provinces (Sweden, Austria, the Federal Republic, the Netherlands). Even if one admits that inequality with respect to death would
continue to exist, it is still rather difficult to convince oneself that the extra number of years obtained is worth all the effort needed to eliminate this inequality. Many writers have pointed out however, that even though a difference in the expectation of life of 2-3 years can be called minimal, the total elimination of, for example, neoplasms in Western Europe would only increase life expectancy by a little more than this amount. The huge amount of effort put into this last aspect is out of all proportion to the effort put into detecting regional differences and doing something about them. Illustrating this point with Dutch statistics, an increase in the life expectancy of the Limburg male by 2.3 years to bring it up to the same level as exists in &eland would be equal to 70% of the possible increase in life expectancy resulting from the elimination of neoplasms and even 70% more than the increase in life expectancy which would occur if a11accidents were eliminated. These figures would be 50% and 114% respectively for the female population. This is evident enough of the relevance of research into regional differences in mortality. REFERENCES This is based on: Schuyt C. De sociale toekomst van de verzorigingsstaat. Beleid en Muurschoppij 2, 190, 1976. Kitagawa E. M. and Hauser P. M. Differential Martality in the United States: A Study in Socio-economic Epidemiology. Harvard Univ. Press, Cambridge, 1973. Data borrowed from respectively: -Centro de Estudos DemogrBficos/lnstituto National de Estatistica. Tgbuas abreviadas de mortalidade distritais e regionais 1959-1962 e 1969-1972. Caderno no. 4. Lisboa, 1976. -Ministerio de Economica/lnstituto National de Estadistica. Tablas de mortalidad provinciales (1969-1972). Ano 1970. Madrid, 1978. Data borrowed from respectively: -1stituto di Demografia. Tavole di mortalita ridotte per le regioni e le repartizioni italiane 1959-1961-1971. Roma, 1977. -&terreichischen Statistisches Zentralamt (unter
352
FRANS W. A. VAN POPPEL Mitwirkung des Gsterreichischen Bundesinstitutes fur Gesundheitswesen,). Regionale Unterschiede in der Sterblichkeit in Osterreich 1969-1973. Beitrage zur Osterreichischen Statistik. Heft 404. Wien. 1976. ~-Average life expectancy for the 25 Swiss Cantons IS calculated on the basis of mortality rates for the period 1969-71. These are determined on the basis of the average number of deaths per year in the age groups
(1) imo = 140 (2) (1 - 44,) = (1 - &/(I - iqo) in which 5qo is derived from sm,, with the aid of Reed and Merrell’s formula, and (3) 4ml = 491 (4 - 244i). The mortality rates for those ages of 20 years and upwards are converted into rates for quinquennial age groups by assuming that, within each decennial age group, the mortality rates for the quinquennial age groups would be in the same proportions as in Switzerland as a whole in 1971. and also by taking into consideration the age structure within the decennial groups as published in the last Census. The mortality rates obtained in this way are then converted into mortality probabilities, and a life table is compiled on the basis of the method set out in Cornpurer Proyramsfor Detnoyruphic Analysis. Arriage E. er al.. U.S. Bureau of the Census, Washmgton. 1976. 5. Data borrowed from respectively: -Gardner M. and Donnan S. Life expectancy: variations among regional health authorities. Pop. Trend.\ IO. IO. 1977. -Wattelar C. et Renaerts M. Tables de mortalite abregees des provinces beiges 1970-1971. Infor-Demo no. 9. Departement de Dtmographie. Universiti Catholique de Louvain, Louvain-La-Neuve, 1976. -Poppel F. W. A. van. Provinciale sterfteverschillen in Nederland in de periode 1971-1975. K.N.A.G. Geoyrafisch Tiidschrifi. Nieuwe Reeks 5. 406. 1978. -Statistisches Bundesamt. AIlgmeine Sterbetafil fir die Bundesrepublik Deutschland 1970/72. Bevolkerung und Kultur, Fachserie A, Reihe 2, Sonderbeitrag, Stuttgart, 1976. -Registrar General Scotland. Annual Report 1977, Part 1. Mortality Statistics. Edinburgh, HMSO. 1978. -The data for the Irish Republic are calculated on the basis of the mortality rates for the period 1970-72. These are then converted in the same way as the Swiss data into mortality probabilities and life tables. The mortality rates are determined on the basis of the average number of deaths in the age groups < 1, l-4. 5-9. etc. up to and including 80+ in 1970, 1971 and 1972 (published in An Roinn Slainte (Central Statistical
Office). Tuarascail ar Staidreamh Beatha (Report on Vital Statistics)). and the number of persons present at the time of the 1971 Census (Central Statistical Office. Crn.su.s of’ Popularion 01’ Ireland 1971. Vol Il. Ages und Conjugal Conditions Clu.wrfird hi, Area.\. Dublin. 1973). -The average life expectancy for Denmark is likewise calculated on the basis of the method published by the U.S. Bureau of the Census. Mortality rates for the period 1975-77 (published in. Danmarks Statistik. Befolkningrns Meddelelser
Berueyelsrr
Kebenhavn)
I975.
I976.
1977. Statistiske
form the basis of these calcu-
lations. These mortality rates relate to the age groups < I. l-29, 30-39 etc. up to and including 7&79 and 80 + Quinquennial mortality rates are derived from these on the basis firstly of the provincial data on the age structure within the age groups l-29. 3&39. etc. up to and including 7s-79 years. and secondly of the mutual relationship between the mortality rates for the age groups l-4. 5-9, l&-14. 15-19. 20-24, 25-29, 3&34. 35-39 etc. up to and including 75-79 years as ascertained for Denmark as a whole on average during the period in question. -Dr G. Desoianaues of the INSEE (Paris) made available the unpublished French data concerning the period 197476. of life in Norway has been calculated 6. The expectation with the help of data published in: -Statistik Sentralbyra. Dodeliqheren i Fvlkmr 1971-1975. (Morta/it)Y in Counties-i971-1975). Norges offisielle statistik A 948. Oslo. 1978. The 5-vearlv (UD to the age of 30) and IO-yearly (from 30 to 80) mortality rates published in these statistics have been converted into probabilities of death with the help of Reed and Merrell’s formulae. and then a life table made from these probabilities. Data for Sweden was derived from: -Statistiska Centralbyran. BeJo/kninysfdriindrinyur. Del 3. Hela riket och Ianen m m. 1974. 1975. 1976. 1977. Stockholm. The published mortality rates for quinquennial age groups (up to the age of 85) have been turned into an average rate for the period 1974-1977. The mortality rate for the age group &I (the number of deaths in the first year of life divided by the number of live births) has been calculated and turned into an average for the period 1974-78. The values of -Im, . have been calcuiated by making , m o = ,qo and by converting smO via Reed and Merrell to 5q0 and then applying (1 - sq,):(l - ,q,) = (1 - 4q,). Finally. the value of ma,,+ has been calculated by weighing the values of +tgr, and msSc against the age structure. -The data for Finland have been calculated as follows. From the mortality rates published for the Finnish provinces (see Ttilastokeskus (Central Statistical Office of Finland), Suomen virallinen tilasto (Official Statistics of Finland) and Vlestonmuutokset (Vital Statistics) 1972. 1973. 1974 and 1975). the average figure for each of the age groups O-4, 5-9, etc. up to and including 75-79, 80+ is calculated for the period 1972-1975 inclusive. The value of ,qO is then determined per province on the basis of the relationship established for the whole country between ,qO and sat,,, The value 4ql is calculated and the life table constructed, in the same way as for Switzerland.