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International Brief

Mortality and Health

by Kevin Kinsella and Yvonne J. Gist

International Programs Center

U.S. Department of Commerce

Economics and Statistics Administration

BUREAU OF THE CENSUS

IB/98-2

Issued October 1998

Countries around the world are in

the midst of demographic aging.

While the pace of aging varies, all

nations are, or soon will be, faced

with important issues regarding

the health of and health care

provision for their expanding

older1 populations.

In particular, countries need to plan

for the health needs of older

women. Although the elderly are

as diverse demographically, socially, and economically as the

nonelderly, one notable difference

between these broad groups is the

relative number of men and

women. While boys outnumber

girls in all countries, gender differences in mortality eventually

produce a changing sex balance

within a population. By age 30 or

35, women start to outnumber

men, and the absolute female

advantage increases with age.

Elderly women greatly outnumber

elderly men in most nations, and

therefore the health and socioeconomic problems of the elderly are,

to a large extent, the problems of

elderly women.

Female Survival Advantage

is Nearly Universal

With a handful of national exceptions, life expectancy worldwide is

higher for females than for their male counterparts. In developed2

countries, an average female life

expectancy at birth of at least 80

years has become the norm,

whereas few countries can boast of

the same level for men (Figure 1).

The average gap in life expectancy

between the sexes is roughly 7

years in developed countries, but

can be as great as 13 years in

parts of the former Soviet Union

as a result of unusually high levels

1

 The term “older” is an arbitrary concept used

only for cross-national comparative purposes.

In this brief, “older” generally refers to ages 60

and over.

2 The “developed” and “developing” country

categories used in this brief correspond to the

“more developed” and “less developed”

classification employed by the United Nations.

Developed countries comprise all nations in

Europe and North America, plus Japan,

Australia, and New Zealand. The remaining

nations of the world are considered to be

developing countries.
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of current adult male mortality

(Figure 2). In developing countries,

the average gender gap in life

expectancy at birth is only 3 years,

due at least in part to high levels of

maternal mortality in some nations.

Nevertheless, girls born today in

nearly half of all developing countries may anticipate living at least

70 years; boys can expect to reach

age 70 in only 28 percent of

developing countries.

Will the Gender

Differential in Life

Expectancy Converge?

Table 1 depicts the spectacular

increases in human life expectancy

that have occurred in many parts of

the world during the last 50-100

years. Since the beginning of this

century, industrialized countries

have made great progress in

extending life expectancy at birth.

Japan enjoys the highest life

expectancy of the world’s major

nations—the average Japanese

born today can expect to live 80

years—and the level in numerous

European nations approaches or

exceeds 79 years.

Three observations can be made

concerning the developed-country

trends in Table 1: (1) the relative

difference among countries has

narrowed with time; (2) the pace of

improvement has not been linear,

especially for males;3 and (3) the

difference in female versus male

longevity, which universally has

been in favor of women in this

century, has widened with time.

Changes in overall life expectancy

in developing regions of the world

have been more uniform. Practically all nations have shown

continued improvement, with some

exceptions in Latin America and

more recently in Africa, the latter

due to the impact of the HIV/AIDS

epidemic. Given the small average

gender gap in life expectancy

relative to developed nations, most

demographers expect to see a

widening of the female/male

difference in upcoming decades,

along the lines of the historical

trend in industrialized nations. One

factor that may promote such a

widening is education, which is

positively related to survival. As

women “catch up” to men in terms

of educational attainment, we might

expect to see relative improvements in survival and health status

(Liu, Hermalin and Chuang, 1998).

Precise explanations of the gender

difference in life expectancy still

elude scientists because of the

apparent complex interplay of

biological, social, and behavioral

conditions. Greater male exposure

to risk factors such as tobacco use,

alcohol consumption, and occupational hazards often is cited as a

source of higher male mortality

rates (Statistics Canada, 1997).

This suggests that the gender gap

in life expectancy might decrease

as a result of increased female

tobacco/alcohol use, and greater

levels and longer durations of

female labor force participation,

compared with previous generations. However, data from industrialized countries still show no clear

pattern of change in the gender

gap; the gap is widening in most of

3

 From the early 1950s to the early 1970s, for

example, there was little or no change in male

life expectancy in Australia, the Netherlands,

Norway, and the United States, while in

Eastern Europe and much of the former

Soviet Union, male life expectancy declined in

the 1970s and 1980s.
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Eastern Europe and the former

Soviet Union, and tends to be

narrowing in other developed

countries. But in some nations with

very high overall life expectancy

(e.g., France, Germany, Japan),

gains in female longevity continue

to outpace those of males.

Female Share of Older

Population Rises with Age

Gender differences in longevity in

developed countries translate into a

preponderance of women at older

ages. Among all persons aged 60

and over in 1998, the developedcountry sex ratio was 70 (i.e., there

were 70 men aged 60 and over per

every 100 women aged 60 and

over). Because women have lower

mortality rates than men throughout life, the proportion female rises

with age. Among the oldest old (80

and over) in developed countries,

the 1998 sex ratio was only 44. As

noted above, demographers expect

that life expectancy will increase

somewhat faster for men than for

women; hence, these sex ratios are

projected to rise considerably by

the year 2025.

Current sex ratios in developing

nations are much higher than in the

developed world: 92 among persons aged 60 and over, and 70

among the oldest old. If the trend

in developing-country mortality

approximates what has been

observed in industrialized nations,

the future gap between male and

female life expectancy might be

expected to widen somewhat. One

likely result would be a decline in

sex ratios at older ages over the

next three decades (Figure 3).

Life After 60

Where infant mortality rates are still

relatively high, as in many developing countries, most of the improvement in life expectancy results from

infants surviving the high-risk initial

years of life. As infant and childhood mortality reach lower levels,

as in developed countries, improvements in average life expectancy

are achieved primarily by declines

in mortality among older segments

of the population.

Table 1.

Life Expectancy at Birth for Selected Countries: 1900 to 1998

(In years)

DEVELOPED COUNTRIES

Circa 1900 Circa 1950 1998

Region/country Male Female Male Female Male Female

Western Europe

Austria 37.8 39.9 62.0 67.0 74.1 80.7

Belgium 45.4 48.9 62.1 67.4 74.1 80.7

Denmark 51.6 54.8 68.9 71.5 73.6 79.1

France 45.3 48.7 63.7 69.4 74.6 82.6

Germany 43.8 46.6 64.6 68.5 73.8 80.3

Norway 52.3 55.8 70.3 73.8 75.4 81.2

Sweden 52.8 55.3 69.9 72.6 76.5 82.0

United Kingdom 46.4 50.1 66.2 71.1 74.8 80.1

Southern and Eastern Europe

Czech Republic 38.9 41.7 60.9 65.5 70.8 77.7

Greece 38.1 39.7 63.4 66.7 75.8 81.0

Hungary 36.6 38.2 59.3 63.4 66.5 75.4

Italy 42.9 43.2 63.7 67.2 75.3 81.7

Spain 33.9 35.7 59.8 64.3 73.8 81.6

Other

Australia 53.2 56.8 66.7 71.8 77.0 83.0

Japan 42.8 44.3 59.6 63.1 76.9 83.3

United States 48.3 51.1 66.0 71.7 72.9 79.6

DEVELOPING COUNTRIES

Circa 1950 1998

Region/country Male Female Male Female

Africa

Egypt 41.2 43.6 60.1 64.1

Ghana 40.4 43.6 54.8 58.9

Mali 31.1 34.0 45.7 48.4

South Africa 44.0 46.0 53.6 57.8

Uganda 38.5 41.6 41.8 43.4

Congo (Brazzaville) 37.5 40.6 45.3 48.9

Asia

China 39.3 42.3 68.3 71.1

India 39.4 38.0 62.1 63.7

Kazakhstan 51.6 61.9 58.1 69.3

South Korea 46.0 49.0 70.4 78.0

Syria 44.8 47.2 66.5 69.1

Thailand 45.0 49.1 65.4 72.8

Latin America

Argentina 60.4 65.1 70.9 78.3

Brazil 49.3 52.8 59.4 69.6

Costa Rica 56.0 58.6 73.5 78.5

Cuba 57.8 61.3 73.0 77.9

Mexico 49.2 52.4 68.6 74.8

Venezuela 53.8 56.6 69.7 75.9

Notes: Figures for Germany and Czech Republic prior to 1998 refer to the former West

Germany and Czechoslovakia, respectively.

Reliable estimates for 1900 for most developing countries are unavailable.

Sources: Siampos, G., 1990, "Trends and Future Prospects of the Female Overlife by Regions

in Europe," Statistical Journal of the United Nations Economic Commission for Europe, Vol. 7,

pp. 13-25; United Nations Department of Economic and Social Information and Policy Analysis

(UNDESIPA), 1995, World Population Prospects: The 1994 Revision, Annex Tables, New York;

United Nations Department of International Economic and Social Affairs (UNDIESA), 1988,

"Sex Differentials in Survivorship in the Developing World: Levels, Regional Patterns and

Demographic Determinants," Population Bulletin of the United Nations, Vol. 25, pp. 51-64; and

U.S. Bureau of the Census, International Programs Center, International Data Base.
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Data from Japan (Figure 4) illustrate the rapid declines in old-age

mortality that characterize many

industrialized nations. Among the

relatively young elderly aged 65-69,

death rates for men and women

plummeted between 1950 and

1995; the female level in 1995 was

only one-fourth of that in 1950.

Major declines can be seen at older

ages as well. As a consequence of

these steep drops, life expectancy

at age 60 rose 9 years for women

and nearly 7 years for men during

the period 1950-95. Under the

mortality conditions of 1995, the

average Japanese woman aged 60

could expect to live an additional 25

years, and the average Japanese

man an additional 20.

The Importance of

Cardiovascular Disease

Death rates due to heart disease

and stroke have declined at older

ages in many developed countries

in recent years. Nevertheless,

cardiovascular disease remains the

primary killer at older ages. One

comprehensive analysis (Murray

and Lopez, 1996) attributes nearly

60 percent of all deaths among

women aged 60 and over in the

early 1990s to cardiovascular

disease; the corresponding figure

for older men was 50 percent.

Cancer deaths at older ages rank a

distant second, but may be more

worrisome in the public eye; in the

1995 Canadian Women’s Health

Test, most women believed breast

cancer to be the number one killer

of women of all ages. Only 16

percent of those surveyed correctly

stated that heart disease is the

number one killer (Wiesenberg,

1996). Although deaths from

cardiovascular disease are expected to remain most prominent in

the future, a major concern of

health practitioners in the industrialized world is the rise in lung cancer

among older women as a result of

increased tobacco use since World

War II.

The epidemiologic transition from

the primacy of infectious and

parasitic diseases to chronic and

degenerative diseases that has

characterized industrialized nations
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has occurred in most developing

nations as well. Cardiovascular

disease is by far the leading cause

of death at older ages in developing

countries, although the impact of

communicable diseases remains

considerable. The share of cancer

deaths at older ages is less pronounced than in the industrialized

world (Figure 5), but is expected to

increase in importance during the

next two decades, again driven

largely by increased cigarette

consumption (Robles, 1993).

Does Living Longer Mean

Living Better?

As life expectancy at birth and at

older ages lengthens, the quality of

that longer life becomes a major

issue. The concept of healthy life

expectancy (also called active life

expectancy or disability-free life

expectancy) refers to the average

number of years that a person may

expect to be free of limitation of

function due to one or more chronic

disease conditions. Measures of

healthy life expectancy often focus

on the ability of persons to complete activities of daily living (ADLs)

such as bathing, dressing, eating,

getting in and out of bed, and

toileting. More refined measures

also consider instrumental activities

of daily living (IADLs) which include

preparing meals, shopping for

personal items, managing money,

using the telephone and doing light

housework (Crimmins, Hayward,

and Saito, 1996).

To facilitate and promote analyses

of healthy life expectancy, the

International Research Network for

Interpretation of Observed Values

of Healthy Life Expectancy

(REVES) was formed in 1989 to

bring together researchers concerned with measuring changes

and inequalities in health status

within and among nations. It is as

yet difficult to precisely compare

such measures among nations

because of computational and

conceptual differences, though

researchers are working toward the

development of integrated measures (Verbrugge, 1997). One

commonality that has emerged

from various studies is that women

who reach older age can expect to

not only do they live longer on

average, but they tend to marry

men older than themselves, and

remarry much less frequently in the

case of divorce or spousal death.

Thus it has become a truism that

most women must anticipate a

period of widowhood in their later

years. Numbers of widows are

rising rapidly in most parts of the

world (Figure 7), as are numbers of

never-married older women.

live more disability-free years than

their male counterparts. However,

because women have longer life

expectancies at any given older

age than do men, the proportion of

remaining years that are free of

disability tends to be somewhat

greater for older men (Figure 6).

Widowhood and Health

Older women are much more likely

to be widowed than are older men;
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Research has documented a

positive relationship between longer

life and marriage (see, for example,

Lillard and Waite, 1995), which

likely can be attributed to the

heightened financial well-being that

accompanies being married. The

death of a spouse may necessitate

a number of adjustments in the

realms of living arrangements,

financial security and personal

relationships. In developed countries, where formal support mechanisms usually are strong, most

older women appear to cope with

such adjustments without a negative impact on their health (Bonita,

1996). In developing countries, the

extended family typically has

provided support for elderly widows. However, the forces of urbanization, migration and lowered

fertility threaten to undermine

traditional social roles. Older

women, many of whom are illiterate

and poor, are increasingly vulnerable, particularly in societies where

social custom and family law

discriminate against women.

Gender Differences in

Morbidity Still Poorly

Understood

Reliable, comprehensive data on

the health of older women (and

often on the health of women in

general) is sorely lacking in most

countries of the world. There are

numerous methodological problems

related to the determination of

health status at older ages

(Ebrahim, 1996), many of which

have been compounded by the

exclusion of older persons from

large-scale studies. A reluctance to

study health status in later life has

been attributed to difficulties

surrounding the multiplicity of

pathological conditions that exist in

old age, and also to ageism (Sen,

1996). And even though women

live longer than men in virtually all

countries, health research on aging

has tended to focus on the ills of

men (Freedman and Maine, 1993).

Research has begun to document

the relationship between lifelong

health, beginning as early as the

intrauterine period, and health at

older age (Barker, 1995; Elo and

Preston, 1992; Smith and Kington,

1997). This life cycle approach to

health and health care has different

implications for women and men,

particularly in countries where

gender bias pervades all realms of

life. Women’s health and access to

health care often are disproportionately affected by high levels of

poverty and economic dependence,

violence, gender inequities in

nutrition and food distribution,

limited decisionmaking power, and

negative cultural attitudes toward

women and girls. The World Health

Organization (1998) has issued a

“gender challenge” to nations and

international organizations, a call

for: a better appreciation of risk

factors involving women’s health;

the development of preventive

strategies to lessen the impact of

diseases that disproportionately

plague older women (e.g., coronary

heart disease, osteoporosis, and

dementia); and an increased

emphasis on understanding why

men die sooner than women.

References

Barker, D.J. P., 1995, “Fetal Origins of

Coronary Heart Disease,” British

Medical Journal, No. 311, pp. 171-74.

Bonita, Ruth, 1996, Women, Aging and

Health, World Health Organization,

WHO/HPR/AHE/HPD/96.1, Geneva.

Crimmins, Eileen M., Mark D. Hayward

and Yasuhiko Saito, 1996, “Differentials

in Active Life Expectancy in the Older

Population of the United States,”

Journal of Gerontology: Social Sciences, Vol. 51B, No. 3, pp. S111-120.

Ebrahim, Shah, 1996, “Principles of

Epidemiology in Old Age,” in S.

Ebrahim and A. Kalache, eds., Epidemiology in Old Age, BMJ Publishing

Group, London.

Elo, Irma T. and Samuel H. Preston,

1992, “Effects of Early-Life Conditions

on Adult Mortality: A Review,” Population Index, Vol. 58, No. 2, pp. 186-212.

Freedman, Lynn P. and Deborah Maine,

1993, “Women’s Mortality: A Legacy of

Neglect,” in Marge Koblinsky, Judith

Timyan and Jill Gay, eds., The Health of

Women. A Global Perspective,

Westview Press, Boulder, CO.

Lillard, Lee A. and Linda J. Waite, 1995,

“‘Til Death Do Us Part: Marital Disruption and Mortality,” American Journal of

Sociology, Vol. 100, No. 5, pp. 1131-56.

Liu, Xian, Albert I. Hermalin, and

Yi-Li-Chuang, 1998, “The Effect

of Education on Mortality Among Older

Taiwanese and its Pathways,” Journal of

Gerontology: Social Sciences, Vol. 53B,

No. 2, pp. S71-82.

Murray, Christopher J. L. and Alan D.

Lopez, eds., 1996, The Global Burden

of Disease, World Health Organization,

Geneva.

Robles, Sylvia C., 1993, “Smoking

among Women in the Americas,” in

Elsa Gomez Gomez, ed., Gender,

Women, and Health in the Americas,

Pan American Health Organization,

Scientific Publication No. 541,

Washington, DC.

Robine, Jean-Marie and Isabel Romieu,

1993, Statistical World Yearbook on

Health Expectancy, Laboratoire

d’Epidemiologie et d’Economie de la

Sante, Montpellier.

Sen, Kasturi, 1996, “Gender,” in S.

Ebrahim and A. Kalache, eds., Epidemiology in Old Age, BMJ Publishing

Group, London.

Smith, James P. and Raynard Kington,

1997, “Demographic and Economic

Correlates of Health in Old Age,”

Demography, Vol. 34, No. 1, pp.

159-170.

Statistics Canada, 1997, Health

Reports, Vol. 9, No. 1, Ottawa.

U.S. Bureau of the Census, 1998,

International Data Base, International

Programs Center, Washington, DC.

Verbrugge, Lois M., 1997, “A Global

Disability Indicator,” Journal of Aging

Studies, Vol. 11, No. 4, pp. 337-62.

Wiesenberg, Sara, 1996, “1995

Canadian Women’s Health Test,”

Canadian Family Physician, Vol. 42,

January, pp. 13-15.

World Health Organization, 1998, The

World Health Report 1998, Geneva.

This is the second profile in a

four-part series on gender and

aging. The initial profile focused

on demographic dimensions; the

next two profiles will examine the

topics of economic security and

caregiving, and consider how the

world’s societies have different

responses to the lives and needs

of older persons. The Gender

and Aging series is produced

with the support of the Office of

the Demography of Aging,

Behavioral and Social Research

Program, U.S. National Institute

on Aging.
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Table 2.

Population and Health Indicators

Percent Percent

female female Female

among among advantage in Health

persons persons life expectancy expenditure

aged 60 aged 80 at birth per capita Persons per Adequate

and over and over (in years) US$ physician Safe water sanitation

Country 1998 Circa 1990-1995

Afghanistan 48 43 -1 NA 7001 10 8

Algeria 53 54 2 149 2330 57 40

Argentina 57 64 7 137 373 64 89

Australia 55 65 6 1294 415 100 100

Bangladesh 46 37 0 7 5309 83 30

Brazil 58 67 10 146 746 92 73

Canada 56 66 7 1945 450 100 NA

China 52 63 3 11 798 72 79

Colombia 54 58 8 51 952 96 70

Egypt 54 59 4 28 1320 90 50

Ethiopia 54 58 2 NA 32650 18 17

France 58 69 8 1869 350 100 96

Germany 59 74 7 1511 313 100 100

India 49 49 2 21 2460 63 29

Indonesia 55 60 5 12 7030 63 45

Italy 57 67 6 1426 210 100 100

Japan 57 67 6 1538 610 96 NA

Kenya 56 57 1 16 10130 49 43

Malaysia 55 61 6 71 2700 90 94

Mexico 54 60 6 89 935 87 70

Morocco 54 54 4 26 4840 59 63

Nepal 50 52 0 7 16830 48 22

Pakistan 50 51 2 12 2940 60 30

Peru 53 59 4 61 939 60 47

Philippines 55 56 6 15 8120 84 75

Poland 60 71 9 84 490 89 100

Romania 57 64 8 58 560 95 97

Russia 66 80 13 159 210 94 NA

South Africa 58 67 8 141 1750 74 46

South Korea 59 73 4 365 1370 93 90

Spain 57 67 8 831 280 99 97

Sri Lanka 52 51 6 18 5927 57 66

Sudan 45 43 2 34 10000 34 12

Taiwan 48 53 6 NA 910 NA NA

Tanzania 54 56 4 4 24880 52 77

Thailand 55 63 7 72 5000 81 87

Turkey 53 62 5 76 1260 92 94

Ukraine 65 77 12 131 230 97 93

United Kingdom 57 69 5 1039 687 100 100

United States 58 67 7 2765 420 100 98

Uzbekistan 58 70 7 116 280 74 53

Venezuela 53 58 6 88 630 88 87

NA - Not available

Source: Demographic data from U.S. Bureau of the Census, International Programs Center, International Data Base; Health indicators as

reported by or calculated from World Bank, World Development Reports 1993, 1994, and 1997, NewYork;World Bank, 1996, Social Indicators of

Development 1996, NewYork; World Health Organization, World Health Report 1995, 1996, and 1997, Geneva; and country sources. Due to

definitional differences among sources, strict comparisons of health indicators may not be warranted.

Percent of population

with access to: