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FOREWORD 

This report is part of a series of analytical studies to look into the 

problem of changing mortality trends observed in a number of countries. 

More specifically, it was hoped that this study, which was contracted 

with the Institute for Social Medicine and the Organization of the Health 

Services of Czechoslovakia, would shed some light on similar changes 

in trend observed in the United States. 

Iwao M. Moriyama, Ph.D.


Director


Office of Health Statistics Analysis


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CONTENTS


Introduction


Background Informatiotl


Mortality


National Trends by Age and Sex--------------------------------------


Current National Data -----------------------------------------------


Limitationof Data by Cause of Death ---------------------------------


National Trendsby Cause of Death ------------------------------------


Western Czechoslovakian Trends by Cause of Death --------------------


Trends for a Heterogeneous Population


Component Parts of Death Rates With Divergent Trends


Future Development oi Mortality


Summary


Page 

1 

4 

5 

5 

8 

9 

11 

13 

19 

22 

24 

25 
IN THIS REPCWT movtality tvends in Gechoslovakia are disczwsed 

by sex, age, and cawse of dea th for the yeavs 1930-67. Aftw a wwtim(? 

peak in the death $-ate, a ma~ked decline in the crude death rate wus experienced in Czechoslovakia. This rapid postww chance was observed 

until the latter part of the 1950 decade after which the death vate began 

to lel~el off. Tlze m,ovemmt of the crude death rate is now upwards. 

&ftiCh of the p~st?~~ decline resulted f.Yom the drop in f?~e deaf~l Yates 

for the infective and parasitic diseases, and diseases of early infancy. 

M~rtality from infective and pa~asitic diseases has naw ~eached such a 

low level that fiwtker decline can have only a minor influence on the 

total death rate. On the other hand, the upwczrd trends of death rates 

for diseases chavactevistic of old age ave governing the movement of 

the death rale. It is therefore expected that the cmde death rate will increase further. 

With respect to the jidure, it is anticipated that the infant mcwtality $-ate 

will undergo further decline. The death $’ates for females 45 years and I 

over will pro bably decrease some mare whereas the death rates for females at other ages are expectedtostabilize at a somewhat 10WW level. 

The death rates for m.zles with the possible exception of that fo~ the age 

groups 55- ?’4yeavs are expected to stabilize at the present level. 

The authov kas developed statistical models to depict the mortality situation in Gechoslowzkia. 

vi 

I 
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MORTALITY TRENDS[ IN CZECHOSLOVAKIA


Mile; Vacek, Ph. D., C.SC.’ 

iNTRODUCTION tive ones and this rc+tlted in the continuous 

decline in the death rate and an increase in 

The past 100 years of social progress in the expectation of life over the past 100 years. 

[hu duveloped countries of today resulted mainly Figure 1 shows the dcrlinc? in the crude death 

from the rapid increase of ~he praduccive capacity rate for Czechoslovakia. It can be seen that the 

which in turn was closely associated with progress decline was unintern)p’ed until 1960, except for 

in all branches of science and technology. The stagnation or even a .ransient increase during 

rusult was a general increase in living standards, both World Wars, i si~nificant increase of the 

inlprovemems in living and working conditions, .lverage life span was the consequence (table 1). 

Lmcl elimination or substantial reduction of mal- Similar developments have been described 

nutrition, In this context shorter working hours, in many countries, starting earlier in some and 

better housing conditions, and the provision of later in others. This could be interpreted (and 

swlitary water and food may be mentioned. actually was) as a direct interdependence between 

ChI the other hand, there appeared--especially the general level of living and progress of medical 

during the past few decades--several important science and public health on the one hand, and the 

noxious factors which have negatively influenced health status of the population (characterized by 

thu populations health. These factors are, among tl]~’ morbidity and morta Iity) on the other. It was 

orh~,t-s, air and water pollution, the increase of generall~ believed that [he death rate would 

nLlisLI hek, the decline of physical activity, continue to decline so long as the standard 

OVLSrntttrition and overweight, and the increase in of living increased and progress was made’ in the 

st r~’ssing situations. medical sciences and in the provision of health 

AIong with the developments in science, services. 

mc’dical and health services developed rapidly, Some doubts concerning the validity of these 

Llllprecedented progress was achieved, especially optimistic predictions could have arisen from the 

in diagnostics, immunology, surgery, and drug 

therapy. At the same time, there was a great 

inc reme in the number of physicians and hospitals, 

~v]li~h increased the accessibility to health sex: Czechoslovakia, 

1869-1961 

selected years, 

HL”~vk’$. Best results were achieved in the control 

(If infective diseases and perinatal mortalily. 

Over a long period of time, the positive Period 

I Expectation of 

li~e in 

I 

years 

~tsp~’cts of this development outweighed the nega - Male Female 

Table 1. Expectation of life at birth, by 

1960 -61------------- 67.64 73. !.2 

1949 -51------------- 60.93 65.53 

L937---------------- 54.92 58.66 

1929 -32------------- 51.92 55.18 

1909 -12------------- 42.24 45.19 

S699-1902 38.36 40.99 

126? -313 ------------- 32.70 35.3q 

1

v\ A	 Ill I I I I 

Ill t 

Iqo w- ~ 

1870 1880 ‘1890 7900 7910 1920 1930 1940 1950 7960 7970


Fi!gure 1, :%Ude~eath rate per l, ClrC population: Czecitoslovakia, 1870-19 L37. 

well-known fact that the ~o~ulation’s health is . . 

conditioned by a number of factors, some of which 

have a positive influence on health, others, a 

negative one. Many of these factors change rapidly 

in the course of time. This is especially true of 

some of the negative factors which have been increasing rapidly during the past several decades. 

In spite of all this, most specialists interested in 

population forecasts believed that further declines 

in the death rate would occur beyond any doubt, 

at least for a number of years. 

Subsequent development in Czechoslovakia, 

as in many other developed countries, has not 

fulfilled these optimistic expectations (fig. 2), 

A considerable increase in mortality in 1962 

could be e@ained as a direct consequence of 

a major influenza epidemic. In the following 

years, however, the low mortality level of 1960-

61 was not reached again. On t-he contrary, there 

has been a manifes; tendency toward further 

increase in the crude death rate, as well as in 

the age-adjusted death rate for males, 

The situation with regard to the average 

life span since 1960 can be described as a 

stagnation with minor fluctuations around thu 

value of 70.5 years (table 2). It will be shown 

below that this apparently stable state of the 

life span is the result of marked antagonistic 

trends in the development of certain causes of 

death. 

The fact that a similar development was 

observed in many other countries attracted considerable attention and led to attempts to ascertain 

the underlying causes of this development. It 

seems very important to arrive at the correct 

solutions to this problem. If a new factor could 

2 
----- -- --- ----- ------

-----------------------

-----------------------

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-----------------------

17,0


\


MALE 

r # ‘\ \ - \ 

% ,/’ ‘---- **- . . 

\

\

\

\ 

\\ FEMALE 

‘\ N\. .’ .“ ‘\\ 

8,0 -+..~x ,/ , ‘\\ 

\ ~ 

+.. -.. . ------ ‘.. —	 CRUDE RATE +.~- --..~ 

To. 

1957 /959 /96/ /963 /965 /967 

Figure2. Crude e.n~ age-adjusted death rates per 1,0130 population, by sex: Czechoslovakia, 1957’-67’. 

11. found which has in recent years changed mortality, etc.), primarily as a consequence 

tlw trend of the death r:.lte, it wuuldbe a task of of new methods of prevention and treatment. The 

vi[:ll importance to locate this factor and then increase in death rates for other causes of death


[0 c,litninate it or at least to neutralize its was probably due to changes in living conditions


inilucnw, On the other hand, if no such factor (environmental factors, habits, etc.) during


L’Xist S, that is to say, if the recent development several past decades.


L-InId be explained as the result of longstanding These conditioning factors can be followed


[ ~c’llds Of kno\vn causative factors, it would lead only indirectly. For example, no precise data are


t[) a better understanding of the interplay of available on smoking habits, obesity, or physics 1


[IIL.!sLfactors and consequently to more reliable


F(~r~wlsts of the future development of mortality.


Some of the factors conditioning the health Table 2. Expectation of life at hi.r’ck,: 

of IhLI population change very slowly, e.g., genetic Czechoslovalcia, 1960 and 1962-67 

I:i~l 01-s or the influence of climate. Recent changes Expectation 

i 11 m [~tltllity, however, have taken place within a Year of life 

L-trnpo rativ~~ly short period of time. It is therefore in years 

possible and expedient to focus attention on factors 1967 70.5 

which recent ly have undergone considerable 1966 70. $ 

Cilallguw. 

LlnLIHually rapid changes have been recorded 

1965 

1964 

1963 

70. ? 

70.7 

70.4 

in Ihti structure of causes of death. Some of 1962----------------------- 69.9 

t Ilc’[11 :lrL, steadi]y dec]ining (illfectiolls, infant 1960----------------------- 70.5 

3 
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----------------

------------

activity among people of a certain age and sex 

group who survive and those who die within 

a certain time interval. Some of these factors 

and their effects on health and on the death rate 

have been studied only on a limited scale in 

epidemiological studies. The results of these 

studies will be taken into consideration in this 

assessment. However, our main basis of analysis 

will be the demographic data for Czechoslovakia 

for the period 1930-67. These data have been 

collected by the same method over a long period 

of time and are virtually complete, 

The report is organized as follows. First, 

some background information on Czechoslovakia 

is given, mainly for the purpose of international 

comparisons. This is followed by a discussion 

of mortality trends according to age and sex. Two 

subpopulations (regions) are compared for the 

purpose of assessing the effect of those factors 

which influence the mortality in both regions with 

differing intensity. Analysis of cause of death 

includes a critical evaluation of validity of these 

data for Czechoslovakia, a brief look at the causespecific mortality for the entire country, and a 

more detailed examination for the Czech regions 

and for the period 1949-67. The report ends 

with a general presentation of some models of 

trends in heterogeneous populations, an application of results on the mortality in the Czech 

regions, a discussion of some problems of mortality prediction, and a summary of the results. 

BACKGROUND INFORMATION 

The Czechoslovak Socialist Republic (or 

more briefly, Czechoslovakia) is situated between 

12° 03’20” E. longitude and between 51°03’26” 

and 47°43’53” N. latitude. The elevation of the 

country can be seen from the following: 

Percent 

of area 

Under 200 meters 11.8 

200 to 500 meters 53,5 

500 to 1,000 meters 32.O 

1,000 meters and above 2.7 

The climate is intermediate between Atlantic 

and Continental. The average temperature in 

Prague is 9.4: centigrade. The yearly avurage 

of sunshine at different places extends from 

1,632 to 2,144 hours. 

The area of Czechoslovakia on Mtirch 1, 

1961 (census year) was 127,860 square kilometers; 

the number of inhabitant on that day was 

13,741,529, or a population density of 107 per 

square kilometer. 

In spite of industrial progress and urbanization, 45.3 percent of the population lived in 

small communities up to 1,999 inhabitants. A 

considerable part of this population, however, 

commutes to and from work in nearby towns. 

Only 18.5 percent of the population lived (on 

March 1, 1961) in towns of more than 50,000 

inhabitants. 

The number of people working in agriculture (including their family members) has been 

decreasing. In 1930, the agricultural population 

amounted to 25.3 percent of the total population; 

in 1961 to 15.9 percent. 

In the period under consideration the land 

area of Czechoslovakia as well as the population underwent a major change. The area of 

Carpatho-Ukraine with a population under 

million was part of Czechoslovakia until 193L), 

that is, before World War II. All data given here 

refer to the territory excluding the CarpathoUkraine. 

After World War H, in connection with territorial changes in Eastern Europe, a transfer 

of the population was carried out, which involved 

a major part of the German population in Bohemia 

and Moravia. The comparability of demographic 

data from the periods 1930-38, 1939-44, and 

1945-67 was not seriously affected, because 

the death rate of the German population in 

Bohemia and Moravia was not significantly different from that of the Czech population. 

The period of World War II was, for mmty 

reasons, exceptional and the statistical data 

for this period should be judged with appropriate 

reserve. This applies particularly to the years 

1944 and 1945, when operations of war affected 

the territory of Czechoslovakia. 

In the period 1930-67, many changes took 

place in the economic field. The number of peas. 

ants and workers in agriculture steadily declimd. 

On the other hand, the number of industrial 

workers, technicians, research workers, and 

4 

1 
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adm inist rat ive workers increased considerably. 

The largest increase was recorded in the mining 

industry, metallurgy, and chemistry. The number 

of employed women greatly increased. 

The birth rate declined; the abortion rate 

increased considerably during the period under 

observation. 

A dense communications network has been 

developed. At present, even the most remote 

village is easily accessible by buslines. This 

is a prerequisite for the proper functioning of 

the health services. The number of physicians 

declined during World War II, but this loss was 

more than compensated for after 1945. The 

number of hospital beds also increased. Since 

1950 all health services have been provided free 

of charge and are accessible to everybody. Any 

umployee who is unable to work is eligible for 

sickness benefit or disability. pension. A small 

“social pension” is granted even to invalid 

citizens who have never been employed. In this 

way, at least the most serious consequences of 

ill health such as pauperization, privation, and 

especially malnutrition have been almost completely wiped out. 

Against these positive influences stand the 

well-known noxious factors of any industrialized 

society, such as air and water pollution, lack of 

physical exercise, obesity, and many others. Rapid 

indust realization together with changes in the 

traditional ways of life has brought about also 

a large amount of discomfort, stress, and conflict situations. 

It is worth noting that all these changes 

in Czechoslovakia lag somewhat behind similar 

devc’lopments in the most advanced industrial 

count ries. Almost’ all factors influencing health 

in a negative way have a delayed, cumulative effect 

on health. The primary causes of contemporary 

development should therefore be sought in the past. 

Changes taking place within very short time intervals usually cannot be accepted as an explanation 

of slowly progressing changes in mortality. 

On the other hand, it seems highly improbable that factors with a delayed effect extending 

over a number of years could explain rapid 

changes in the death rate such as have taken 

place in the last decade, especially around 1960. 

These problems will be discussed in more detail 

in the following chapters. 

MORTALITY 

National Trends by Age and Sex 

The statistical data on trends of age- and 

sex-specific death rates can be taken as accurate. 

They cannot answer the question as to how the 

changes in mortality trends came about, but they 

do show the changes which were most marked. 

The trends of age- and sex-specific death 

rates in Czechoslovakia during the years 1930-

67 are illustrated in figure 3. The main features 

of these trends can be summarized as follows. 

In all age and sex groups there was a declining 

trend. In all age groups the decrease was less 

marked among males. In both sexes the gradient 

of decline was much steeper among children 

and diminished with increasing age. 

The general tendencies can be seen in fiL~re 

4 whe i-e the average death ra:es for the p?riod 

1960-66 are compared with the average death 

rates for the decade of 1930-39. The decrease 

of death rate 

by (percent) will be denoted as 

more than 75 very pronounced 

50-75 pronounced 

25-50 intermediate 

less than 25 minor 

The distribution of males by the rate of 

decrease is shown in figure 4. The results can 

be summarized as follows. 

I I Actua 1 

range of 

Decrease in death rate Age decrease 

group (in 

I I percent) 

Very pronounced 0-14 82-78 

Pronounced 15-44 59-51 

Intermediate 45-54 37 

Minor 55+ 16-7 

Among females the decrease in the death 

rate was more marked for all age groups. 

Here, too, the decrease diminished with increasing 

5

--- ---

-- ---

---------

MALE FEMALE 

300,0. 300,0 I 

85+ 

200,0 200,0 I 85+ 

~-s 75-84 ~ ~ 100,0 100,0 ~ ~ - ___ — 75’84 -, &.. -

\ ‘\ \ 

50,0. ~ ~ ~ $, - .— 65-74 50,0. . ~.’ 

‘.. ‘. %-, 

‘,. Under — 65-74 

. --—./-. Iyear ~.. 

20,0. - 55-64 20,0 - .. 

,-. Under 

I year 

10,0. 10,0. ~ 55-64 

~ 45-54 L--! 

~ 

~ 45-54 

2,0. \ ,. VI \ 20 =-, ., J*4 

1. ‘1, \ — 35-44 

s-.. \ L 

1,0. 1,0. . . . 

~ 7, ‘b. , 

v’.._\_\ ‘\ 

\ ‘ ----------- 5-14 %, 

L--, 

\\--- S-,4 

4 

1930 /94c /950 /960 1967 /930 1940 /950 /960 1967 

Figure 3. Death rate per I,000 popu1at ion, by sex and age: Czechos 1ovakia, 1930-67.


age. The decrease of death rate among fenzales, this part of the world. ‘Ilm death rate increases 

subdivided in the analogous way, was as follows.	 significantly in the years with major influenza 

epidemics. In addition to the deaths from influenza, 

excess mortality occurs for a number of other 

Actual conditions such as chronic bronchitis and ischernic 

Decrease i.n death rate Age range of 

decrease heart disease during an influenza epidemic. Major group (in influenza epidemics occurred in the years 1’%39, percent) 1959, and 1962. In addition, there were several 

minor epidemics which affected general mortality 

to a lesser extent. The general features of the 

age- and sex- specific trends, ignoring the transitory changes, may be described as follows. 

The death rate of children (both sexes) 

The curves in figure 3 display some conspicuous before the war showed only a moderate decline; 

irregularities, especially a transient increase after the war the decline was accelerated esin the last years of World War II; other less pecially in the 1950’s. Since 1960 a leveling-off 

marked peakswerecaused byinfluenza epidemics. ~as been observed. 

Influenza is the only epidemic disease which, The death rate for the age groups 15-24 

at irregular intervals, influences mortality in and 25-34 years can be described in a similar 

6 
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--------

--------

--------

--------

--------

--------

--------

------- ----------

---------

--------

--------

--------

--------

--------

--------

--------

the 65-74-year-old males, mortality was almost 

MALE FEMALE stable throughout the period under observation. 

It is worth noting that a slight decrease was 

recorded for this age group in the first years 

of World War II. In the ages above 75 years 

the picture was similar. Only a small relative 

decline in the rate was observed before 1960, 

followed by a slight increase. 

Among females 45-64 years of age, there was 

a minor decline in mortality before the war. 

After the war the mortality continued to decline 

until 1960 when it leveled off. For females aged 

65-74 years, the trend was almost flat, with 

a slight decline in the first years of World 

War II and again during 1954-61. Among females 

in the age group 75-84 years, the picture before 

1945 was similar to that for females 65-74 

Table	 3. Ratio of death rates, by sex and 

age: Czechoslovakia, 1940-66 

Sex and age 

* 

Male Ratio of death 

(1930-39=100) 

rates 

Under 1 year 78.6 35.7 18.5 

1-4 years ;:.; 28.1 17.5 

1960- ;;w;-

1966 

5-14 years 

15-24 years 

31.9 

86:3 47.9 

21.8 

40.7 

25-34 years 86.6 52.1 44.0 

Figure L+,Decl ine in the death rate in Czechoslovakia 35-44 years 84.7 53.3 47.3 

from 1930-39 to 1960-66, by sex and age. 45-54 yeara 

55-64 years 

95.7 70.6 

97.3 87.5 

63.3 

83.3 

(I930-39= 100) 65-74 years 

75-84 years 

96.6 93.5 

97.0 91.6 

92.8 

89.8 

85 years and over-- 97.8 83.3 88.5 

Female 

wuy, except that the decline in mortality was 

m LICh slower. Under 1 year 78.0 35.3 17.5 

tle prewar decline in mortality among 1-4 years 66.7 27.5 13.7 

males 35-44 years was insignificant; after the 5-14 years 70.4 21.0 13.4 

15-24 years 78.9 27.8 15.8 

wilr it accelerated. In 1958, the death rate began 25-34 years 78.1 34.6 20.8 

to level off. Since 1963 there has been evi- 35-44 years 79.2 48.6 33.9 

LiL’n~~ d a minor increase. 45-54 years 85.2 59.9 50.5 

55-64 years :3.; 67.7 57.4 

Among males, aged 45-54 and 55-64 years, 65-74 years 78.5 66.7 

lhL$ L~L’ddl rate before the war was almost stable. 75-84 years 95:3 87.4 78.9 

A mild decline after the war came to a standstill 85 yeara and over-- 99.1 90.4 83.9 

a IULInd 1 ~>5S; in the age group 45-54 years, a 

S1ight increase in mortality was observed. For lRatio for 1940-49 excludes 1945. 

7 
100 

I r 

MALE 

90 \ 

80 / { 

70 I 

FEMALE / 

60 I J 

50 / ,/ 

40 / \ / 

\ / 

. 30 i 

/ 

20 / 

10. 

0 10 20 30 40 60 70 80 90 ?00 

A%OE 

Figure 5. Ratio of life table death rate in 1960-61 

to life table death rate in 1929-32: Czech lands. 

(1 929-32 = 100) 

years, but a slight decrease occurred after 

World War H. The trend of the death rate for 

females above 85 years was also similar; a 

minor increase before the war might be mentioned. 

The general features of the development. are 

shown in table 3. In comparing death rates by sex, 

it may be seen that the females were already lower 

than those for males in the 1930’s. The difference 

increased in the course of the following 25 

years. The sex differences in the rate of decline 

may be shown using the probability ies of death 

from the life tables. In figure 5 a curve has 

been drawn giving the course of the death 

rate for the period 1929-32. The decline in 

female mortality is shown by a fairly regular 

curve, but striking irregularities are seen in 

the curve for males. The first peak around 

20 years of age in the curve for males corresponds probably to an increase of fatal transport accidents which partly compensated for the 

mortality decline from infective diseases (amlong 

others tuberculosis), The second peak—between 

60 and 70 years—resulted, beyond doubt, from 

the rising trend of myocardial infarction and 

of bronchogenic carcinoma. These CL1L[5CSd 

death are highly prevalent among males in this 

age group. 

Current National Data 

In addition to the study of time scric,s, 

cross -sectional analyses can be useful thr 

the purpose of this study. If the age- and scx -

specific death rates of two (or more) differ~”nt 

regions are compared during a certain com ­

paratively short period, the resulting inte L-­

regional variations will be determined by the sanlL, 

factors which are responsible for the changefi 

of mortality in time. 

Two contrasting regions were chosen for such 

a comparison: the region of Northern Bohemia, 

a highly industrialized area for many decades, and 

the region of Eastern Slovakia, which is mainly 

agricultural (fig. 6). 

Mortality among infants and children of ag~,s 

1-9 years was higher in the agricultural region. 

In the age groups from 10 through 34 years 

among males and from 10 through 49 year> 

among females the rates were nearly equa 1 

(with minor deviations in both directions), 

while above the age of :35 years in males and 

above 55 years in females the mortality in tlw 

agricultural region was considerably lowL’r 

(table 4). 

These results are in keeping with the results of the analysis of trends in time series. 

The infant and child mortality in Czechoslovakia 

(as well as in many other countries) rapidly 

declined in the course of industrializat ion, wllilv 

Figure 6. Terr i tory of Czechoslovakia, 
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-----------------------------------

-----------------------------------

-----------------------------------

----------------------------------- -- ---- --- -- -- - ---- --

-------- -------- -------- ---

-------- -------- --------- --- -------- -------- -------- ---

-------- --------- -------- -------- ---

-------- --------- -------- -------- ---

-----------------------------------

--------- -------- -------- --------- ---

--------

-----------------------------------

-----------------------------

Table 4. Death rates, by age and sex: Northern Bohemia and Eastern Slovakia, 1963 

Female 

Age 

Northern Eastern Northern Eastern 

Bohemia Slovakia Bohemia Slovakia 

.-.—. population 

specitled group 

in 

Under 1 year 29.05 36.20 23.59 27.21 

I.-4 years-.=---------.---.-.-v---------------- 1.44 2.08 0.84 1.71 

5-9 vcars 0.74 0.86 0.36 0.40 

io-14years 0.64 0.45 0.29 0.22 

15-19 years ZO-24 years ~5-’29 years 

1.36 

1.88 

2.18 

1.02 0.75 

2.26 0.54 

1.66 0.78 

0.45 

0.66 

0.71 

30-34 years - - - . - . . - .- .- - . - 2.54 1.88 0.86 1.13 

35-39 years ..-:----- 3.27 2.45 1.50 1.14 

40-44 years-----------=-----------------------

&5-49 years -----.-- 4.06 

6.75 

3.69 2.49 

5.57 3.18 

2.25 

2.74 

50-54 years -.------ 12.05 7.53 5.46 5.17 

55-59 years 17.68 12.71 8.61 7.46 

60-64 years 32.38 20.41 15.05 11.78 

65-69 years 51.83 29.74 26.57 23.59 

70-74 years 69.26 54.67 l++.;: 40.72 

Rate per 1,000 

75-79 years -.--.--” ---.-s-- .-”----- ..- 118.50 85.88 71.53 

80-84 .

vears 

85 years and over 

th~. dc’cline & mortality amottg young adults was 

much S1OWCYand the decline (if any) among older 

m:~les ond females was only slight. 

[t certainly cannot be assumed that the older 

pcoplcha vcnotprofited bytheprogressof medical 

scicmcu and the improvement of preventive and 

the’rapcutic mi,dicalcare; these benefits, however, 

were fully outweighed by the effect of factors, 

highly prcwalent in any industrial society, which 

unfavorably influenced the population’s health. 

While’ the positive aspects of technical 

dt.(v~’lopment make themselves felt fully and 

rapidly in the infant and child mortality, the 

cum _tlative effects of negative factors associated 

with industrial developrnen tare strongest among 

th~’ elderly and fully compensate for the effect 

of p.witive factors, 

As regards the cross-sectional analysis, no 

stwh compensation was possible in thepreviously 

LtgrIcultural region, and the result was a lower 

lCILI1 of mortality among the elderly. 

13y similar arguments not only the parallel 

d~’v~’lopment of mortality in all highly industrial164.25 128.50 137:42 134.57 

263.38 202.71 248.66 202.10 

ized countries but also the different onset of this 

developmentcan be explained. 

Limitation of Data by Cause of Death 

The rapid decline in the general death rate 

during the past several decades is a consequence 

of a decline in the incidence of certain diseases 

or even eradication of some diseases, and 

of a reduction of the fatality rate in others. 

This decline was partly compensated for bythe 

increase in the rate for other causes of death. 

The dynamism of the mortality trends cannotbe 

grasped withouta thoroughanalysisof the causespecific mortality trends within homogeneous 

groups ofnosological units. 

Such an analysis is impeded by all factors 

which impair the validity and comparability of 

statistical data on causes of death extending 

over long periods. Of particular importance are 

changes in medical nomenclature and in the 

contents ofnosological categories. More precise 

diagnostic criteria and their dissemination in 

9 
medical practice often resulted in shifting certain pathological conditions between categories 

of the International Classification of Diseases 

(ICD). For example, in 1955 only 17.7 percent of all 

deceased persons in Czechoslovakia had a postmortem examination; in 1965 not less than 31.6 

percent of the deaths we’re autopsied. This 

improved the cause-of-death statistics considerably, especially as regards sudden and unexpected deaths where the postmortem examination is obligatory. The increased portion of 

people who die in hospitals, and case-finding 

programs involving several chronic diseases, 

also contributed to the improvement of cause-ofdeath diagnostics. It also turned out that even 

minor changes in the regulation and practice of 

certification of death, or of the application of 

cause-of-death selection rules often resulted 

in significant shifts among categories in causeof-death statistics. 

When conspicuous changes in the disease 

trends are observed, the question should be 

asked how far they result from changes in the 

incidence or fatality of the respective disease 

or nosological group and how far they can be 

explained by artifacts o~iginating in one of the 

phases of the diagnostic process .ar selection 

of the underlying cause. Some of the factors 

influencing the mortality trends by cause of 

death are of a systemwic character and can 

cause a considerable bias. 

Cause-of-death statistics, e.g., from :he 

year 1967, are without doubt more valid than 

those from the 1950’s. Even improvements in 

diagnostics, certification, and coding, however, 

necessarily cause artificial trends. The statis ­

tica~ analysis alone cannot detect these artifacts; only detailed knowledge of the whole process 

(from the diagnosis to the selection of the underlying cause) can help to assess the validity of 

mortality data. The results of special epidemioIogical investigations, are often not subject to 

the limitations of routine statistics and are 

therefore useful in the detection of bias in 

demographic statistics. 

For example, in the short period of 1959-61 

the death rate for chronic bronchitis more than 

doubled. This was, most likely, the result of the 

new Czech and Slovak editions of the ICD Manual 

containing more detailed subdivisions. Befcn-l1959, in more than half of these deaths “Cor 

pulmonale” was entered on the death certificate 

as cause of death without any indication of the 

underlying cause and was therefore classified 

among “Other heart diseases” (ICD No. 434). 

So-called “multiple causes of death” were 

not a major problem. According to Czechoslovakian experience, it would seem that the 

cases where it was not possible to determine 

the underlying cause of death from “train of 

morbid events leading directly to death” were 

rare exceptions. Experience with the revision of 

completed death certificates has shown that the 

entering of several diagnoses not belonging to 

the main “train of morbid events leading to 

death” was only exceptionally the result of hard 

thinking and deliberate choice of a “m .tItiple 

cause. ” In most cases, several diagnoses were 

entered without proper consideration as to 

which of them belonged to the main sequence 

and which to “other significant conditions contributing to death, ” and which diagnoses should not 

be entered at all. There can be no doubt that 

careless completion of death certificates could 

bias the results. 

All of the above-mentioned factors limit the 

validity of the trends in cause-specific mortality. 

For example, the mortality trends for pneumonia 

and chronic bronchitis in the period 1949-67 are 

at least partly caused by artifacts. The number 

of deaths from pneumonia was clearly overreported in the 1950’s because some cases of 

terminal pneumonia were erroneously reported 

as underlying causes of death. At the same time, 

the number of deaths from chronic bronchitis 

was underreported since many deaths were attributed simply to “Cor pulmonale” and coded 

in the category ICD No. 434. In both instances 

the statistical data from 1967 on are more reliable, but the actual trend cannot be detected 

since the improvement of the cause-of-death 

diagnostics itself has created spurious trends. 

It is therefore necessary to regroup the causes 

of death into broader classes within which errors 

in diagnosis may have compensated for each 

other. 

10 
.

...... ......... ..

National Trends by Cause of Death 

Data on causes of death are available only 

for 1!?37, and then annually for the period 1949 

to date. Figure 7 presents in graphic form the 

trends for 10 classes with thehighest death rates. 

A picture is presented of the dramatic 

development which in less than 20 years has 

completely changed the mortality pattern in 

Czechoslovakia. A continual increase was observed in the groups of neoplasms, cardiovascular diseases, diseases of the nervous system 

(shove all, cerebrovascular), as well as of accidents, poisonings, and violence, A continual 

decline has been recorded in the classes of 

infective and parasitic diseases and senility, 

symptoms, and unknown causes. Other classes 

were less numerous and--especially as causes of 

death-less important; the general tendency was: 

400 

+ . 

........................................................................... 

200 

100 . . I ““”-”””’’”’”””””’””””’””

first decrease, later stabilization, and, in the 

1960’s, a minor increase. This third group ineludes diseases of the respiratory system, the 

digestive tract, and the genitourinary system. 

The increase in infant mortality from certain 

diseases of early infancy resulted from the 

fact that in 1965 the World Health Organization 

(WHO) definition of aliveborn child was adopted 

by Czechoslovakia. 

Remarkable are the major fluctuations in 

the cardiovascular andcerebrovascular diseases. 

They coincide with outbreaks of major influenza 

epidemics and therefore can be explained as their 

direct consequence. The causes of the reversal 

of the declining trend in a few classes will be 

discussed later. It would be emphasized that the 

leveling-off or reversal of the previous downward 

trend cannot be fully explained by changes in the 

age and sex structure of the population. 

/ + — H - / \ . / . / 1 

. . .A ++-* +*+ ++++++ 2 

................................................................................ 

.+ \ \l 1’

.::::::. ...... .. .,,,,,.,,,,*.w . . . . . . . . . . . . . . . . . . . . . . . . . ,,,:..:..:.::.:.:::. ~ 

50 A	 I I 

.-. 

20 

10 I I I I I I I I 4 I I I I I I I I I I I 

/937 /949. /955 /960 1967 

1. Discmses of circulatory system 6. Diseases of digestive system 

2. Neoplrtsms 7. Diseases of genitourinary system 

3. Diseases of nervous system and sense organs 8. Certain diseases of early infancy 

4. Diseases of respiratory system 9. Senility and ill-defined conditions 

S. Accidrmts, poisonings, and violence ““. 10. Infective mrd parasitic disewes 

Figure 7. Death rate per 100,000 population for the 10 most frequent groups of causes of death: Czechoslovakia, 

1937 and 1949-67. 

11

---------------------------------- --------------------------------------------------------- ------------------- --------------------------------

-------------------------------- ---------------------------------- ------------------------------ --------------------------------- -------------------- -------------------------------

The mortality pattern has changed signifi- were of all causes of death has changed between 

cantly in the course of the past 30 years. The 1937 and 1966 as follows: 

percentages which the 10 most frequent classes 

Class of the International Classification of Diseases (7th Revi-si.on) 

I. Infective and parasitic diseases 

II. Neoplasms 

Diseases of the nervous system and sense organs 

v:; : Diseases of the circulatory system 

VIII . Diseases of the respiratory system 

IX.	 Diseases of the digestive system 

Diseases of the genitourinary system 

$ Certain diseases of early infancy 

Symptoms, senility, and ill-defined conditions 

m?; : Accidents, poisonings, and violence 

1937 1966 

19.7 

10.3 2::; 

12.5 

1::; 33.1 

1:.; 

::; 

2;7 2.3 

2.0 

1;:: 2.0 

4.9 7,6 

The trends of the crude mortality rates in 17 

classes of the ICDallowthefollowingpreliminary 

conclusions. 

1. Apart from the classes which had only 

a minor share amongcausesofdeath, thedevelopment of mortality in Czechoslovakia between 

1937 and 1966 can be characterized as follows. 

Infective, respiratory, and digestive diseases, 

diseases of early infancy, senility, and unknown 

causes of death declined from 659.8 to 191.3 

per 100,000 population, or from 50.4 percent 

to 19.2 percent of all deaths. Neoplasms, circulatory diseases, and accidents increased from 

446.4 to 617.4 per 100,000 population, or from 

34.1 percent to 61.9 percent of all deaths. 

2. Diseases with a marked declining trend 

were highly prevalent among children and young 

adults; the only exception was, of course, the 

category “Senility and ill-defined conditions.” 

On the other hand, diseases showing an upward 

trend were characteristic of old age. 

3. The general trend of the crude death 

rate-regularly declining and, in the 1960’s slowing down—was a consequence ofrelatively rapid 

and partly antagonistic trends in the various 

causes ofdeath. 

4. The results of our observation during”the 

past 10 years (1958-67) may be summarizedas 

follows: 

Among infective and pavasiticdiseases (class 

I of the ICD), the decline continued at an almost 

constant rate, but the death rates for these 

diseases have reached such a low level that a 

further decline could have onlya minor influence 

on the total death rate. 

The increasein neopkzstns(class H)continued 

very regularly. 

In diseases ofthenervous system and sense 

onjwts(class VI) there has been aslightincrease 

aftera temporarydecline (most likelyanartifact). 

Some 90 percent of the deaths in this groupware 

of cerebrovascular origin. 

An inconsiderable increaseincardiotxuculav 

diseases could beexplainedasaresult ofthe aging 

of the population. The development of the death 

rate in this group willbe discussed laterinmorc 

detail. In each year with a major influenza 

epidemic a conspicuous but only temporary increase was observed. 

Diseases of thevespiratory system (class 

VIH) were steadily decliningafterthe introduction 

of antibiotics in general medical practice. They 

reached their minimum in 1955-56; after that 

a slight increase followed. ItwiHbe shown later 

that this increase resulted from improvements 

in certification of death. 

Ctmkzin diseases of early infancy (class 

XV) were declining fora number of years, above 

all as a consequence of improved preventive 

and therapeutic care for mother and child, but 

partly also as a consequence of the declinin;~ 

12 
------------------------

------------------------

------------------------

------------------------

birth rate, The slight increase in the 1960’s 

was coused by the adoption of the WHO definition of a liveborn child. 

SvmPtams, senility, and ill-defined conditions 

(clas~ XVI) continued to decline and in 1967 

reached its lowest rate of 18.3 per 100,000 

population, 

The rapid decline of mortality lasted until 

19S9. The subsequent leveling-off can be explained 

as follows. The declining death rate in classes 

I, VIII-XII, and XV of the ICEI reached such a 

low level in the 1950’s that even a continuing. 

decline could contribute very little to the general 

trend of mortality; on the other hand, the persisting 

increase of cardiovascular diseases and malignant neoplasms changed the mortality pattern 

in such a way thar since about 1960 these two 

groups of diseases have played a decisive part 

in the development of the general death rate. 

The mechanism of interaction of antagonistic 

trends will be analyzed in “Trends for a Heterogeneous Population. ” 

Western Czechoslovakian Trends 

by Cause of Death 

The development of mortality after World 

War II (from 1949 to 1967) had a very different 

character from the period ending in 1948 (fig. 3), 

Immediately after the war, a rapid decline of 

mortality began, above all among children and 

young adults. Besides other factors, it was the 

result of large advances in medical science and 

of better health care following the unification 

of the health services in 1951. 

“Ile general structure of the eastern part 

of the state was different. In the period under 

study in this paper, Slovakia was less industrialized, LIntil recently, Slovakia had higher 

death rates and a different pattern of causespecific mortality (table 5). Slovakia has been 

going through stages of development similar to 

[ilosc of the western part of the Republic, with 

a somewhat delayed onset, but at a higher speed. 

It was therefore expedient to separate the 

two parts of Czechoslovakia, since the trends 

in the cause-specific mortality were the main 

object of study. Only the analysis for the western 

part of Czechoslovakia (Czech regions) will be 

given hc’re. It contains a more detailed survey 

of mortality by causes of death for the period 

from 1949 through 1967. The most important 

results can be seen from figure 8. 

A very significant decline of mortality from 

infective and parasitic diseases (ICD Nos. 001-

138) resulted from the rapid decline of the 

incidence and fatality of pulmonary and extrapulmonary tuberculosis. The most favorable results were achieved among children and younger 

adults. Because the screening programs, diagnostics, and evidence of tuberculosis were on 

a fairly high level, the established trend can be 

accepted as reliable. 

A considerable decline was recorded in the 

death rate for syphillis and its sequelae; almost no 

deaths from diphtheria, whooping cough, and 

poliomyelitis were recorded in 1966-67. 

The death rate for malignant neoplasms 

(140-205) has been increasing continuously and 

regularly throughout the period 1949-67. A minor 

part of this upward trend can be explained 

by the changing age structure of the population. 

For example, the death rate for males increased 

by 67.0 percent in the period 1949 to 1966. 

Only 17.5 percent of this can be attributed to 

changes in the age structure of the population; 

the remaining 51.4 percent were partly due to 

better diagnostics (see the decline of “unspecified 

neoplasm”), and a substantial part was a real 

increase, mainly of the deaths from malignant 

neoplasms of the respiratory system (160-164). 

Other” groups with a considerable increase were 

genitourinary cancer (180-181) and leukemia 

and other hemoblastoses (200-205). By far, most 

important was the increase in lung cancer. These 

three categories will be denoted as subgroup A; 

all other sites will be included in the subgroup B. 

The increase of mortality was as follows: 

Rate pev 

100,000 

males 

Sub.gvoup A 

1949 39.5 

1960 99.1 

1967------------------------ 137.1 

Subgroup B 

1949 ------------------------ 127.1 

1960 13o.9 

1967 148.2 

13 
400 

300 

1


3 200 

2 

; 

3 

100 

I 1 I ,

1 1/ I , I 4 

50 

5 4 

1, I.<tmic h,,,, d,waw \ ~ 

!. Card!., .,,” 1.,disease, except lHD 

3. CmebmvMmImI diwas., \ _ _ 

10 4. Accid.nfd !.juri.. ~, ~ufo,dafl ~ 6 & Senilityand 111.d.li.ti mmdhl.mn 

1 1 ! , 1 I I ! I I 

/ 

1949 1955 1960 “ 1967 

400 

300 

200 

7 

30 

1 ! 1 1%1 

Ivl I I I I 

20 I I I I I I 1 ,. ! I ! ! I I I I I .. u 4-I-!-.”” 

{ 

. 

.30 1 1 1 1 I I I 

I 1 T l\ 1 t I I 

[ I I 11 I 1 1 

-. 1. Iscb.mo hmfl J, ,.,”. ,,, 2. ctiw~.c.k rii,ets,,, ,X,,p, *“D 

70 a. Ccrobm.Mc”lar di,ecs,, 

4, Accidmfd i.j.rlm 

5. S.iddm 

8. Senility..d f11.dmned m.dlu.n + 

I 

EH3

I I I I I I I I I I I I 1 1 I 1 t I 

1949 1955 1960 !967 

1949 19.55 1960 1967 

Figure 8, Death rate per 100,COO populat ion for 12 selected causes of death, by sex: Czech regions, 1949-67,


14

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---------------------------------

---------

-----------------

--------------------

-------------------

-----------------

-----------------

------------------------------------

-------------------------------

--------------------

---------------------------------

---------

----------------- --------------------

-------------------

-----------------

-----------------

Table 5. Death rates for selected causes of death,by sex: Czech regions and Slovakia, 

1949 and 1966 

Cause of death M 

m Rate per 100,000 population 

All causes 1,176.6 1,267.0 892.3 1>265.1 

Selected causes 1,095.1 1,159.2 813.1 1,132.7 

Infective and parasitic diseases 20.0 139.4 34.2 158.4 

Malignant neoplasms 278.3 166.6 162.7 85.2 

Cerebrovascular and cardiovascular diseases 497.0 :;;.:, 321.1 181.4 

Diseases of the respiratory systeml 107.0 101.6 157.8 

Diseases of the digestive system 50.1 73:6 35.9 91.7 

Certain diseases of early infancy 23.0 66.5 28.0 137.1 

Senility and ill-defined conditions 11.2 59.2 27.7 2;:.; 

Accidents, poi.soni.ngs, and violence 108.5 102.4 101.9 . 

Female 

All causes 982.3 1,091.3 756.5 1,159.1 

Selected causes 892.4 994.8 686.4 1,054.4 

Infective and parasitic diseases 11.0 89.5 16.7 127.1 

Malignant neoplasms 198.4 159.0 126.8 86.8 

Cerebrovascular and cardi.ovascularldiseases 495.0 436.1 349.8 211.7 

Diseases of the respiratory system 62.3 96.3 73.1 133.7 

Diseases of the digestive system 41.7 54.5 29.2 70.0 

Certain diseases of early infancy 14.5 43.4 18.3 103.5 

Senility and ill-defined conditions 17.4 81.1 40.0 298.2 

Accidents, poisonings, and violence 52.1 34.9 32.5 23.4 

1

Except upper respiratory infections and influenza. 

‘I%c’t.tpwardtrend insubgroupAwas verymarked, only above 85 years was a significant increase


while the increase in subgroup B canbeexplained recorded, no doubt as a consequence of improved


as a consequence of the aging of the population, diagnostics in this age group.


and partly also as a result of improved diag- In the subgroup of benign neoplasms (210-


noses, especially in the oldest population groups. 229), only a minor decline was observed, but


More details are given in table 6. the deaths from neoplasms of unspecified nature


In almost all of the age groups, there was (230-239) have shown aconsiderabledecline which 

a marked increase in the male death rate for was, beyond doubt,producedby betterdiagnostics. 

subgroup A. On the other hand, the death rate Diseases of the heterogeneous class of alfor subgroup B declined in all age groups above lergic, endocrine system, metabolic, and nutri34 years. tional diseases (240-289) were infrequent as 

hfollowsfrom table7thatthere wasadecline causes of death. Worth notice are diabetes melin the age-specific female mortality from cancer lituswithanupward trend andallergic asthmawith 

in all age groups between 25 and 74 years, and 

15

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-------- --------- -------- -------- ---

-------- -------- --------- -------- --

-------- -------- --

------------------------------------------

-------- -------- -------- -------- --

------------------------------------------

-----------------------------------------

----------------------------------------- -----------------------------------

-----------

--------------

-------------

------------

------------

------------

------------

------------

------------

------------

------

Tab Le 6. Death rates among males for malignant neoplasms, by age: Czech regions, 1949 

and 1960 

Age 

Under 1 year .------- --.----- -

1-4 years 

5-14 years -----..--

15-24 years 

25-34 years 

---..,----

“------- -“------ ----”---

35-44 years 

45-54 years -.--=---

55-64 years 

65-74 years -

75-84 years - 85 years and over -

Rate per 100,000 males in 

specified group 

4.6 4.4 

11.6 

::; 3.2 

. 6.0 

10.2 8.1 10.8 

22.0 16.8 28.5 2?:; 

93.5 63.6 100.9 116,6 

365.9 156.9 326.2 346.3 

646.0 295,1 692,0 787.5 

611.3 304.3 1,000.0 1,133.3 

275.5 223.3 706.0 960.6 

lSubgroup A includes malignant neoplasms of respiratory system (160-164), malignant 

neoplasmsof genitourinary organs (180,181), and neoplasms of lymphatic and hematopoietic 

tissues (200-205).


2Subgroup B includes all other malignant 

a decreasing trend. Rickets as acause of death 

has completely disappeared. 

Diseases of the blood and blood-forming 

organs (290-299), although infrequent as causes 

ofdeath, declinedin all age groups. 

Table 7. Death rates among females for 

malignant neoplasms, by age: Czech re­ gions, 1949 and 1960 

Age 1960 1949 

Rate per 100,000 

females in 

specified group 

Under 1 year 4.6 

1-4 years 8.6 

5-14 years ::; 

15-24 years ::; 

25-34 years 19.7 2;:? 

35-44 years 54.4 71.5 

45-54 years 185.5 187.6 

55-64 years 374.7 391.5 

65-74 years 729.4 730.0 

75-84 years 1,148.8 1,126.4 

85 years and over 1,171.1 1,010.8 

neoplasms. 

Mental disorders (300-326) (above all, psychoses) can, beyond doubt, appear as underlying 

causes of death; it is, however, not clear under 

what circumstances this is justifiable. Thepracticein the period 1949-67 was obviously variuble 

and the downward trend is probably spurious. 

Cerebrovascular diseases (330-334), as a 

cause of death, constitute one of the most important nosological groups. Among males, the death 

rate for this group has increased by 55.6 percent 

in the period 1949-67. Less than halfof this increase can be attributed to theaging of the population. The age-specific male death rates for 

cerebrovascular diseases in 1949 and 1%(1 are 

shown in table 8. Up to the age of 64, there was a 

considerable decline, The rate for the age~$oup 

65-74 showed only an insignificant change, buta 

marked increase was observed for the age group 

over 75 years. Since the quality of clinical diagnoses improved and the number of postmortem 

examinations increased considerably, it can be 

assumed that the real trend was declining in all 

age groups butthattheimprovementofdia~mostics 

produced a spurious upward trend, especially 

among the elderly. 

16

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------------

------------

------------

------------

------------

------

Table 8. Death rates among males 25 years 

of age and over forcerebrovascular disease, by age: Czech regions, 1949 and 

1960 

Age 1960 1949 

Rate per 100,000 

males in 

specified group 

25-34 years 2.5 

25-44 years ::: 11.4 

45-54 years 30.5 46.6 

55-64 years 139.3 192.7 

65-74 years 555.3 543.1 

75-84 vears 1,566.4 1,146.4 

85 yea;s and over 2,359.2 1,820.6 I t 

Other diseases of the nervous system (340-

36’]) caused not nlorethan Spercent (males) and 

(-ipercent (females) ofall deaths among diseases 

of the nervous system and sense organs (330-

W8) and had a decreasing tendency over the 

period 194Q-66(decrease bysome50 percent). 

The death rate for the combined group of 

cerebrovascular and cardiovascular diseases 

(3:3(1.334 and 400-468) increased among males 

between 1949and 1966 from 433.9 in1949t0497.0 

per 100,000 population, that is, by14.5 percent. 

But the age-adjusted death rate (probabilities 

from lWQ, age structure 1966) for1949was 5’15.S 

per 100,000. This group, as acause ofdeath, in­

~r~i~sd therefore by a smaIler percentage than 

would result from the change of the population 

structure by Qge. (In 1967 the expected and observed frequencies were almost equal.) 

Among females, the influence ofchangingage 

StIYICtUre was even more sib~ificant. The death 

rate for cerehrovascular and cardiovasculardis-. 

eases between 1949 and 1966increasedfrom436.1 

to 495.0 per 100,000, or 13.5 percent. A%’the 

expected increase was 38.6 percent, the actual 

increase was considerably lower. 

! Thechange inthe deathxate for the groupof 

circulatory diseases canbeexplained,forthetime 

being, only tentatively. There has been a very 

rapid decline inthe death rate formyocardialdeXenerati~n(~W ,narnely, adecrease ofS6percent 

LiKILIIl~ males and SO percent among females in 

the period lWIJ to 1966. The most probable explanation is the overreporting ofmyocardial degeneration in the 1950’s. It is well known that 

this diagnosis was often reported as the cause of 

death, instead of undesirable terms such as “unknown cause” or “senility.” 

A more realistic picture of therealtrendcan 

be obtained from the period 1960-67. Iftheexceptional year 1962 is left out (major influenza 

epidemic), the prevailing trend can be found by 

the least-squares method. The average rate of 

yearly increase found in this waywas O.9percent 

for males and 0.8 percent for females. Since 

some 0.3 percent can be explained as the result 

of changes in the age structure, the net yearly 

increase of the age-adjusted death rate from 

cerebrovascular and cardiovascular diseases can 

be estimated atabout 0.5percent. This seems to 

be amorereliable evaluation of the recent trend 

of this nosological group than the hypothesis of a 

decline inferred from the period 1949-66. 

The most important single cause of death is 

coronary heart disease (420) which shows a remarkable upward trend among both males and 

females. The male-female ratio in 1966-67 was 

1.5:1. The upward trend for both sexes, however, 

seems to be somewhat overestimated because 

the diagnosis of coronary heart disease has improved greatly during the period 1949-67. But a 

major part of the observed increase was, no 

doubt, real; this conclusion has been corroborated 

by results of special epidemiological studies. 

There was a major increase in hypertensive 

(heart) disease (440-447) around 1960, and since 

that time the death rate has remained on this 

higher IeveI. Very rapid changes in the death rate 

for any cause of death (except for epidemic diseases) necessarily arouses suspicion that it is 

artificial. Here again, the improved reporting of 

the underlying cause of death is most likely 

responsible for the increase. 

Chronic rheumatic heart disease (410-416) as 

a cause of death has shown, so far, no improvement,, in spite of the decIining incidence of rheumatic fever in the population. 

Diseases of arteries (450-456) and diseases 

of veins (460 -46S) have also displayed a major 

increase, with considerable fluctuations in both 

directions. 

All this seems to corroborate the above hypothesis that the decrease in the age-adjusted 

death rate from diseases of circulatory system, 

observed in the 1950’s, was only spurious and was 
caused by better diagnostics. On the other hand, 

the slight increase found in the 1960’s is probably 

a true picture of the present development. 

Acute upper respiratory infections can only 

exceptionally be underlying causes of death. Influenza in the years of major epidemics was an 

important cause of death. In other years, the 

deaths from “influenza” should probably have 

been attributed to pneumonia; the resulting error 

is, however, insignificant. 

Other respiratory diseases (490-527) can be 

divided into two subgroups with widely differing 

trends. Deaths from pneumonia (490-493), formerly very frequent, declined after the introduction of antibiotics and became stable at a new 

level in the 1960’s but showed major fluctuations 

in the years of influenza epidemics. The death 

rate for chronic bronchitis and other respiratory 

diseases was rather irregular. In the 1950’s the 

death rate for this cause was low; it increased 

suddenly in 1960 and since that time has remained, 

with some fluctuations, on this comparatively 

high level. The low level of mortality from this 

cause in the 1950’s was due to incorrect reporting 

of deaths because the direct cause—cor pulmonale—was often entered as a single cause of 

death and the underlying cause (in Czechoslovakia, 

most often chronic bronchitis) was not mentioned 

on the death certificate. The observed fluctuations 

can be attributed partly to the effect of influenza, 

partly, however, to changing diagnostic and coding 

practices. In view of the increasing exposition of 

the population to dust and increasing air pollution, 

and with regard to the results of special epidemiological studies, the conjecture can be ventured 

that the true picture of the trend in the period 

1949-67 was a continual increase starting in 1949 

at a much higher level and ending in 1967 at a 

still somewhat higher level (by some 25 percent) 

than reported. If this conjecture were correct, 

the death rate for chronic bronchitis in the Czech 

part of the country would be the second highest 

in Europe, following the United Kingdom. 

After a sharp decline around 1955, the death 

rate for diseases of the digestive system maintained a constant level for several years followed 

by a slight increase beginning in 1962. ~is indicates the possible existence of heterogeneous 

subgroups with antagonistic trends. Actually, an 

increase was observed in several categories, 

especially in diseases of liver, gallbladder, and 

pancreas (580-587). On the other hand, a decline 

was recorded in ulcer of stomach (540), appendicitis (550-553), gastroenteritis and colitis, and 

peritonitis (576). 

Diseases of the genitourinary system (class 

X), as causes of death, were almost constant for 

a number of years and began to increase after 

1961. This was particular true of infections of 

kidney (600). Their role among causes of death 

was, however, insignificant, 

Diseases from classes XI-XIII (complications 

of pregnancy, childbirth, and the puerperium, diseases of the skin, and diseases of the bones and 

organs of movement) were only rarely causes of 

death. 

Congenital malformations (class XIV) had a 

stable trend. In relation to the number of births 

(which was declining) the rate was, however, increasing, probably as a result of improved diagnoses and reporting. Recent data are fairly reliable. 

Certain diseases of early infancy (class XV) 

showed an increase for similar reasons to those 

given above. Significant was the increase of the 

death rate from postnatal asphyxia and atelectasis 

(762), pneumonia of newborn (763), and diarrhea 

of newborn (764). 

Class XVI, “Symptoms, senility, and iH-defined conditions, ” reflected in its development 

the improvement of diagnostics and reporting of 

causes of death. In 1949, for example, it included 

4.7 percent of all male deaths and 7.4 percent of 

female deaths, while in 1967, not more than 0.8 

and 1.8 percent. This could not have any major 

effect on the cause-specific mortality in other 

classes. 

Accidents, poisonings, and violence (class 

XVII) constitute a group with a not very significant 

upward trend. The age-adjusted death rate for 

accidents increased by 5 percent from 1949 to 

1966 among males and somewhat more among 

females. On the other hand, the age-adjusted 

rate was almost constant between 1960 and 1~66 ,

,. but increased again in 1967. 

The ratio of the male to the female death 

rates was 3:1 in 1949 and nearly 2:1 in 1966-67. 

Several factors are responsible for the higher 

mortality of males: first, a greater proportion 

of men in high-risk occupations; second, their 

18 
larger participation in motoring and high-risk 

sports activities; and third a higher number of 

suicides, 

The modest increase of the death rate for 

accidents resulted from antagonistic tendencies. 

During the period underobservation thedeathrate 

for motor vehicle accidents was increasing proportionately to the density oftraffic on theroads. 

Accidental falls, as causes of death, are characteristic of old age and increased, therefore, 

because the proportion ofthe elderlyin thepopulation increased. Some of the new technological 

processes in industry tend toreducethe incidence 

of casualties at work. On the other hand, fatal 

accidents in agriculture increased greatly. 

It has been shown that the general trendof 

mortality is a result of summing up individual, 

partly antagonistic trends. This applies to the 

overall as well as to the age- and sex-specific 

mortality trends. These “elementary trends” 

often have a simple course, depending on the 

changes of certain factors which influence theincidence or fatality rate of diseases which are 

frequent causes of death. 

The heterogeneity of individual trends was 

very marked. Besides causes ofdeathwithastable 

trend, a number of causes of death were found 

with a strong tendency to long-term increase 

which was neutralized by the equally strong declining tendencies among other causes of death. 

It has been shown that it is always difficult 

and sometimes impossible to establish, free from 

bias, all individual trends of mortality. It will be 

expedient to study, in the first place, only broad 

groups of causes of death where errors in estimate 

of trends can—to a certain degree—counterbalance each other. 

TRENDS FOR A 

HETEROGENEOUS POPULATION 

Suppose that the general death rate can be 

divided into mutually exclusive components, for 

! example, death rates by cause of death: 

q(t)= ql(t) + q2(t) + . . . + q“(t) (1) 

where t denotes time. The rates CIi(t) can be 

considered as continuous functions of t,having 

the first and second differentials. If simple 

mathematical models of the observed data (death 

rates) are found, the function (1) can be analyzed 

by mathematical methods. 

As shown above, the time series of causespecific death rates representing homogeneous 

components of the general mortality are often 

monotonous and have an approximately constant 

rate of increase or decrease: 

log qi(t) = ai + t.bi (2) 

qi(t) = eai+tbi 

q(t)= ~qi(t) = ~eai ‘tbi (3) 

1 1 

The shape of q(t)can be found as follows: 

dq(t) 

—= pi e’, +’bi (4) dt 

dzq(t) , ~= ~bzeai+’di >() 0 (5)

The function q (t)is therefore convex if 

bi+O 

for at least one value, bi. If 

bi > 0 for all j 

bi > 0 for at least one ~ 

then (4) is positive and q(t) has an upward trend. 

If all bi are nonpositive and at least one 

bi is negative, then (4) is negative and q(t)has 

a downward trend. 

If at least one b, is positive and at least one 

negative, then 

Iim q(t) = lim q(t) = + co 

t =—* t=+co 

and since the function q(t)is convex and continuous, it will exhibit a change of the downward 

into an upward trend (part a of fig. 9). 

19 
-------- --------------

------------------------

--------------------------- -----------------------

at a lower level can be represented by a polygonal 

line 

or (7) 

x - ___L_L_ 

tl t2 tl t2 

(b) 

If two elementary antagonistic trends of the


,010 \ type (7) are confounded, the general trend may


have the form (part b of fig. 9) exhibiting again a
 C 

passage from one level to another—this time, 

J“ however, connected by a convex polygonaI line with 

A

1 B \ .-----., 1 a minimum. A passage between the two flat levels 

can be also monotonous or concave with a rela­

!30 

(cJ tive maximum. 

Another representation of the passage be- 100 

tween two flat levels provides the “logistic 80 curve” (8). 60 

The function .40 

20 

ai - bi -12-10-8-6-4-202 468 /0 /2 /4 qi (t) = +bi, C,>o, ki>o (8)

I+kiecit 

Figure9. Mathematical
models of trends in hetero­


geneous populations I. 

tends to bi if t increases and tends to ai if t 

decreases: 

For our purpose only the segment of the Iim qi(t) = ai Iim qi (t) = b, 

curve (3) has a real meaning where t=-ce t=+oa 

Osq(t)<l (6) For example, the equation 

a-b It is assumed that the condition (6) is always ful- ql(t) _— 

– ~t+ ~ +b, l>a>b>o, b<$

filled. 

It follows from (6) that (3) can be a satisfactory approximation of the actual trend only represents the decrease from the level a to b.


within a limited time period. Sooner or later the The equation


upward phase must level off and, under constant


conditions, it will tend to become stabilized at a 92(t) = ~

b-a + a


certain new level. Any permanent change of the


main determinants of death will probably result


in an equally permanent change of the mortality represents the increase from b to a.


level. The sum 

For example, a mortality decline in the time 

interval from tl to t2followed by a stabilization ql(t) + q2(t) = a + b 

20 
----- ------ -

---- ----- - ----

--

----- ---- ----- ---- ----- ----- -----

-------------- ----- ----

is a constant; this is the expression of a stable 

level of mortality. 

The resulting equation 

Y =a+b 

represents a straight line parallel to the x-axis. 

A shift in time of one of the two components 

can he expressed by the substitution, for example, 

t=t’+5 or t=t’–4, 

so that 

or 

b-a 

~4(~)= ~~_4+1 ‘a 

The results 

Y = 91(t) + ~2(~) 

y = gl(t) + q3(t) 

y = ql(t)+ q4(t) 

are charted by figure 10. 

This schematic example shows that even a 

minor change, namely a somewhat earlier (or 

delayed) onset of the accelerated increase of one 

of the two components, for example, r12(t), can 

produce unexpected and bizarre swellings or depressions which would certainly be suspect of 

being caused by artifacts, should they be seen in 

any statistical material based on observation. A 

search for some special factor or factors responsible for this “swelling” or “depression” would 

be in this case futile since no such factors exist. 

In a similar way the curve “C” in figure 9 is 

connecting two different levels. And again, a shift 

of one component along the x-axis has created an 

irregular course with a transitory “depress ion.” 

It has been shown that under certain assumptions as regards elementary trends the superim -

position of these trends leads to a convex curve. 

It can be either Y-shaped, and then it represents 

a monotonous (steadily increasing or declining) 

course, or U-shaped, reflecting a change from 

declining to increasing phase. 

These models resemble the actual situations 

which existed in Czechoslovakia after World War 

II.	 Groups of causes of death have been found with 

marked antagonistic trends. Increasing trends 

were observed, among others, in lung cancer, 

ischemic heart disease, chronic bronchitis, and 

road casualties. On the other hand, communicable 

diseases (above all tuberculosis), pneumonia, diseases of early infancy, and degeneration of the 

myocardium were declining throughout the period 

under observation. Only a minor part of causes of 

death remained approximately constant. 

(0) 

A+B,+C 

c ..—.------

(b) 

(C) 

A+Bj c 

- -

-z-­

-F ~ ~ / ~ /- ~ 

3 / 

.- .-. .-. — --.--> L- ..-.c —. —----

12 -10-8-6-4-202 4681012f4 

Figure 10. Mathematical models of trends in hetero­


geneous populations II.


21

Some of the elementary trends had a regular 

and monotonous trend. Exceptionally, the Ushaped form was found, but in each case it could 

be shown that the group was heterogeneous and 

consisted of at least two homogeneous subgroups 

with antagonistic trends. For example, “Other 

respiratory diseases” with a U-shaped trend 

were broken down into pneumonias which were 

declining during the period under observation and 

chronic respiratory conditions, with an upward 

trend. 

The trend of any cause of death—or of any 

homogeneous group of causes of death—is brought 

about by changes in the main causative factors. 

When negative factors prevail an upward trend 

will result, and vice versa. 

In Czechoslovakia the known conditioning 

factors have gone through considerable and rapid 

changes within the past several decades, causing 

equally rapid and profound changes in the pattern 

of cause-specific mortality. It took only a few 

years to eradicate poliomyelitis and to reduce 

substantially the death rate from tuberculosis, 

pneumonia, and diseases of early infancy. On the 

other hand, a considerable change occurred, 

within relatively short periods, in smoking habits, 

in general patterns of behavior, etc. It may be 

accepted that some of the changes in mortality 

were the direct consequence of the changing 

environment, habits, and social relations. In some 

instances, such a relationship could be revealed 

by special epidemiological studies. Many of the 

factors, however, are still unknown. Even in these 

cases, however, it is rational to presume that the 

rapid changes among diseases of unknown etiology— so far as they are not artificial—can be 

explained in a similar way. 

It stands to reason that a stable level of 

causative factors will eventually result in a constant level of the death rate for a specific cause 

of death. After a rapid change of the main factor 

(or factors) a passage from one level to another 

will follow: 

~- ,.rA /---

If, on the other hand, the changes of the most 

important conditioning factors are of longstanding 

character, a long-term trend of the corresponding 

cause of death can be ex~ected. All three types 

of elementary trends have been observed since 

World War II. 

COMPONENT PARTS OF DEATH 

RATES WITH DIVERGENT TRENDS 

Some of the important causes of death after 

World War H showed a regular trend so that one 

of the curves mentioned in the preceding section 

could be fitted with observational data. This 

applies, among others, to infections, malignant 

neoplasms, ischemic heart disease, and accidents. 

Many other causes of death, however, showed in 

their development irregularities which could only 

be interpreted as artificial. It was therefore not 

feasible to carry out the breakdown into elementary trends. 

Instead, an attempt will be made to regroup 

the causes of death into three main sections with 

upward, downward, and stationary trends. It is 

assumed that the above-mentioned irregularities 

and diagnostic errors will compensate for each 

other within these broader groups. 

Group A with an upward trend includes the 

following causes of death: malignant neoplasms 

(ICD Nos. 140-205), diabetes (260), vascular 

lesions of the central nervous system (330-334), 

heart diseases except myocardial degeneration 

(400-434, except 422), vascular diseases and 

hypertension (440-468), chronic respiratory diseases (500-527), and diseases of liver, gallbladder, and pancreas (580-587). 

Group B with a downward trend among males 

contains infective and parasitic diseases (001 -

138), benign and unspecified neoplasms (210-239), 

mental disorders (300-326), diseases of the 

nervous system except cerebrovascular (3-10-

369), degeneration of myocardium (422), pneumonia (490-493), ulcer (540-542), infections of 

kidney (590-594), diseases of prostate (610-612), 

diseases of the skin and organs of movement 

(690-749), certain diseases of early infancy (760-

776), and senility and ill-defined conditions (780-

795). 

Among females, group B includes the same 

diseases. except infections of kidney and diseases 

22 
of prostate, but includes also asthma (241), diseases of blood and blood-forming organs (290-299), 

diseases of the digestive organs (exce~t diseases 

of liver, gallbladder, and pancreas, 530-578 ), and 

complications of pregnancy, childbirth, and the 

puerperium (640-689). 

Group C includes all remaining causes of 

death, among others, influenza. 

The same letters A, B, and C will denote the 

death rates from the corresponding group of 

causes of death. 

A’, B ~ and C’wiH be used for the observed 

data; A, B, and C will denote the values of the 

interpolated curves. 

The polygons A’(t), B ‘(t) have a regular, 

generally convex course, so that log A’(t), 

log B‘ (t) are approximately linear. An attempt 

can therefore be made to fit straight lines 

Y=log A(t), y = log B(t) 

by the least-squares method. 

MALE 

3,0 

ogA 

The polygons log A’ and log B1 as well as 

log A (t), log B (t) in the western part of Czechoslovakia (Bohemia and Moravia) in the period 

1949-66 are charted by figure 11. 

The interpolation A(t), B(t) is satisfactory. 

The goodness of fit was tested by the x2-method, 

and it was found that the differences are well 

within the limits of random variations. 

C (t) is equal to the arithmetic mean of 

C’(t), t = 1949, . . . . 1966. 

The values A and B computed from the 

interpolated values log A and log B, the horizontal straight line C and the sum A + B +C are 

charted by figure 12. To facilitate comparison 

both the observed and interpolated values of the 

curves A, B, C and A + B+C are shown in 

figure 12. 

Major deviations (A+ B + C) (A’ +B’+C’) are 

seen, in the first place, in the years of major 

influenza epidemics. 

FEMALE 

q A’ 

2,9 

2,a 

27 

2,6 

25 

2,4 

Z/l 

109B’ 

2.2 

1095 

2.1 

;949 1955 /960 /9.56 1949 /955 /960 1966 

Figure 11, Linear interpolation of the 1ogar ithinsof the components A,B of the death rate for males and for fe­


males: Czech regions, 1949-66,


(A - with upward trend; B - with downward trend)


23 
The results can be summarized as follows: 

Both variable components had, for all practical purposes, a constant rate of change (decrease 

or increase). The third component, C, had no 

influence on the shape of the overall mend 

A + B + C; it only moved the curve upwards. 

At first, the interpolated curve A + B + C 

was declining; later it flattened out, reached the 

minimum value around 1959-60, and has been increasing since then. 

The change in the overall trend set in despite 

the fact that the trends of the elementary groups 

A, B, and C showed no variations in the rate of 

change. This can be explained as follows. At first, 

the declining trend prevailed; later, by the changes 

of both A and B curves, the absolute increase 

and decrease were balanced, still later the increasing trend prevailed. 

MALE 

FUTURE DEVELOPMENT OF 

MORTALITY 

It might seem useful to extrapolate the curve 

reflecting the trend of the sum A + B + C (fig. 

12) and to use it as a basis for prediction of the 

future mortality trend. A closer scrutiny will 

show, however, that such a prediction has only 

a limited value. As stated earlier, the elem entary 

trends corresponding t o the development of indi-<idual causes of death (for example, lung cancer) 

are likely to have the form of logistic curves 

reflecting the change from one stable level to 

another. This process can, of course, be repeated 

if new factors emerge influencing mortality, or 

if some factors significantly change their intensity. So far, we have seen only the initial phase 

of the curve “A” (fig. 12) characterized by the 

FEMALE 7,400 

poo 

poo bB+c 

1.100I-U-U4+A I,loo 

1,0( 100 I 1 %.1 1 I I I I \ I I I i \ I I-m A A<!B+c 

900 

800 I 1 1 ! 1 1 I I I I 1 AI v , 800 

. . A 

700 

600 

500 

400 400 

300 

2G0 200 I ! I I , 1 , 1 I , I I I I B 

100 I I I I I I I I I I I I I I I I 100 c 

01 I I I I I I I I I I I I I I I I I 01 I I I I I I I I I I I I I I I I I 

1949 /955 /960 /966 /949 /955 /960 /966 

Figure 12. Breakdown of the crude death rate for males and for females into three components: Czech regiens, 1949-66. 

(Causes of death with: A - upward trend; B - downward trend; C - stable trend) 

24

approximately constant rat e of growth. After that, 

however, a second phase will necessarily follow 

with a diminishing rate of growth, eventually 

leveling off. Any reliable estimate of the time 

when the change in elementary trends will take 

place seems impossible on the basis of observational data which are now available. 

A further increase in the crude death rate in 

the next several decades is almost certain. The 

crude death rate is near to 10 per 1,000 population, The average life span is about 70 years 

and probably will reach 72 years in the foreseeable future. The net reproduction rate has 

been near 1 for a number of years. If these 

demographic levels are maintained, the crude 

death rate will tend to the value 

1,000 . 1,000 . — = — 72 = 14 per 1,000 0 

@o 

Only a substantial and permanent increase in the 

net reproduction rate or a revolutionary discovery 

in medical science, especially in prevention or 

treatment of one of the major killers among the 

common diseases, could alter this outlook. 

As regards the age-specific mortality of 

males, a continuing decline in infant mortality is 

very likely. On the other hand, the possibility of 

a further increase in mortality of adults (25-44 

years) as a result of frequent road casualties 

cannot be excluded. A further increase in the 

death rate for the age group 55-74 years seems 

also probable because of ischemic heart disease 

and lung cancer trends. 

A continuation of the declining trend in the 

female age-specific mortality can be expected in 

age groups above 4S years. Later, it will probably 

be followed by a temporary stabilization at a 

somewhat lower level. 

The above predictions are based only on 

tinalysis of demographic data. A few remarks 

which follow will deal with the problem, whether 

the underlying causes of mortality themselves 

‘ cannot be changed. 

The cross-sectional analysis, limited in this 

paper to a comparison of two regions (see “Current National Data’ ‘), has shown that major differences in mortality still exist among regions 

and districts which cannot be fully explained by 

differences in the age structure of the population 

or by any other objective reasons. This conveys a 

hope that improvement, especially in preventive 

medical care, which would bring the whole country 

to the level of the most advanced areas could 

help to overcome—at least temporarily—the 

present stagnation. 

Special epidemiological studies of morbidity 

in relation to the level of health services have 

shown that a sizable proportion of patients 

suffering from cardiovascular and other chronic 

conditions who could greatly profit from systematic medical treatment for some reasons do not 

get it. Similarly, in a significantly high proportion 

of apparently healthy people pathological symptoms or signs have been found characterizing the 

examinees as “vulnerable” who could profit from 

individual preventive medical care. 

Even without a major breakthrough in medical 

science, the application of contemporary knowledge could considerably influence some of the 

conditioning factors of mortality. The present 

balance of positive and negative factors leading 

to stagnation of mortality, in the first place of 

the male mortality, is by no means unalterable. 

However, it would not be realistic to expect too 

much. Many of the unfavorable factors are very 

difficult to change (e.g., air pollution, smoking, 

obesity, stress, etc.); on the contrary, an increased effect of some of them, or occurrence 

of new health hazards, cannot be excluded. 

SUMMARY 

The development of mortality on the present 

territory of Czechoslovakia during the past 100 

years is characterized by a steady decline (ending 

in 1960) of the crude death rate. At first the decline was slow, later accelerated, still later 

slowed down again, and reached the minimum in 

1960-61. Since that time it has been slightly increasing. 

A greater part of the increase in the 1960’s 

was due to changes in the age structure of the 

population. The age-adjusted death rate showed 

only a minor increase in male mortality and 

slight decline in female mortality. Age-specific 

mortality showed a slight tendency to increase 

among adult males, especially in the age groups 

55-74 years. A slight decline was observed among 

females over 45 years. 

25 
The female death rate was already lower 

than that for males in 1930 and the gap widened 

from 1930 to 1967. In this period of time, all 

age- specific death rates declined; the gradient of 

decline was largest in the infant and child mortality and diminished with increasing age. At all 

ages, death rates for females had a larger 

gradient of decline than those for males. 

Dramatic changes were recorded in the pattern of death rates by cause. 

In the course of time, many changes were 

made in nomenclature and classification of diseases and in diagnostic methods and fashions as 

well as in the regulations and practice of the 

rules for selection of underlying cause of death. 

Consequences and limitations arising from this 

have been discussed in detail. 

A cross-sectional analysis in different areas 

of the state, international comparisons, and 

results of special epidemiological studies have 

been used as subsidiary methods in the analysis 

of demographic data. 

Main features of the cause-specific mortality 

development were: in.crease-neoplasms, cerebrovascular and cardiovascular diseases, chronic 

bronchitis, and road casualties; decline (or stable 

state)—all other causes, above all, the infective 

diseases. 

A small number of nosological units highly 

frequent as causes of death and showing a large 

rate of change (increase or decline) were mainly 

responsible for the general trend of the death 

rate. Tuberculosis and pneumonia were most 

important among diseases with a declining trend; 

lung cancer, ischemic heart disease, cerebrovascular conditions, and chronic bronchitis were the 

leading conditions among causes of death with an 

upward trend. 

It is worth noting that almost all of the above 

mentioned causes of death with an upward trend 

are more frequent among males and among older 

people. 

Another important characteristic of the conditions with an upward trend is that so far no 

efficient methods exist that could substantially 

reduce their incidence or fatality. 

For the analysis of the general trend, the 

causes of death were divided into three large 

groups: 

000 

A’ - causes of death with an upward trend 

B’ - causes of death with a declining trend 

C’- causes of death with stable frequencies 

It has been shown that in the period of 1949-67 

the functions 

y = log A’, y= log B’ (1) 

were approximately linear. The straight lines 

y= log A, y= Io~B (2) 

were fitted to the polygons (1) by the leastsquares method. It was found that 

y= A+B+c (3) 

is a convex line with a minimum reflecting the 

change from the declining to the increasing phase 

of the observed mortality trend. 

From the analysis of trends the following 

important inference can be made: The convex 

form of the general trend in heterogeneous populations can result from superposition of antagonistic trends with constant rates of change. No 

new intervening factors need be sought to account 

for the leveling-off or reversal in the mortality 

trend. 

At first, in 1949, the causes of death with a 

declining trend were very frequent as causes of 

death and the declining trend therefore prevailed. 

Later, both trends began to balance and the curve 

of mortality flattened out and reached the minimum 

in 1960. Afterwards, the conditions with an upward 

trend outweighed the other conditions and the mortality curve began to rise. 

In the future, the crude death rate will 

further increase. The age-specific death rates of 

males will tend to be almost stable, except for 

the age group 55-74 showing a small increase. 

The possibility of an increase in other age groups, 

however, cannot be excluded. The infant mortality 

will probably continue to decline. 

The age-specific death rates of females will , 

probably further decline in the age groups above 

45 years. The diminishing rate of decline allows 

the prediction that before very long the female 

death rates will also become stabilized at a 

somewhat lower level. 

* “.S. GOVERNMENT PRINTING OF,,CC - t 96S -398-237 P. 0. * t 

26 
OUTLINE OF	 REPORT SERIES FOR VITAL AND HEALTH STATISTICS 

Public Health Service Publication No. 1000 

Series 1. 

SeVies 2. 

Series 3. 

Series 4. 

Sevies 10. 

Series 11. 

SeVies 12. 

SeVies 13. 

Series 14. 

Sevies 20. 

Sevies 21. 

Seyies 22. 

Pvo,yams and collection proceduyes.— Reports which describe the general programs of the Naticma 

Center for Health Statistics and its offices and divisions, data collection methods used, definitions, 

and other material necessary for understanding the data. 

Data evaluation and methods reseaych. —Studies of new statistical methodology including: experimental tests of new survey methods, studies of vital statistics collection methods, new analytical 

techniques, objective evaluations of reliability of collected data, contributions to statistical theory. 

Analytical studies. — Reports presenting analytical or interpretive studies based on vital and health 

statistics, carrying the analysis further than the expository types of reports in the other series. 

Documents and committee vepovts. — Final reports of major committees concerned with vital and 

health statistics, and documents such as recommended motfel vital registration laws and revised birth 

and death certificates. 

Data from the Health Intevuiew Suvuey. —Statistics on illness, accidental injuries, disability, use of 

hospital, medical, dental, and other services, and other health-related topics, based cm data collected 

in a continuing national household interview survey. 

Data from the Health Examination Suvvey. —Data from direct examination, testing, and measurement of national samples of the ~pulation provide the basis for two types of reports: (1) estimates 

of the medically defined prevalence of specific diseases in the United States and the distributions of 

the population with respect to physical. physiological, and psychological characteristics; and (2) 

.malvsis of relationships among the various measurements without reference to an explicit finite 

universe of persons. 

Data fvowz the Institutional Population Surveys. — Statistics relating to the health characteristics of 

persons in institutions, and on medical, nursing, and personal care received, based on national 

samples of establishments providing these services and samples of the residents or patients. 

Data fvom the Hospital Discha~ge ,Suvvey. -Statistics relating to discharged patients in short -stay 

hospitals, based on a sample of patient records in a national sample of hospitals. 

Data on lzealth vesouvces; manpowev and facilities. —Statistics on the numbers, geographic distribution, and characteristics of health resources including physicians, dentists, nurses, other health 

manpower occupations, hospitals, nursinz hc)mes, and outpatient and other inpatient facilities. 

Daia on mo~tality.- \7arious statistics on mortality other than as included in annual or monthly 

reports—special analyses by cause of death, age, and other demographic variables, also geographic 

and time series analyses. 

Data on natality, ma?-viage) and divo~ce. — L7arious statistics on natality, marriage, and divorce other 

than as included in annual or monthly reports—special analyses by demographic variables, also 

geographic and time series analyses, studies of fertility. 

Data fyom tlze .Vational Natalit>, and Mol-tality SL~vL,eys. —Statistics on characteristics of births and 

deaths not available from the vital records, based on sample surveys stemming from these records, 

including such topics as mortality by socioeconomic class, medical experience in the last year of 

life, characteristics of pregnancy, +,t!. 

For a list of titles of reports published in these series, write to: office of Information 

N:ltional Center for Iiealth Statistics 

U.S. Public Health Service 

Washington, D.C. 20201