Social change and population health David Leon London

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Social change and population health David Leon London School of Hygiene & Tropical Medicine

Social change and population health David Leon London School of Hygiene & Tropical Medicine david. leon@lshtm. ac. uk Tackling Population Health Challenges, University of Southampton 12 June 2014 1

Preston curves S. H. Preston. Pop Stud, Vol. 29, 1975; Reprinted Int. J. Epidemiol

Preston curves S. H. Preston. Pop Stud, Vol. 29, 1975; Reprinted Int. J. Epidemiol 36 (3): 484 -490, 2007 2

Preston curve Global diffusion of knowledge and its application S. H. Preston. Pop Stud,

Preston curve Global diffusion of knowledge and its application S. H. Preston. Pop Stud, Vol. 29, 1975; Reprinted Int. J. Epidemiol 36 (3): 484 -490, 2007 3

International trends in life expectancy at birth 4

International trends in life expectancy at birth 4

Life-expectancy at birth (years) by country 1950 -2012 90 90 Males 85 85 80

Life-expectancy at birth (years) by country 1950 -2012 90 90 Males 85 85 80 80 Females UK 75 Sweden 75 Japan 2010 2005 2000 1995 1990 1985 1980 1975 1970 1965 2010 2005 2000 1995 1990 1985 1980 1975 55 1970 55 1965 60 1960 60 1955 65 1950 65 1960 70 1955 Russia 1950 70 5

Japan 6

Japan 6

Japan’s starting point 1945 7

Japan’s starting point 1945 7

Post-war Japan • Tradition of strong commitment to health improvement • Minimal diversion of

Post-war Japan • Tradition of strong commitment to health improvement • Minimal diversion of resources into military • Development of strong economy • Rapid urbanisation • Very late adoption of smoking • Capacity to adopt and adapt new technologies from vanguard countries in all spheres (industry and health care) 8

Western Europe 9

Western Europe 9

Trends in European life expectancy 1970 -2009 90 Females Males 90 85 85 80

Trends in European life expectancy 1970 -2009 90 Females Males 90 85 85 80 80 75 75 70 70 65 65 60 Belgium, Denmark, Finland, France, Germany, Ireland, Italy, Netherlands, Norway, Portugal, Spain, Sweden, UK 55 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 55 60 10

Trends in European life expectancy 1970 -2009 90 Females Males 90 85 85 80

Trends in European life expectancy 1970 -2009 90 Females Males 90 85 85 80 80 75 75 70 70 Consistent upward trends 65 60 65 Belgium, Denmark, Finland, France, Germany, Ireland, Italy, Netherlands, Norway, Portugal, Spain, Sweden, UK 55 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 55 60 11

Trends in European life expectancy 1970 -2009 90 Females Males 90 85 85 80

Trends in European life expectancy 1970 -2009 90 Females Males 90 85 85 80 80 75 75 70 70 . . . despite obesity epidemic 65 60 65 Belgium, Denmark, Finland, France, Germany, Ireland, Italy, Netherlands, Norway, Portugal, Spain, Sweden, UK 55 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 55 60 12

Post-war communist Europe 13

Post-war communist Europe 13

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Major barrier to diffusion of new knowledge 16

Major barrier to diffusion of new knowledge 16

Post-war communist Europe • Public health function remained with pre-war focus on infectious disease

Post-war communist Europe • Public health function remained with pre-war focus on infectious disease • Low level expenditure on health care and health technology • High expenditure on military investment • Population health improvement not central political priority • Cultural, scientific and technological isolation (especially in biomedicine) 17

Fall of the Berlin Wall 1989 18

Fall of the Berlin Wall 1989 18

Fall of the Berlin Wall 1989 Extraordinary natural experiment 19

Fall of the Berlin Wall 1989 Extraordinary natural experiment 19

Trends in European life expectancy 1970 -2009 90 90 Females Males 85 85 80

Trends in European life expectancy 1970 -2009 90 90 Females Males 85 85 80 80 75 75 70 70 65 65 Western Europe Central and Eastern Europe 60 60 Hungary, Poland, Czech Republic, Slovakia 55 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 55 20

Collapse of Soviet Union 1991 22

Collapse of Soviet Union 1991 22

Trends in European life expectancy 1970 -2009 90 90 Females Males 85 85 80

Trends in European life expectancy 1970 -2009 90 90 Females Males 85 85 80 80 75 75 70 70 65 65 Western Europe Central and Eastern Europe Baltics states 60 60 Estonia, Latvia, Lithuania 55 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 55 23

Possible reasons for improvement in Eastern Europe • Change in attitudes to health (at

Possible reasons for improvement in Eastern Europe • Change in attitudes to health (at level of individual and the state) • Dietary change • Alcohol and tobacco control strategies • Improvements in access to effective primary and secondary prevention 24

Males 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994

Males 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 90 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 Trends in European life expectancy 1970 -2009 Females Western Europe 90 85 85 80 80 75 75 70 70 65 65 Central and Eastern Europe Baltics states Russia 60 60 Russia 55 55 25

Russia 26

Russia 26

Major changes in Russian society …. Brehznev 1977 -85 “Era of stagnation” Yelstin 1991

Major changes in Russian society …. Brehznev 1977 -85 “Era of stagnation” Yelstin 1991 -99 Putin 1999 -2008 Putin 2012 Medvedev 2008 -12 Gorbachev 1985 -91 “Perestroika” and “Glasnost”

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU members (pre-2005) 75 75 70 70 65 65 Russia 60 60 55 1950 1960 1970 1980 1990 2000 2010 28

Life expectancy at birth 1955 - 2010 85 80 85 Males Russia UK 64

Life expectancy at birth 1955 - 2010 85 80 85 Males Russia UK 64 (2011) 79 (2011) 80 75 75 70 70 65 65 60 60 55 1950 1960 1970 1980 Females 1990 2000 2010 55 1950 Russia UK 1960 1970 76 (2011) 83 (2011) 1980 1990 2000 2010 29

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU members (pre-2005) 75 75 70 70 65 65 Russia 60 55 1950 Gorbachev anti-alcohol campaign 60 1970 1980 1990 2000 Gorbachev anti-alcohol campaign 2010 55 1950 1960 1970 1980 1990 2000 2010 30

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU members (pre-2005) 75 75 70 70 65 65 Russia 60 55 1950 Gorbachev anti-alcohol campaign 60 1970 1980 1990 2000 Gorbachev anti-alcohol campaign 2010 55 1950 1960 1970 1980 1990 2000 2010 31

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU members (pre-2005) 75 75 70 70 65 65 Russia Collapse of Soviet Union 60 60 55 1950 1960 1970 1980 1990 2000 2010 Collapse of Soviet Union 32

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU members (pre-2005) 75 75 70 70 65 65 Russia Collapse of Soviet Union 60 60 55 1950 1960 1970 1980 1990 2000 2010 Collapse of Soviet Union 33

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU members (pre-2005) 75 75 70 70 65 65 Russia Chaos and economic liberalisation 60 60 55 1950 1960 1970 1980 1990 2000 2010 Chaos and economic liberalisation 34

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU members (pre-2005) 75 75 70 70 65 65 Russia Chaos and economic liberalisation 60 60 55 1950 1960 1970 1980 1990 2000 2010 Chaos and economic liberalisation 35

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU members (pre-2005) 75 75 70 70 65 65 Russia Chaos and economic liberalisation 60 60 55 1950 1960 1970 1980 1990 2000 2010 Chaos and economic liberalisation 36

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU members (pre-2005) 75 75 70 70 65 65 Foreign currency crisis Russia 60 60 55 1950 1960 1970 1980 1990 2000 2010 Foreign currency crisis 37

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU

Life expectancy at birth 1955 - 2010 85 85 Males 80 Females 80 EU members (pre-2005) 75 75 70 70 65 65 Putin elected Russia 60 60 55 1950 1960 1970 1980 1990 2000 2010 Putin elected 38

Alcohol a key driver of fluctuations

Alcohol a key driver of fluctuations

Strong evidence that alcohol drives fluctuations in male life expectancy in Russia 1965 -2008

Strong evidence that alcohol drives fluctuations in male life expectancy in Russia 1965 -2008 Source : V. Shkolnikov and E. Andreev 40

Cardiovascular disease in Russia 41

Cardiovascular disease in Russia 41

Mortality from circulatory disease and acute alcohol poisoning among men aged 50 -54 years,

Mortality from circulatory disease and acute alcohol poisoning among men aged 50 -54 years, Russia, 1960 -2008 180. 0 160. 0 1000. 0 Total circulatory disease 140. 0 Acute alcohol poisoning 800. 0 120. 0 100. 0 600. 0 80. 0 400. 0 60. 0 40. 0 200. 0 1960 20. 0 1965 1970 1975 Source : Data provided by Evgueny Andreev 1980 1985 1990 1995 2000 2005 0. 0 2010 Acute alcohol poisoning mortality per 100, 000 Total circulatory disease mortality per 100, 000 1200. 0

Mortality from circulatory disease and acute alcohol poisoning among men aged 50 -54 years,

Mortality from circulatory disease and acute alcohol poisoning among men aged 50 -54 years, Russia, 1960 -2008 180. 0 160. 0 1000. 0 Total circulatory disease 140. 0 Acute alcohol poisoning 800. 0 120. 0 Challenge to received wisdom that alcohol is cardioprotective 600. 0 400. 0 100. 0 80. 0 60. 0 40. 0 200. 0 1960 20. 0 1965 1970 1975 Source : Data provided by Evgueny Andreev 1980 1985 1990 1995 2000 2005 0. 0 2010 Acute alcohol poisoning mortality per 100, 000 Total circulatory disease mortality per 100, 000 1200. 0

Hazardous drinking and mortality from various types of circulatory disease Men aged 25 -54

Hazardous drinking and mortality from various types of circulatory disease Men aged 25 -54 years, Izhevsk, 2003 - 5 Underlying cause of death Number of deaths Hazardous drinking (proxy report) OR* (95% CI) Alcoholic cardiomyopathy 98 15. 70 (9. 5, 25. 94) Other cardiomyopathy 51 3. 84 (2. 05, 7. 18) 90 2. 05 (1. 24, 3. 40) 28 3. 43 (1. 51, 7. 81) 219 3. 04 (2. 17, 4. 24) Cerebrovascular disease Other circulatory disease Ischaemic heart disease * OR adjusted for age, smoking and education 44 Source : Leon, Shkolnikov, Mc. Kee, Kiryanov, Andreev, IJE, 2010

Russia highest out of all 33 countries for men and women 45

Russia highest out of all 33 countries for men and women 45

Cardiovascular disease makes a major contribution to Russia’s low life expectancy Life expectancy at

Cardiovascular disease makes a major contribution to Russia’s low life expectancy Life expectancy at birth (years) in 2009 Men Women United Kingdom 78. 1 82. 3 Russian Federation 62. 7 74. 7 Difference (UK minus Russia) 15. 4 7. 6 Contribution of CVD to difference 7. 5 6. 3 Contribution of IHD to difference 4. 0 3. 2 46

Recent trends

Recent trends

Cardiovascular mortality trends 1965 -2011 by sex Age-standardised rates per 1000 700. 0 Cerebrovascular

Cardiovascular mortality trends 1965 -2011 by sex Age-standardised rates per 1000 700. 0 Cerebrovascular disease 600. 0 500. 0 400. 0 males 300. 0 200. 0 Ischaemic heart disease males females 100. 0 1960 1970 Source : Shkolnikov 1980 1990 2000 2010 1960 1970 1980 1990 2000 2010

Cardiovascular mortality trends 1965 -2011 in males by country Age-standardised rates per 1000 700.

Cardiovascular mortality trends 1965 -2011 in males by country Age-standardised rates per 1000 700. 0 Cerebrovascular disease 600. 0 500. 0 Russia 400. 0 300. 0 200. 0 UK 100. 0 UK Norway 0. 0 1960 Ischaemic heart disease 1970 1980 1990 Source : Shkolnikov & WHO HFA 2000 2010 100. 0 Norway 0. 0 1960 1970 1980 1990 2000 2010

Cardiovascular mortality trends 1965 -2011 in females by country Age-standardised rates per 1000 700.

Cardiovascular mortality trends 1965 -2011 in females by country Age-standardised rates per 1000 700. 0 Cerebrovascular disease 600. 0 500. 0 400. 0 300. 0 Ischaemic heart disease Russia 200. 0 100. 0 UK Norway 0. 0 1960 Russia 200. 0 1970 1980 1990 Source : Shkolnikov & WHO HFA 2000 2010 100. 0 UK Norway 0. 0 1960 1970 1980 1990 2000 2010

Its not just alcohol. . . • Smoking in men • Availability of primary

Its not just alcohol. . . • Smoking in men • Availability of primary and secondary prevention approaches and technologies – Statins under-utilised – Very poor control hypertension – Low levels revascularisation procedures • Access to and organisation of good standard medical care – Screening programmes but poor follow-up – Continuity of care following hospitalisation – Inadequate level expertise in primary care 51

A new project : 2014 -2019

A new project : 2014 -2019

Institute of Internal Medicine SBRAMS, Novosibirsk, Russia Cardiovascular disease in Russia: strengthening evidence about

Institute of Internal Medicine SBRAMS, Novosibirsk, Russia Cardiovascular disease in Russia: strengthening evidence about causes, mechanisms, prevention and treatment Finland Max Planck Institute for Demographic Research 53

Sex differences in life expectancy 54

Sex differences in life expectancy 54

Life expectancy at birth (years) in 191 countries, 2004 Japan Lithuania UK Female life

Life expectancy at birth (years) in 191 countries, 2004 Japan Lithuania UK Female life expectancy at birth Russia China India Ghana Kenya Zimbabwe Male life expectancy at birth 55

Life expectancy at birth (years) in 191 countries, 2004 Japan Lithuania UK Female life

Life expectancy at birth (years) in 191 countries, 2004 Japan Lithuania UK Female life expectancy at birth Russia China India ITY L UA Ghana Q E F EO N LI Kenya Zimbabwe Male life expectancy at birth 56

Life expectancy at birth (years) in 191 countries, 2004 Japan Lithuania UK Female life

Life expectancy at birth (years) in 191 countries, 2004 Japan Lithuania UK Female life expectancy at birth Russia China India Rise of individual Ylife-style LIT A risk factors U Ghana EQ FE O E LIN Kenya Zimbabwe Male life expectancy at birth 57

European experience 58

European experience 58

Western Europe 2 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990

Western Europe 2 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 Sex differences in European life expectancy 1970 -2009 Female – Male e 0 (years) 14 12 10 8 6 4 59

Czech Republic, Hungary, Poland, Slovakia 2 1970 1972 1974 1976 1978 1980 1982 1984

Czech Republic, Hungary, Poland, Slovakia 2 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 Sex differences in European life expectancy 1970 -2009 Female – Male e 0 (years) 14 12 10 8 6 4 60

Estonia, Latvia, Lithuania 2 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988

Estonia, Latvia, Lithuania 2 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 Sex differences in European life expectancy 1970 -2009 Female – Male e 0 (years) 14 12 10 8 6 4 61

Russia 2 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992

Russia 2 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 Sex differences in European life expectancy 1970 -2009 Female – Male e 0 (years) 14 12 10 8 6 4 62

Sex differences in life expectancy • European countries vary dramatically in the extent of

Sex differences in life expectancy • European countries vary dramatically in the extent of gender differences in behaviour (healthrelated and other) • Western Europe showing decline in differences • Convergence in behaviours in Western Europe – eg decline in smoking in men, stability or increase in smoking in women • Differences in Eastern Europe persist despite improvements in mortality in many countries 63

Conclusions • Communism and its collapse in Europe illustrates the profound influence of the

Conclusions • Communism and its collapse in Europe illustrates the profound influence of the “social” on health • Diffusion of knowledge and best practice in health care and public health central across borders crucial for population health • Rapidity of improvements a cause for optimism • Russian experience vivid warning that things can go badly wrong • The willingness and ability of governments to prioritise improvements in health care and public health critical • International variation in sex-differences in mortality underlines importance of (less tractable) cultural factors in determining health 64

Thank you 65

Thank you 65

Increase in life-expectancy at birth England Wales 1841 -2009 Years Gain 1901 -1951 F

Increase in life-expectancy at birth England Wales 1841 -2009 Years Gain 1901 -1951 F = 22 years M = 20 years 80 70 Male Gain 1841 -1901 F = 6 years M = 4 years 60 50 Female Gain 1951 -2000 F = 10 years M = 10 years 40 30 1841 1861 1881 1901 1921 1941 1961 Source : Government Actuary Department and Human Mortality Database 1981 2001 66