The Demography and Epidemiology of Human Health …978-94-007-1315-4/1.pdf · The Demography and...

The Demography and Epidemiologyof Human Health and Aging

Jacob S. Siegel

The Demography andEpidemiology ofHuman Health and Aging

In consultation with S. Jay Olshansky

123

Jacob S. SiegelJ. Stuart Siegel Demographic ServicesNicholson Lane 580920852-5710 North BethesdaMarylandUnit [email protected]

In Consultation withS. Jay OlshanskySchool of Public HealthUniversity of Illinois at ChicagoWest Taylor Street 160360186 Chicago IllinoisRoom [email protected]

ISBN 978-94-007-1314-7 e-ISBN 978-94-007-1315-4DOI 10.1007/978-94-007-1315-4Springer Dordrecht Heidelberg London New York

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To Irv, Ronnie, and Dave and our parents

Preface and Acknowledgments

Health demography and its companion, the epidemiology of aging, are not welldefined fields among the academic areas of study. A subdiscipline of demographylabeled health demography has been identified and it essentially applies thematerials, methods, and perspectives of demography to the study of health. Healthdemography overlaps greatly with the epidemiology of aging, and the distinctionmainly reflects the difference in the academic training of the analyst. This booktries to set forth the basic materials of this area of study and to give it more formaldefinition and scope.

Health demography and the epidemiology of aging incorporate materials from anumber of established disciplines, mainly sociology, demography, epidemiology,public health, gerontology, and actuarial science, but also bioethics, genetics,biostatistics, biology, medicine, geography, and computer science. Although the listabove is long, the natural home of the subject is in departments of gerontology,demography, and epidemiology. The scope of the subject, as I envision it, issuggested by the Table of Contents of the book. It is apparent that I cover a broadarea. The field ranges from the highly theoretical to the very practical. I deal withthe theories regarding human aging and longevity, derived from molecular andevolutionary biology and biodemography, as well as with the issues involved inthe expansion of hospital facilities in a city by local health administrators, derivedfrom applied demography and spatial epidemiology. I consider the range of theoriesregarding the question of how long humans can live, and I consider the practicalproblems of how to bring demographic and epidemiological methods, materials,and perspectives to serve the health needs of local communities.

The book describes the latest sources of data on mortality and population healthand presents the principal research findings based on these sources. It bringstogether the latest methods of measuring population health phenomena, includingthose for mortality, morbidity, and combinations of measures of mortality andmorbidity. In this connection it considers such varied measures as the many typesof life tables, the design of health surveys, and geographic information systemsfor health research and administration. While maintaining a primary focus on thedemographic and epidemiological aspects of the subjects treated, the book covers

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viii Preface and Acknowledgments

socioeconomic variations in mortality and health, reproductive health, the healthdeterminants and consequences of migration, health policy and administration,and selected bioethical issues. The measures described are often illustrated withexamples in the form of calculation paradigms, so that the reader has a model forreplicating the measures, and I suggest software packages for implementing someof the more elaborate methods described.

The geographic scope of the text, the tabular material, and the references andsuggested readings relate to both the national and international area. The healthdemography of the less developed countries is given a substantial share of attention,in deference to the size and distinctive character of their populations and the extentand complexity of their health problems. At the same time, primary attention isgiven to the population health of the industrialized countries, especially the UnitedStates, where most of the readers of this volume work or will work as professionaldemographers, gerontologists, or epidemiologists. If no other geographic referenceis given, the reader may assume that the area referred to is the United States.Nevertheless, readers from other countries and students of international comparativepopulation epidemiology will find much in it of interest for them.

Since this book is intended to be comprehensive and interdisciplinary, it canbe used as a text for courses taught in a broad range of scientific disciplinesrelating to population health and the epidemiology of aging, and as a referencework and handbook for demographers, epidemiologists, gerontologists, and publichealth specialists who work in this area. The book is offered as a text for advancedundergraduate and graduate students in medical sociology, the demography andepidemiology of aging, health demography, and social gerontology, and as supple-mentary reading in the instructional programs of these disciplines. It should servethe needs of the many instructors who prefer a single integrated comprehensivetext in the area of health demography for use in their courses. There is sufficientmaterial for a two-semester course, but with selective omissions, it can be adaptedfor use in a one-semester course. For shorter and less advanced study of the subject,such sections of the book may be omitted as those on mortality models in Chap. 3,multistate life tables in Chap. 8, and the methods of preparing local populationestimates in Chap. 16, and Chaps. 12 and 17.

Inasmuch as human aging/longevity is the subject of study, the reader maylook for material on the characteristics of various health conditions, the risks ofsuccumbing to them, and ways of treating them, even specific recommendationsfor how to overcome them. This book is concerned with the prevalence of diseasesand the risks associated with various health conditions, but it is not a how-to-do-ithandbook for treating specific illnesses or for achieving a long life. It does, however,describe the research relating to longevity/aging and so implicitly it provides generalguidelines for extending human longevity.

Readers may note the absence of measures of reliability or statistical significance.Although much is said qualitatively about the accuracy of the underlying data,discussion and presentation of measures of statistical significance are omitted,partly in the interests of simplifying the writing and tabular presentation. Computersoftware for calculating many of the measures in this book include the associatedmeasures of significance.

Preface and Acknowledgments ix

It is always a matter of great interest and concern to the prospective readerto ascertain what prior technical preparation is required to take most advantageof a book of this kind. Training in some areas is essential, training in others inadvisable, and training in still other areas is helpful. Training is essential in thefundamentals of statistics, and in mathematics up to the equivalent of a basiccourse in mathematical analysis. Courses in demographic techniques and socialresearch methods are advisable but not essential, and a basic course in epidemiology,biostatistics, or medical sociology is helpful. A course in biostatistics providesa strong background for some of the topics treated here. Much of the material“needed” is covered in this very book, however, since it is intended to be a relativelyfree-standing and self-contained text.

While I have tried to make this book rather comprehensive in its field, it providesonly an introduction to many topics. Other related works that will extend theknowledge of the reader on topics basic to the subject matter of this volume include:

Jacob S. Siegel & David A. Swanson (Eds.), Methods and materials of demography(2nd ed. Elsevier/Academic Press, 2004): Provides a comprehensive discussion ofthe basic techniques of demographic analysis.

Richard G. Rogers, Robert A. Hummer, & Charles B. Nam, Living and dying in theUnited States (Academic Press, 2000): Gives a comprehensive presentation of thesocial and economic differentials in adult mortality in the United States at the endof the 20th century.

S. Jay Olshansky and Bruce A. Carnes, The Quest for Immortality (W.W. Nortonand Company, 2001): Presents a highly readable discussion of the facts and fictionsregarding longevity.

Louis G. Pol and Richard K. Thomas, The Demography of Health and HealthCare (Second Edition, Kluwer Academic Publishers, Norwall, MA, 2000):Focuses on applied health demography and provides additional material on healthgeodemography.

Leon Gordis, Epidemiology (Third Edition, Philadelphia: Elsevier Saunders, 2004).

Stanton A. Glantz Primer of Biostatistics (Sixth Edition. New York: McGraw-Hill,2007).

These books can be referred to for further discussion of the tools of demography, themethods of epidemiological analysis, and the basic issues of “longevity science.”I cover many of the same topics, but bring them together under one cover as anintegrated, continuous narrative, even if in less detailed fashion.

In the interest of expediting the publication of the book, I drew on some materialthat I previously authored and that was published by Elsevier/Academic Press,to whom I express my thanks. The publications of the U.S. Census Bureau, thePopulation Reference Bureau, the World Bank, the World Health Organization, andthe United Nations have been especially helpful as documentation for many of thetopics covered in this book and I gratefully acknowledge my use of them also.

In the preparation of this work, I was fortunate in being able to consult withS. Jay Olshansky, Professor of Epidemiology and Biostatistics, School of Public

x Preface and Acknowledgments

Health, University of Illinois at Chicago. He would have been a co-author of thebook, had his schedule in the last few years permitted it. As it turned out, I plannedand prepared the initial version of the entire work, Dr. Olshansky then reviewedand commented on this draft, and I completed the text for publication. I have fullresponsibility for the form and content of the text submitted to the publisher. I oweDr. Olshansky a debt of gratitude for his willingness to contribute his expertise inmaking the book both more authoritative and more useful for students of publichealth and gerontology.

Professor Murray Gendell, my former colleague at Georgetown University, washelpful in reviewing Chap. 15, Health Policy, and, especially, in identifying andinterpreting recent sources of material in this area. Dr. Hazel Denton, of JohnsHopkins University, very graciously agreed to review Chap. 9, Reproductive Health,an area of her special expertise. Both Dr. Gendell and Dr. Denton provided manyvaluable comments on these particular chapters that contributed to refining the text.

Professor David Swanson, of the University of California, Riverside, kindlyprovided illustrative material on litigation between hospitals for Chap. 16. CherylSiegel Boyd, of Jefferson Medical University, provided practical insights intothe bioethical issues of organ transplantation. Rose V. Siegel, formerly a healthstatistician with the National Center for Health Statistics and the U.S. Navy,prepared the initial draft of the subject index of the book, which I then editedand completed for publication. Trisha Moslin, of the Population Reference Bureau,collaborated in preparing a number of the figures.

Writing a book of this type is possible only because many scholars and analystscame before, conducted their research, and shared their specialized knowledge withothers in their publications, research papers, and lectures. I profited greatly fromexchanges with current contributors to the field of health demography, biodemog-raphy, biogerontology, and population epidemiology as I proceeded in my writing.In particular, I took special advantage of the writings, seminar presentations, andscholarly notes of Mark Hayward of the University of Texas, Teresa Seaman ofthe University of California at Los Angeles, Maxine Weinstein of GeorgetownUniversity, Jane Menken of the University of Colorado, James Vaupel of the MaxPlanck Research Institute, Bruce Carnes of the University of Oklahoma, TommyBengsston of the University of Lund, Kathleen O’Connor of the University ofWashington, Leonard Hayflick of the University of California at San Francisco,Eileen Crimmins of the University of Southern California, Robert Binstock ofCase Western Reserve University, and Jean-Marie Robine of the University ofMontpellier, and many others.

I also want to acknowledge the contribution of the following persons in the U.S.Federal government, who provided either advice or materials: Robert Anderson,Elizabeth Arias, Lois Fingerhut, Ellen Kramerow, Michael Molla, and HarryRosenberg of the National Center for Health Statistics; Charles Heller of the Agencyfor International Development; Howard Iams of the Social Security Administration;Celia Bortlein, Frederick Hollmann, Dean Judson, and David Waddington of theCensus Bureau; Anne Martin of the Centers for Medicare and Medicaid; and MitraToosi of the Bureau of Labor Statistics. Several analysts in the National Institutes

Preface and Acknowledgments xi

of Health were kind enough to discuss special topics with me: Rebecca Clark ofthe National Institute of Child Health and Human Development; John Haaga andDonald K. Ingram of the National Institute on Aging; and Catherine Norton of theNational Institute of Mental Health. Anthony Mann of the National Academy ofSciences provided guidance as to relevant publications from his organization ona variety of subjects. Keith Horvath, Robert Ledermann, and Annette Stine of theNational Heart, Lung, and Blood Institute played the dual role of informing meof current research in cardiovascular medicine while incidentally attending to mypersonal health when I served as a volunteer patient in the Institute.

I gratefully acknowledge the support and encouragement of J. Scott Bentley,Senior Executive Editor, Elsevier/Academic Press, who oversaw the project fromits beginning to its mid-stage. In its later stages, Evelien Bakker, Senior PublishingEditor, Springer, with the able assistance of Bernadette Deelen-Mans guided thework to publication with grace and efficiency.

Finally, I offer the usual disclaimer to exempt the many persons and organizationscited above from responsibility for any errors of omission or commission in thisbook and I accept full responsibility for its contents. It is de trop to add that thisfreedom from responsibility applies to my former longtime employers, the U.S.Census Bureau and Georgetown University, and to my several short-term academicemployers around the country. Professor Olshansky and the School of Public Health,University of Illinois at Chicago, are also free of any responsibility for the contentsof this book, including any opinions offered. At the same time, I wish to express mygratitude to all these parties for the opportunity of working with them or under theirauspices and for advancing my knowledge of the materials that are the subject ofthis book.

Jacob S. Siegel

Contents

Part I Scope of Health Demography, Sources, and Qualityof Data

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Outline of the Book .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Definition and Scope of Health Demography and Related Fields . . . . . . . . . 5

Demography and Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Health Demography, Population Epidemiology,

and Related Fields . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Concepts of Health, Health Conditions, and Longevity.. . . . . . . . . . . . . . . . . . . 9

Health and Health Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Aging and Longevity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Selected Issues Relating to Human Health and Longevity.. . . . . . . . . . . . . . . . 13References and Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

2 Sources and Quality of Data for Mortalityand Health Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19National Censuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

U.S. Censuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Censuses of Other Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Vital Statistics and Related Administrative Records . . . . . . . . . . . . . . . . . . . . . . . 21National Vital Statistics Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Other Administrative Records Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

General National Sample Surveys and National Health Surveys .. . . . . . . . . 37U.S. General National Sample Surveys.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37National Health Surveys and National Health Care Surveys . . . . . . . . 38

Epidemiological Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Nature and Types of Epidemiological Studies . . . . . . . . . . . . . . . . . . . . . . . 47U.S. Epidemiological Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

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xiv Contents

Randomized Clinical Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Meta-Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Qualitative Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Quality of Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Census and Survey Data, Vital Statistics,and Administrative Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Epidemiological Studies and Clinical Trials . . . . . . . . . . . . . . . . . . . . . . . . . 58Meta-Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Methods of Survey Collection of Health Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Methods of Interviewing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Methods of Collecting Sensitive Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Methods of Collecting Data on Rare Events . . . . . . . . . . . . . . . . . . . . . . . . . 64Confidentiality and Disclosure Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Appendix 2.1 Compendia on Health and Mortality Data . . . . . . . . . . . . . . . . . . 66United States Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66International Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

References and Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Censuses and Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Vital Statistics and Other Administrative Sources . . . . . . . . . . . . . . . . . . . . . . 68Secondary Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Quality of Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Part II Concepts and Measures of Mortality and Morbidity

3 Concepts and Basic Measures of Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Uses and Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Uses of Death Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Definition and Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Sources and Quality of Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Special Sources of Data for Mortality Studies . . . . . . . . . . . . . . . . . . . . . . . 75Quality of Mortality Statistics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Factors Important in Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Observed Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Crude Death Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78Age-Specific Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80Measures for Comparing Age Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94Cause-Specific Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

Adjusted Summary Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111Age-Adjusted/Age-Standardized Measures . . . . . . . . . . . . . . . . . . . . . . . . . . 112

Appendix 3.1 Standard Errors for Random Variabilityof Mortality Statistics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

References and Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Contents xv

4 The Life Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135Definitions and Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

Definitions and Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135Functions of the Standard Unabridged Life Table . . . . . . . . . . . . . . . . . . . 137

Construction of the Standard Life Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141General Considerations .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141Construction of the Complete Standard Life Table . . . . . . . . . . . . . . . . . . 142Construction of an Abridged Life Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148Other Types of Basic Life Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158

Analysis of the Standard Life Table. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164Level and Age Pattern of Deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

Limitations of Standard Life Tables and Proposed Adjustments . . . . . . . . . . 173Synthetic vs. Real Cohorts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173Other Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174Proposed Adjustments of the Standard Life Table . . . . . . . . . . . . . . . . . . . 175

Extensions of the Standard Life Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177Multiple-Decrement Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177Cause-of-Death Elimination Life Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178Multiple Increment-Decrement Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

Applications of the Life Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186Demographic Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186The Longevity Dividend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198Some Socioeconomic and Public Health Applications . . . . . . . . . . . . . . 202

Appendix 4.1 Some Life Table Relations in Continuous Notation .. . . . . . . 206Appendix 4.2 Arriaga Method of Decomposing Change

in Life Expectancy at Birth Among Age Groups . . . . . . . . . . . . . . . . . . . . 208References and Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

5 Measures of Health Status, Functioning,and Use of Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217Concepts of Health Conditions and Classification of Diseases . . . . . . . . . . . . 217

Concepts of Health Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217Classification of Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218Population Measures of Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219

Prevalence Ratios and Incidence Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219Age-Specific and Age-Cause-Specific Measures . . . . . . . . . . . . . . . . . . . . 220

Survival Period for a Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230Age, Period, and Cohort Effects on Health Measures . . . . . . . . . . . . . . . 233

Concepts and Measures of Functioning.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241Concepts and Classification of Functioning .. . . . . . . . . . . . . . . . . . . . . . . . . 241Assessing Disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245Population Measures of Disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246Other Measures of Functioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249Measuring Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252

xvi Contents

Measures of Overall Health Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253Subjective Health Status and Subjective Survival . . . . . . . . . . . . . . . . . . . . 253Evaluating Health Progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254Physiological Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255

Measures of Use and Availability of Health Servicesand Support Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260Selected Measures of Use of Health Providers . . . . . . . . . . . . . . . . . . . . . . . 260Formal and Informal Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261

Appendix 5.1 Method of Calculating the Historical Trendin the Median Age of Disablement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262


Part III Mortality and Morbidity Considered Jointlyand in Relation to Fertility, Migration, and PopulationAge-Sex Structure

6 Health Inequalities, General Trends in Mortalityand Morbidity, and Associated Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271Measurement of Inequality of Mortality and Health . . . . . . . . . . . . . . . . . . . . . . . 271

Introductory Methodological Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271Measures of Inequality Within Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272

Measurement of International Inequality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280Principal Trends and Causes of Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282

Trends in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282International Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291

Principal Causes and Trends of Morbidity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295Mental Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295Neurological Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298Chronic Physical Diseases of Later Life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300Common Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303

Epidemiological and Health Transitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304The Epidemiological Transition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304Health Transitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305

Summary Note on Developments in Mortality and Morbidity . . . . . . . . . . . . 309Factors Associated with Mortality and Morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . 310

General Overview: Biological, Social, Individual,and Stochastic factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310

Biological Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311Environmental and Ecological Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317Lifestyle and Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320The Stochastic (Chance) Factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337Interrelations of Genetic and Nongenetic Factors . . . . . . . . . . . . . . . . . . . . 338Early Life Influences on Health and Mortality in Later Life . . . . . . . . 342

Contents xvii

Reclassification of Diseases Accordingto Social/Preventive Causes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346

Limited Effectiveness of Personal Behavior in RetardingAge-Related Health Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347

Demographic Characteristics of the Disabled and NursingHome Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348Disabled Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348Nursing-Home Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352


7 Demographic and Socioeconomic Group Differencesin Morbidity and Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363Concepts of Group Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364Some Measures of Group Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366

Simple Comparisons.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366More Complex Comparisons .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367

Demographic and Socioeconomic Explanatory Variables . . . . . . . . . . . . . . . . . 375Selection vs. Causation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376

Demographic and Socioeconomic Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . 378Gender Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378Differences Between the Races and Hispanics/non-Hispanics . . . . . . 385Marital Status and Family Arrangements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395Socioeconomic Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399Religious Participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408Use of Small-Area Data for Analysis of Health Variations . . . . . . . . . . 409

Variation in Quality of Health Care and Access to Health Care . . . . . . . . . . . 414Concluding Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415References and Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415

8 Gauging Population Health: Measures Linking Mortalityand Morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423Relation Between Changes in Mortality and Changes in Morbidity . . . . . . 423Measurement of Healthy/Active/Disability-Free Life Expectancy . . . . . . . . 425

Prevalence-Ratio Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426Event-Exposure Method .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435The Multistate Life Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441Microsimulation and Health Status Transitions . . . . . . . . . . . . . . . . . . . . . . 455

Measurement of Health-Related Quality of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . 455Quality-Adjusted Life Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456Disability-Adjusted Life Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457Other Measures of Health-Related Quality of Life . . . . . . . . . . . . . . . . . . 462

Calculation of the Health Life Cycle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463References and Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463

xviii Contents

9 Reproductive Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469Definition, Sources, and Quality of Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469

Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469Sources and Limitations of Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470Collecting Data on Sensitive Subjects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471General Characteristics of Reproductive Health Studies . . . . . . . . . . . . 472

Biodemographic Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472Fetal Sex Ratio and the Sex Ratio at Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . 472Age at Menarche, Age at Menopause, and Length

of the Reproductive Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476Fecundity, Fertility, and Reproductive Aging . . . . . . . . . . . . . . . . . . . . . . . . 482

Maternal and Perinatal Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492Maternal Mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492Pregnancy Losses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 495Perinatal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508Factors Important in Maternal and Perinatal Mortality . . . . . . . . . . . . . . 509

Family Planning and Sexual Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513Role of Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513Concepts of Effectiveness of Contraception.. . . . . . . . . . . . . . . . . . . . . . . . . 513Contraceptive Methods and Prevalence.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514Sexual Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520

Monitoring and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 522Appendix 9.1 .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523Appendix 9.2 .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523References and Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525

10 Health and Migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533International Migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535

Sources and Limitations of Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535Background Data on Immigration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537Health Issues as Determinants and Consequences of Migration . . . . 537

Internal Migration.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 551Sources and Limitations of U.S. Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 551Health Issues as Determinants and Consequences of Migration . . . . 553

Temporary, Seasonal, and Circular Migration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561Temporary and Seasonal Migration .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561Circular Migration .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562

Migration and Mental Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563Health and Mortality of Refugee and Internally Displaced Populations . . 566

Background Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566Deriving Demographic and Health Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569


Contents xix

11 Special Health Issues in Less Developed Countries . . . . . . . . . . . . . . . . . . . . 579Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579

Sources and Quality of Data for Less Developed Countries . . . . . . . . . 579General Context for the Health Situation in the Less

Developed Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580General Burden of Disease by Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583

Life Expectancy, Maternal Mortality, and Undernutrition .. . . . . . . . . . 583Health Expectancy .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583Burden of Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585

Leading Causes of Death and Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 586Noncommunicable Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 586Communicable Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595Leading Causes of Disability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610

Leading Risk Factors Accounting for Disease, Injury, and Disability . . . . 611Culture/Lifestyle, Poverty, and Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612

Traditional Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615Relation to Animals and Zoonotic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . 616Lifestyle Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 618Family Planning, Poverty, and Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619

Environment, Poverty, and Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 620Lack of Clean Water, Poor Sanitation, and Air Pollution .. . . . . . . . . . . 620Chemical and Biological Contamination of the Food Supply . . . . . . . 623Extremes of Weather, Famine, and Malnutrition .. . . . . . . . . . . . . . . . . . . . 624

Financial, Geographic, and Cultural Barriers to AccessingHealth Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635


12 Interrelations of Health, Mortality, and Age Structure . . . . . . . . . . . . . . . . 641Concepts and Measures of Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642

Concepts of Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642Measures of Population Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 643

Trends and Consequences of Population Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . 654Trends in Population Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 654Consequences of Rapid Population Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . 656Health Dependency Ratios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663

Models of Mortality, Morbidity, and Age Structure . . . . . . . . . . . . . . . . . . . . . . . . 665Construction of Model Life Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 666Models of Age Structure Linked to Mortality Models . . . . . . . . . . . . . . . 674Relationships Between Mortality and Age Structure

of Western Populations.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 676Models of Morbidity and Disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 678

Appendix 12.1: MORTPAK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 678References and Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 679

xx Contents

Part IV Theories of Aging and Longevity and Projectionsof Mortality and Health

13 Concepts and Theories of Longevity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 685Concepts of Longevity .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 685

Individual Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 686Population Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 687

Sources of and Quality of Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 689Analysis of Changes at Very Advanced Ages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 693Historical and Theoretical Evidence for Increased Longevity .. . . . . . . . . . . . 694

Demographic Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 695Epidemiological Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 704Biological and Biomedical Perspectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 705Evolutionary Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 711Engineering Reliability Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 714

Research Programs to Increase Longevity .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 715Improving the Functioning of the Immune

and Endocrine Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717Genetic Alterations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 718Organ Regeneration and Replacement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 720Caloric Restriction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 720Pharmacological Interventions .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 721Robot-Assisted Surgery and New Uses of Imaging Devices . . . . . . . . 722Electronic Medical Record-Keeping and Bioinformatics . . . . . . . . . . . . 723


14 Models of Aging, Health, and Mortality,and Mortality/Health Projections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 731Models of Aging, Health, and Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 731

Reprise on Causation of Health Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . 731Concepts of Individual Aging Trajectories . . . . . . . . . . . . . . . . . . . . . . . . . . . 732Concepts of Mortality/Morbidity Trajectories . . . . . . . . . . . . . . . . . . . . . . . 737

Mortality and Health Projection Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741Mortality Projections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 742Projections of Health Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 760


Part V Applications to Health Policyand Health Administration

Scope of Part V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 775

15 Health Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 777More Developed Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 777Health Promotion/Disease Prevention vs. Treatment/Cure of Diseases . . . 778

Adding More Years vs. Improving the Quality of Years Lived . . . . . . 780

Contents xxi

Allocation of Resources Between Research on SpecificDiseases and on Research on Aging Processes . . . . . . . . . . . . . . 783

Inequality in Health Risks and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 786Factors and Trends in the Costs of Health Care . . . . . . . . . . . . . . . . . . . . . . 792Issues in Health Insurance and Effects on Mortality

and Morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 804Demographic and Economic Factors Affecting U.S.

Entitlement Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 812Less Developed Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 821

Some Problems Facing the Health Systems of LDC . . . . . . . . . . . . . . . . . 822Paying for Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 823The Global Health Funding Crisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 824International Goals and Assessment of Progress . . . . . . . . . . . . . . . . . . . . . 826


16 Applied Health Demography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 833Area Population Estimates and Projections for Public Health Programs.. 833

Establishing a New Health Facility or Expanding an Old One . . . . . . 834Note on Methods of Estimation and Projection

of Subnational Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 836Indicators of the Local Health Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 838

Estimation of Health Characteristics of Small Areas . . . . . . . . . . . . . . . . . . . . . . 840Design-Based Estimates: Small Area Estimates

from Sample Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 841Model-Based Estimates: Use of Indirect Data . . . . . . . . . . . . . . . . . . . . . . . 841

Graphic Devices for Health Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 850Data Portrayal and Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 850Types of Thematic Maps and Their Uses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 851Geographic Information Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 855

Projections of the Health Situation and Resources . . . . . . . . . . . . . . . . . . . . . . . . . 862Projections of the Health Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 862Projections of Health Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 863

Planning for Public Health Emergency Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 866Measuring Vulnerable Populations and Losses in a Disaster . . . . . . . . 866Measuring Excess Deaths and the Excess Death Rate . . . . . . . . . . . . . . . 867


17 Some Ethical and Legal Aspects of Health Demography . . . . . . . . . . . . . . 877Fertility Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 877

Genetic Testing and Gene Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 877Sex Determination of Births . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 878Assisted Reproductive Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 879Human Cloning .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 880Fertility at Unconventional Ages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 881Issues in Female Reproductive Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 882Right to Parenthood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 885

xxii Contents

Mortality/Health Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 888Implications of Extension of Human Longevity . . . . . . . . . . . . . . . . . . . . . 888The Right to Die vs. the Obligation to Live . . . . . . . . . . . . . . . . . . . . . . . . . . 889Stem Cell Research and Bone Marrow and Organ Transplantation . 893Provision of Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899Genetic Testing and Gene Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 908


Appendixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 915Appendix 1: Selected List of Journals in the English

Language for the Study of Health Demography . . . . . . . . . . . . . . . . . . . . . 915General Internet Sources of Data on Health Demography .. . . . . . . . . . . . . . . . 916Appendix 2: Review of General Analytic Devices and Special

Survey Methods.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 917General Analytic Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 917

Ecological Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 917Cohort Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 918Multivariate Logistic Regression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 919Proportional Hazards Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 920Grade-of-Membership Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 922Meta-Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 923Propensity Score .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 924

Special Survey Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 925Techniques for Collecting Sensitive Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . 925

Survey Design for Rare Events: Multiplicity/Network Sampling . . . . . . . . . 926References and Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 928Appendix 3: Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 930Appendix 4: Classifications of Countries and Regions . . . . . . . . . . . . . . . . . . . . 960Appendix 5: List of Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . 963

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 965

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