Socio-economic Differential Mortality

Sci-ecnmic Differential Mrtality Industrialized Scieties United Natins Ppulatin Divisin (New Yrk) Wrld Health Organizatin (Geneva) Cmmittee fr Internatinal Cperatin in Natinal Research in Demgraphy CICRED (Paris) Istitut di Ricerche sulta Pplazine del Cnsigli Nazinale delle Ricerche (Rma) 1984 Dipartiment di Scienze Demgrafiche dell'università «La Sapienza» (Rma)

Sci-ecnmic Differential Mrtality in Industrialized Scieties United Natins Ppulatin Divisin Wrld Health Organizatin (New Yrk) (Geneva) Cmmittee fr Internatinal Cperatin In Natinal Research in Demgraphy CICRED (Paris) Istitut di Ricerche sulla Pplazine del Cnsigli Nazinale delle Ricerche (Rma) 1984 Dipartiment di Scienze Demgrafiche dell'università «La Saplenza» (Rma)

SOCIO-ECONOMIC DIFFERENTIAL MORTALITY 3

FOREWORD The 3rd Meeting f the UN/WHO/CICRED Netwrk n Sci-Ecnmic Differential Mrtality in the Industrialized Scieties was cnvened in Rme, Italy frm 24 t 27 May, 1983. It was attended by 54 researchers (29 Italians and 25 nn-italians) representing 29 institutins (10 Italians and 19 nn-italians). These figures reflect the interest that the researchers take in the prblem f sciecnmic differential mrtality. They als shw the eagerness f ppulatin research institutins t cperate with ne anther, since the rganizatin f the Meeting is based n the principle f self-help, each institutin bearing the cst f its participatin in the cmmn endeavur The Meeting was hsted by the Istitut di Ricerche sulla Pplazine (IRP) f the Cnsigli Nazinale delle Ricerche and the Dipartiment di Scienze Demgraflche (DSD) f the Université di Rma «La Sapienza». The tw hst centres generusly tk charge f the cst f printing the Meeting's prceedings. The CICRED Chairman wishes t thank them sincerely n behalf f the internatinal cmmunity f demgraphers. Jean BOURGEOIS-PICHAT February 1984

TABLE OF CONTENTS pag. Frewrd 5 PART ONE Third Jint UN/WHO/CICRED Meeting n Sci-Ecnmic Differential Mrtality in Industrialized Scieties (Rme, Italy, 24-27 May 1983) 11 I. Backgrund and general features f the Meeting 13 II. Sessins' reprts.. 1) Classificatin f sci-ecnmic status 14 2) Census based prspective studies 15 3) Prblems and pprtunities fr research n the basis f limited data.... 17 4) Eclgical and gegraphical apprach 18 5) Infant mrtality and sci-ecnmic status 19 III. Future activities f the Netwrk 1) Publicatin f the prceedings f the Meeting 20 2) Publicatin f a review f the state-f-the-art 20 3) Next meeting f the Netwrk in 1986 20 IV. Recmmandatins 1) Infant mrtality research 21 2) Gegraphical apprach 21 3) Cuntries where census-based prspective studies have nt been implemented 22 4) Cuntries where census-based prspective studies have been implemented - 22 5) Data cmparability imprvement 23 6) Disseminatin f findings 23 Annex: List f participating institutins 24 PART TWO Facts and wrks: cuntry reprts 27 I. Classificatin f sci-ecnmic status 29 A nte n the classificatin f sci-ecnmic status fr investigating mrtality differentials in Australia (Alan D. LOPEZ) 31

pag. Classificatin f sci-ecnmic status: sme remarks n the discussin in Nrway (Lars B. KRISTOFERSEN) 43 Sci-ecnmic classificatin in Swedish statistics (Rbert ERIKSON) 53 Sci-ecnmic classificatins used in Finnish mrtality studies (Tapani VALKONEN) 63 II. Census-based prspective studies 67 La mrtalité seln le milieu scial en France (Guy DESPLANQUES) 69 Census-based prspective studies in Nrway (Lars B. KRISTOFERSEN) 103 Essai de cnfrntatin de quelques études prspectives de mrtalité (Guy DESPLANQUES) 121 HI. Prblems and pprtunities fr research n the basis f limited data 129 New research directins n sci-ecnmic differential mrtality in the United States f America (Harry M. ROSENBERG and Marilyn M. McMILLEN) 131 Develpments in research n sci-ecnmic determinants f mrtality since 1981 in the Netherlands (Jeren K.S. van GINNEKEN) 167 Recent mrtality change amng wrking vis-à-vis nn wrking ppulatin at age f ecnmic activity and agricultural vis-à-vis nn-agricultural wrkers in Pland (Marek OKOLSKI) 171 Prblems and pssibilities f research in cuntries with limited data (Wilfried LINKE and Jan Van REEK) 179 IV. Gegraphical and eclgical apprach 185 Reginal variatins in mrtality in Nrway (Gerd S. LETTENSTR0M and Jens-Kristian BORGAN) 187 Cnsidératins préliminaires pur une étude sur la mrtalité par causes en Tscane (Silvana SALVINI et Silvana SCHIFINI D'ANDREA 201 Infant mrtality and mther educatin degree at the birth in Italy (Marzia VALLI TODARO) 215 V. Infant mrtality and sci-ecnmic status 221 Mrtalité infantile en Italic La qualité des dnnées et les pssibilités d'améliratin (Marcell NATALE) 223 Facteurs différentiels de la mrtalité fet-infantile en Italie (Antnella PINNELLI) 227 Facteurs sci-démgraphiques des disparités réginales de la mrtalité infantile en France (DINH Quang Chi) 245

pag. Infant mrtality in seven Eurpean scialist cuntries (Andras KLINGER) 269 Trends f perinatal and infant mrtality in Sweden and in ther Nrdic cuntries and their assciatin with demgraphic and sci-ecnmic variables (Anne Marie BOLANDER) 283 VI. General Other tpics 321 Brief ntes t describe the psitin f England and Wales cncerning sci-ecnmic differential mrtality (A.Jhn FOX) 323 Quelques réflexins tirées du séminaire de Paris sur «l'influence des plitiques sciales et de santé sur l'évlutin future de la mrtalité» (Jacques VALLIN) 327 Hw gd are the data? Sme methdlgical pints and a quality assessment prgram in Switzerland (Fred PACCAUD and Christph MINDER) 331 Sme features f mrtality in the 1970's in Hungary (Peter JOZAN) 337 A nte n scial inequality f death in mre develped cuntries (Harald HANSLUWKA) 345

11 PART ONE THIRD JOINT UN/WHO/CICRED MEETING ON SOCIO-ECONOMIC DIFFERENTIAL MORTALITY IN THE INDUSTRIALIZED SOCIETIES ROME, ITALY, 24th-27th MAY, 1983

13 I. Backgrund and general features f the meeting In June 1979, a Meeting was jintly cnvened by the United Natins and the Wrld Health Organizatin in Mexic City (Mexic) with a view t assessing the sci-ecnmic determinants and cnsequences f mrtality. The Meeting stressed the need fr further research int the matter and CICRED was assigned the task f prmting research relating t industrialized cuntries. This task fitted int the Prgramme f Inter-Centre Cperative Research launched by the CICRED General Assemly in August 1977. The Prgramme is aimed at strenghthening cperatin amng ppulatin research institutins having similar scientific pints f interest and is based n the tw principles f mutual exchange and self help. In view f carrying ut the task assigned by the Mexic City Meeting, CICRED created a Netwrk n Sci-Ecnmie Differential Mrtality in Industrialized Scieties. The first meeting f the Netwrk was cnvened in Geneva (Switzerland) n 3 rd and 4* July 1980 under the jint spnsrship f UN, WHO and CICRED. It was held in the WHO Headquarters. The secnd meeting f the Netwrk was cnvened in Wiesbaden (Federal Republic f Germany) frm 1st t 3rd July 1981. it was hsted by the Federal Statistical Office. The prceedings f the tw meetings have been published**). The Wiesbaden meeting decided that the third meeting f the Netwrd wuld be cnvened in Spring 1983 and wuld deal with the fllwing tpics; (i) classificatin f sci-ecnmic status; (ii) prblems and pssibilities f research in cuntries with limited data; (iii) census-based prspective apprach; (iv) eclgical and gegraphical apprach; (v) infant mrtality and sci-ecnmic factrs. Fr each tpic a «fcal persn» was designated. On the jint invitatin f the Istitut di Ricerche sulla Pplazine (IRP) f the Cnsigli Nazinale delle Ricerche and the -Dipartiment di Scienze demgrafiche (DSD) f the Université di Rma «La Sapienza», the United Natins, the Wrld Health Organizatin and CICRED cnvened the third meeting f the Netwrk in Rme (Italy) frm 24 th thrungh 27 th May 1983. The pening sessin f the meeting was chaired by Antni Glini. The fllwing speakers welcmed the participants: Lén Tabah, n behalf f the UN Ppulatin Divisin, Harald Hansluwka, n behalf f the WHO Divisin f Glbal Epidemil- ( ) Sci Ecnmic Differential Mrtality in Industrialized Scieties, Vl. 1, UN-WHO-CICRED, 1981,91 pages. Sci Ecnmic Differential Mrtality in Industrialized Scieties, Vl. 2, UN-WHO-CICRED, 1982, 63 pages.

14 gical Surveillance and Health Situatin Assessment, Eugeni Snnin, n behalf f DSD, Antni Glini, n behalf f IRP, Jean Burgeis-Pichat, n behalf f CICRED. The meeting held five sessins t discuss the tpics selected in Wiesbaden. Discussins n each tpic are presented in the relevant sessin's reprt (see sectin II belw). Furthermre, the meeting examined three additinal subjects: (i) quality and cmparability f data and findings; (ii) relatinship f research and actin prgrammes; (iii) future activities f the Netwrk. The meeting made varius recmmandatins (see sectin IV belw). The papers cntributed t the meeting are reprduced in Part Tw. II. Sessins' reprts 1. Classificatin f sci-ecnmic status (Fcal persn and rapprteur: A.Jhn Fx) In the first part f the sessin, participants described classificatin f sciecnmic status develped and used in their cuntries, mainly in fficial census publicatins. CICRED will be keeping cpies f these classificatins fr distributin t any researcher wishing t undertake crss-natinal cmparisns. Fr this purpse, it was suggested that each cuntry shuld cntinue t prvide CICRED with up-t-date classificatin as the ld classificatins are mdified. There was sme discussin f the theretical limitatins f rutine appraches t the analysis f sci-ecnmic differentiatin in mrtality (see, fr example, paper by Lpez). There was als sme discussin f the imprtance f mrbidity and health services (again raised by Lpez). The weighting f ccupatin, industry, size f rganizatin and status in the determinatin f sci-ecnmic grup varied by cuntry as did the way in which marginal grups, such as the unemplyed, the sick, the retired, students, husewives and permanently sick peple, were handled (cntrast, fr example, the appraches described by Desplanques, Kristfersen and Fx). Participants varied in their desire fr a sci-ecnmic scale t be «ranked» in a single dimensin. Als, there was sme discussin f classificatin based n: (a) surveys f peples' assessments f a «status», f their designatin f different ccupatinal grups; (b)multivariate classificatins based n, fr example, ccupatin, educatin and incme using statistical techniques such as cluster analysis r factr

analysis; (c) univariate classificatin based n husing r educatin and alternatives (see, fr example, Valknen's paper); (d)husehld units, family units r small gegraphic areas. There was als sme discussin f the rle f sci-ecnmic analysis in the status f mrtality differentials. It was widely accepted that, in mst develped cuntries, gvernment plicies in the fields f health, educatin, transprt and husing included strng emphasis n the rle f gvernment agencies in prmting mre equality (f access, f use, etc.). An imprtant rle f sciecnmic analysis was, therefre, a part f the prcess f evaluatin. This meant, in particular, that we shuld bear in mind the need t establish realistic time series data. A mre secndary rle was that in the study f causative factrs. In this sense, it was ften thught t be f imprtance t have access t mre detailed ccupatinal data (the recent use f data published by Denmark, Nrway and Finland illustrates this pint). Other grupings may be equally imprtant (e.g. immigrant grups r race in USA). Nrway (Kristfersen) and the UK (Fx) emphasized the imprtance f ccupatinal histry and scial mbility in prmting a better understanding f differentials. It was cnsequently disappinting t hear frm Denmark (Andersen) that ccupatinal descriptins based n tax register returns were less reliable than thse previusly btained frm censuses.. In trying t change the directin f the discussin t braden hrizns and t persuade researcher and statistical agencies t widen alternative classificatins, Fx briefly cmpared classificatins based n ccupatin, husing and educatin. The headings he cnsidered were: why we measure inequalities; availability f infrmatin; scpe f each measure; cst f data cllectin, cding and rehabilitatin f cding; ppulatin distributin; interactin; scial mbilité; etc. 15 2. Census-based prspective studies (Fcal persn and rapprteur: Guy Desplanques) The cnventinal methd f measuring mrtality levels cnsists f dividing the number f deaths, knwn thrugh vital registratin, by the ttal ppulatin btained frm census data. This can be perated sundly fr the whle cuntry r each regin r each age-sex grup. But as cncerns grups defined by scicnmic r matrimnial status, the measures btained are nt precise. Better measures f mrtality can be made n the basis f the prspective methd r the lngitudinal methd. In the lngitudinal methd, infrmatin n

16 the same individuals are gathered and linked frm the varius administrative dcuments: census frm, vital registratin frm, etc. Recrd linkage allws the descriptin f the demgraphic histry f grups f individuals as it develped in the past. This methd has varius ptentialities: (i) it is pssible t study mrtality and als scial mbility, gegraphical mbility, etc. fr grups defined by varius characteristics; (ii) the methd has nt the shrtcmings f the cnventinal methd; (iii) if the grup studied is cnstituted by individuals brn n the same day (r in the same mnth), cllecting infrmatin is easy and at a lwer cst. The prspective methd is similar t the lngitudinal methd but is specifically riented tward the future: a sample f individuals is cnstituted frm the census: they are fllwed up in the curse f time, their varius vital events (marriage, divrce, birth f a child, death,...) being registered. This enables the demgrapher t accurately measure varius demgraphic phenmenns. At present, certain cuntries have published findings btained n the basis f lngitudinal r prspective methds(*>: Denmark, Finland, France, Nrway, United Kingdm. The findings, and thse unpublished which were prvided by the participants t the meeting, gave rise t many new insights in the field f mrtality differentials: thse wh wn their huse r apartment have a lwer mrtality level than tenants (England and Wales). the mrtality gap between scial grups is widening (France), the mrtality rate is higher amng thse unemplyed than thse wrking; thse wh are ecnmically inactive die mre frequently than d the active peple, the frequency f certain causes f death varies accrding t the scial grup, etc. (*) DENMARK. Ddelighed g erhverv (Occupatinal mrtality), 1970-1975, Statistike Undersgelser n 37, Kbenhavn, 1979. NORWAY. Occupatinal mrtality, Central Bureau f Statistics Rapprter 79/19, Osl, 1979 (by Kirstfersen); Occupatinal mrtality 1970-1973, Statistiske Analyser n" 21, Osl 1976. FINLAND. Occupatinal Mrtality 1971-1975 (by H. Sauli), Central Statistical Office f Finland, n 54, Helsinki, 1979. FRANCE. La mrtalité des adultes seln le milieu scial: Résultats de la péride 1955-1979 (par G. Desplanques), Cllectins de l'insee, série D, n 44. ' UNITED KINGDOM. Lngitudinal Study: sci-demgraphic mrtality differentials 1971-1975, Series LS, n I (by Jhn Fx and Peter Gldblatt), HMSO, 1982.

These findings are s far mstly descriptive. It is hped that in the future the develpment f research will make it pssible t answer the kind f questins such as: Des the situatin f unemplyment r that f widwhd increase the death risk? Is the ccupatinal activity f the childbearing mther psitive f negative t the health f her futur child?... As pinted ut abve many cuntries have cnducted mrtality studies n the basis f the lngitudinal and/r prspective methd. Others have recently adpted it: Italy, Austria, Sweden, the latter being at the stage f data analysis. The implementatin f the legislatin n medical secrecy r fr the prtectin f the individuals freedm (Netherlands, France,...) culd be an bstacle t such a develpment. 17 3. Prblems and pprtunities fr research n the basis f limited data (Fcal persn and rapprteur: Wilfried Linke) Sme backgrund infrmatin was given n the activities f an infrmal wrking grup which was held in Wiesbaden n 15 th and 16'h June, 1982, in preparatin fr the present sessin. The meeting was attended by participants frm Netherlands, Switzerland, the Federal Republic f Germany and the WHO. Subjects f the discussins were the prblems and pssibilities f research n differential mrtality in situatins with privacy limitatins and where linkage f recrds is difficult r nt pssible. The participants reprted abut the research wrk they had undertaken in the past r were planning fr the future. As a result f the discussins held, a paper was prepared and submitted t this meeting!*). It cntains the fllwing three paragraphs:. A. Necessity f resarch int sci-ecnmic differential mrtality; B. Feasibility f research int sci-ecnmic differential mrtality in industrialized scieties with privacy limitatins; C. Investigatin f the phase preceeding death. Paragraph B which is the mst imprtant part f the paper, was cntributed by Mr. Van Reek. The fcal persn intended t prepare a schedule f current and planned investigatins especially using nn-recrd-linkage methds. Fr this aim the members f the Netwrk were invited t prvide infrmatin abut the bjectives, the surce f data and the methds applied in investigatins f this kind. Three cntributins were received frm Mr. Van Ginneken (The (*) Reprduced in Part Tw.

18 Netherlands), Mr. Rsenberg (USA) and Mr. Oklski (Pland). It shuld be nted in this cntext that fr the cming years in the USA, several studies making use f linkage f recrds are planned. Similar studies, hwever, are nt planned fr the ther cuntries mentined abve. In the Federal Republic f Germany, it is intended t perfrm a brader evaluatin f files f wrkers and emplyees subject t cmpulsry scial ld age insurance. It wuld permit a detailed evaluatin f deaths f the grups mentined by demgraphic and sci-ecnmic characteristics. There was an agreement, that studies with the design mentined in the secnd part f the backgrund paper wuld give useful infrmatin fr thse cuntries in which recrd linkage is difficult r impssible. Such studies might be seen as a first step twards determining the extent f differential mrtality. Their limitatins were als cnsidered. It was hped that such studies will be fllwed by studies using lngitudinal r prspective design. 4. Eclgical and gegraphical apprach (Fcal persn and rapprteur: Antni Glini) Three papers were submitted fr the sessin. They dealt with gegraphical variatins f the causes f death in Tuscany (S. Selvini and S. Schifini d'andrea), the reginal variatins f the mrtality level in Nrway (G. S. Lettenstrm and J. K. Brgan) and the reginal variatins f the Italian infant mrtality rate with relatin t the mthers' educatin (M. Valli Tdar). The discussin went beynd the findings gathered in these papers. In almst all cuntries there are strng reginal differences, bth in life expectancy and age-sex specific prbabilities f dying. In many cases, such differences are persisting r bradening in the curse f time. Fr instance, in Italy, the gap between the maximal and minimal regial values f e l5 fr males was 5.5 years in 1950-52 (58.1 against 52.6) and als 5.5 years in 1977-79 (60.2 against 54.7). Ging dwnward in the territrial scale and bserving smaller territrial units, the gap is larger, at arund 8-10 years. In each cuntry reginal differences in mrtality are mre imprtant fr males than fr females. Such gegraphical differences cannt always be explained by reginal variatins f health facilities r sci-ecnmic level. The «eclgical apprach» takes int accunt a larger number f variables. It seems a very useful tl fr a better understanding f gegraphical mrtality differentials. A greater number f eclgical surveys shuld be encuraged.

19 5. Infant mrtality and sci-ecnmic status (Fcal persn and rapprteur: Anne-Marie Blander) After the presentatin f the cntributed papers (reprduced in Part Tw), there was a brief discussin n sme prblems related t the analysis f perinatal and infant mrtality and their assciatin t sci-ecnmic and demgraphic variables. Attentin was paid. t the fact that differences related t the ccupatin f father had nt the same significance as thse related t that f the mther neither fr deaths arund the birth, nr in the pstnenatal perid. As a rule the number f deaths are ften t lw in the Nrdic cuntries t achieve any statistical significance. It was als pinted ut that birth-weight culd serve as a substitute fr mrtality in cuntries with cmplete reprting f such data as it wuld frm a mre sensitive measurement f sci-ecnmic and ther differences. An ther prblem mentined in this cnnectin was the adjustment fr differences in birth distributin, similar t thse ften made fr age differences in grups t be cmpared. The danger f such standardisatins was underlined especially as regards perinatal mrtality, where lw birth-weight is ne f the best indicatrs f increased risks f dying when cmparing different grups. General birth-weight differences as thse between male and female births shuld evidently be cntrlled fr when estimating the risks. The very lw incidence f pregnancies in yung mthers (under 20 years) in the Nrdic cuntries, culd pint at a negative selectin as t sci-ecnmic factrs, which wuld explain part f the mrtality risks in this grup. Graphs shwing the percentage distributin accrding t mthers age in Sweden gave sme evidence f the presence f selective r cnfunding factrs t be aware f when studying the births f the yungest as well as the ldest mthers. A cmparisn f late fetal and early nenatal mrtality between the 8 cuntries participating in the WHO study f the 1973 births revealed a prbable underreprting in Japan f deaths within in first days f life and a crrespnding verreprting f late fetal deaths, which was cnfirmed by the Japanese participant in the meeting. This had caused a slight miscalculatin in the infant mrtality rate and thus als in the life expectancy at birth, a mistake that had been detected and was n its way t be crrected. The cnclusin f the discussin f the infant mrtality sessin was the need fr mre research in this field, especially as regards the study f differentials within and between cuntries.

20 III. Future activities f the Netwrk The activities mentined belw are apprved by the participants t the meeting. 1. Publicatin f the prceedings f the Meeting The reprt f the Meeting and the cntributed papers will be gathered in a bk and published in Spring 1984, with the assistance f the tw hst centres, the Institute f Ppulatin Research f the Natinal Cuncil f Research f Italy and the Department f Demgraphic Science f the University f Rme «La Sapienza». The bk will bear the n 3 f the Sci Ecnmic Differential Mrtality in the Industrialized Scieties series. It will cnstitute a cntributin f the Netwrk t the frthcming Internatinal Ppulatin Cnference, cnvened by the United Natins in Mexic City (Mexic) in August 1984. 2. Publicatin f a review f the state-f-the-art Under the respnsibility f A.Jhn Fx, and with the assistance f the Wrld Health Organizatin, a review f the state-f-the-art will be drafted and published in 1985. It will bear the n 4 f the Sci Ecnmic Differential Mrtality in the Industrialized Scieties Series. 3. Next meeting f the Netwrk in 1986 The furth meeting f the Netwrk will be cnvened in Spring 1986. The members f the Netwrk are invited t deply all effrts t carry ut new pieces f research n sci-ecnmic differential mrtality during the cming years in view f actively cntributing t the 1986 meeting. There will be tw categries f cntributed papers: (i) natinal reprts prviding the findings f studies carried ut in each cuntry during the 1983-1986 perid; (ii)transnatinal reprts which cnstitute in-depth analyses f certain specific tpics, in a transnatinal perspective. As cncerns the secnd categry f cntributed papers, the fllwing tpics are selected and taken in charge by vlunteering participants: Cmparative study f sci-ecnmic differential mrtality in Eastern

Eurpean cuntries (Peter Jzan, Central Statistical Office f Hungary, Budapest); Cmparative study f sci-ecnmic differential mrtality in Western Eurpean cuntries (Lars Kristfersen, Central Bureau f Statistics f Nrway, Osl); Quality f cause-f-death infrmatin as related t sci-ecnmic differential mrtality (Harry M. Rsenberg, Natinal Center fr Health Statistics, Hyattsville, Maryland, USA); Elabratin f theretical framewrk fr sci-ecnmic differential mrtality (Tapani Valknen, Department f Scilgy, University f Helsinki, Finland); Explanatin f sci-ecnmic differential mrtality amng the ecnmically inactive peple (Jacques Vallin, Institut Natinal d'etudes Démgraphiques, Paris, France); Migratin and mrtality (Antni Glini, Istitut di Ricerche sulla Pplazine, Rma, Italy); Scial mbility and mrtality (Rbert Eriksn, Department f Scilgy, University f Stckhlm, Sweden). 21 IV. Recmmandatins The participants t the meeting made recmmandatins n the varius research tpics regarding sci-ecnmic differential mrtality. 1. Recmmandatins n infant mrtality research Research shuld be carried ut, taking int accunt nt nly the father's ccupatin but als ther sensitive factrs such as mther's ccupatin, mther's age, birth weight...etc.... Under-reprting f deaths within the first days f life shuld be detected t ensure crrect measures. 2. Recmmandatins n the gegraphical apprach In a great number f cuntries, gegraphical mrtality differentials have been strngly evidenced. There is a need t deepen ur knwledge n the matter. In particular, attentin shuld be paid t the risk factrs generated by uncntrled industrializatin.

22 3. Recmmandatins cncerning cuntries where census-based prspective studies have nt been implemented In cuntries with limited data r limitatins due t cnfidentiality legislatin, research n sci-ecnmic differential mrtality shuld nt be drpped ut. On the cntrary, research prjects shuld be implemented, fcusing n the measurement f easily available sci-cnmic differentials and based n subgrups easily delimited: members f ld-age pensin schemes, emplyees f industrial crpratins, ppulatin f small gegraphical areas... etc.... Such prjects will pave the way in the future t brader studies using mre rigrus design. 4. Recmmandatins cncerning cuntries where census-based prspective studies have been implemented (a) Lngitudinal bservatin which is the basis f such studies shuld be expanded. The principle f lngitudinal bservatin is t gather fr each individual pieces f infrmatin frm varius surces and/r varius pints in time and t link them tgether. Lngitudinal bservatin shuld be cntinued and expanded since it is the best way t btain relevant measurement f mrtality differentials and trends in these differentials (see sessin reprt in II. 2) b) Methdlgy shuld be imprved and analysis enlarged, as cncerns the fllwing items: (i) By the time being, differentials in sci-ecnmic mrtality are mstly prvided by bservatin f deaths ccuring in the varius ccupatins, the ecnmically inactive peple being ften excluded frm bservatin. But there is a mrtality excess amng inactive peple vis-à-vis active peple f same ages. On the ther hand, a great number f peple die after they have retired frm the wrkfrce. Therefre, bservatin has t include inactive peple in rder t ensure accurate and exhaustive measurement f differentials in sci-ecnmic mrtality. (ii) By the time being, sci-ecnmic mrtality differentials are mstly studied n the basis f the individual's ccupatin and/r incme. Other criteria might be taken int accunt, wrk cnditin, husing cnditin, educatinal attainment, family... etc... They might thrw new light int the field. (iii) Every effrt shuld be deplyed t separate the impact f sci-ecnmic cnditin and that f sex n mrtality differentials. New criteria f scial classificatin shuld be sught t determine mre accurately sci-ecnmic differential mrtality amng females. In particular, there is a need t take int

accunt the varius perids f ccupatinal activity and inactivity in the female life cycle. (iv) Every effrt shuld be deplyed t assess mre clearly the relatinship between scial mbility, gegraphical mbility and mrtality differentials. 23 5. Recmmandatins fr data cmparability imprvement There is an urgent need t imprve the cmparability f data and findings. Internatinal bdies such as the Statistical Office f the Eurpean Ecnmic Cmmunities shuld be asked t persuade cuntries t harmnize their ccupatinal (r sci-ecnmic status) classificatins. In particular, gvernment agencies shuld be asked t hld data in a way which culd allw basic re-grupings cmmn t all industrialized cuntries. Members f the Netwrk shuld cntinue in the future t prvide CICRED with up-t-date classificatins as the ld classificatins are mdified. 6. Recmmandatins regarding disseminatin f findings Researchers shuld attempt t disseminate mre bradly their findings amng the decisin-makers and the public. They shuld try t disseminate mre quickly the methdlgical elements f their wrk amng fellw-researchers in ther cuntries. They shuld try als t indicate t their clleagues the varius risks f bias, f under-reprting... generated by their methdlgy, their way f ccupatins' re-gruping etc.... t avid misleading interpretatin.

24 ANNEX List f participating institutins Istitut di Ricerche sulla Pplazine (IRP), Cnsigli Nazinale delle Ricerche, Viale Beethven 56, 00144 Rme (Italy) Dipartiment di Scienze demgrafiche (DSD), Università di Rma «La Sapienza», Via Nmentana 41, 00161 Rme (Italy) ISTAT, Viale Liegi 13, Rme (Italy) Istitut Scienze Infrmazini, Università di Bari, Via Amendla 173, Rme (Italy) Università di Trin, Via Cappadcia 34, Rme (Italy) Università di Napli, P.zza Mattei 3, Rme (Italy) Osservatri Epidemilógic, Regine Lazi, Via R.R. Garibaldi 7, Rme (Italy) Dipartiment Statistic, Università di Firenze, Via Curtatne 1, 50123 Firenze (Italy) Università di Palerm, Via Giusti 21, 90144 Palerm (Italy) Università di Bari, V.le Kennedy 85, Bari (Italy) Antni Glini Agstin Lri Rssella Palmba Eugeni Snnin Nra Federici August Asclani Carla Bielli Graziella Caselli Anna De Sarn Viviana Egidi Giuseppe Gesan Dinisia Maffili Marcell Natale Annunziata Nbile Antnella Pinelli Givanni Cariani Alessandr De Simni Elvira Mallard Givanni Marrcchi Firella De Rsis Sergi Favilli Enz Lmbard Carl Perucci Carlina Tasc Antni Santini Silvana Salvini Silvana Schifini d'andréa Marzia Valli-Tdar Luigi Di Cmité

25 Denmarks Statistik, Serjgade 11, Pstbks 2550, Cpenhagen (Denmark) Statistics Swedem Karlavagen 100 Stdehlm, S-11581 Stckhlm (Sweden) Department f Scilgy, University f Stckhlm, S-10691 Stckhlm (Sweden) Central Bureau f Statistics f Nrway, Pstbx 8131, DEP, Osl 1 (Nrway) Ppulatin Statistics Sectin, Hungarian Central Statistical Office, Kelety Karly u. 5/7, 1525 Budapest H (Hungary) Federal Institute fr Ppulatin Research, Gustav-Stresemann-Ring 6, D-6200 Wiesbaden (Germany FR) Institute f Demgraphy, A-1030 Vienna (Austria) The City University, Nrthamptn Square, Lndn EC1 (United Kingdm) Department f Scial and Preventive Medicine, University f Bern, CH-3012 Bern (Switzerland) Health Statistics Service, Hallwylstrasse 15, CH-3OO3 Bern (Switzerland) Department f Ecnmics, University f Warsaw, Ul. Dluga 44/50, 00241 Warsaw (Pland) Mrtality Statistics Branch, Divisin f Vital Statistics Natinal, Center fr Health Statistics, 3700 East-West Highway, Hyattsville, Maryland 20782 (USA) Department f Scilgy, University f Helsinki, Franzeninkatu 13, SF-00500 Helsinki 50 (Finland) Institut Natinal d'études Démgraphiques, 27 rue du Cmmandeur, 75675 Paris Cedex 14 (France) Ott Andersen Anne-Marie Blander Rbert Eriksn Jens-Kristian Brgan Lars Kristfersen Peter Jzan Wilfried Linke Wlfgang Lutz A.Jhn Fx Sue Teper Christph Minder Fred Paccaud Marek Oklski Harry M. Rsenberg Tapani Valknen Jacques Vallin

26 I.N.S.E.E., 18 bulevard Adlphe Pinard, Dinh Quang-Chi 75014 Paris (France) Guy Desplanques Central Bureau f Statistics, P.O. Bx 959, Jeren K.S. Van 2270 AZ Vrbung (Netherlands) Ginneken Ppulatin Divisin, United Natins, Lén Tabah New Yrk, N.Y. 10017 (USA) Shir Hriuchi Wrld Health Organizatin, G.E.S. Unit, Harald Hansluwka CH-1211 Geneva 27 (Switzerland) Alan Lpez C.I.C.R.E.D., 27 rue du Cmmandeur, Jean Burgeis-Pichat 75675 Paris Cedex 14 (France) Bui Dang Ha Dan

27 PART TWO FACTS AND WORKS: COUNTRY REPORTS

29 SECTION I CLASSIFICATION OF SOCIO-ECONOMIC STATUS A nte n the classificatin f sci-ecnmic status fr investigating mrtality differentials in Australia (Alan D. LOPEZ) Classificatin f sci-ecnmic status: sme remarks n the discussin in Nrway (Lars B. KRISTOFERSEN) Sci-ecnmic classificatin in Swedish statistics (Rbert ERIKSON) Sci-ecnmic classificatins used in Finnish mrtality studies (Tapani VAL- KONEN)

A NOTE ON THE CLASSIFICATION OF SOCIO-ECONOMIC STATUS FOR INVESTIGATING MORTALITY DIFFERENTIALS IN AUSTRALIA 31 Alan D. LOPEZ Statistician, Glbal Epidemilgical Surveillance and Health Assessment, Wrld Health Organizatin, Geneva. Situatin Sme Theretical Cnsideratins Despite the relative scarcity f studies n scial and ecnmic mrtality differentials in Australia, the findings f studies which have been carried ut cnsistently pint t the existence f marked differences in ill-health and mrtality amng Australians.(D As has been repeatedly fund in ther develped cuntries, the prest health prfiles ccur amng the lwer educated, amng migrants, amng thse in the lwer-status ccupatins and, mst ntably, amng the Abriginal ppulatin. Whereas the higher mrbidity and mrtality f Abriginals is, t sme extent at least, t be expected given the nmadic existence f sme tribal grups, the distance frm health services fr many thers, the pr sanitary cnditins which cmmnly prevail n Abriginal reservatins, and the hazardus health behaviur f many Abrigines living in urban areas, the explanatin f sci-ecnmic differentials in health amng the nn-indigenus ppulatin is smewhat mre intricate. In principle, at least, all sectrs f Australian sciety are guaranteed identical access t health services, live in a similar scial and ecnmic envirnment, and enjy similar legislative prtectin frm industrial accidents r ther health risks at the wrk place. Only in a handful f ccupatins, mstly in the mining industry, can the ccupatinal hazard nwadays be cnsidered as a significant health risk. In rder t investigate the pattern and extent f, as well as the factrs underlying such differentials in ill-health, an apprpriate and meaningful Nte: The views expressed in this paper are thse f the authr and d nt necessarily reflect the pinins r plicies f the Wrld Health Organizatin.

32 classificatin f the ppulatin which is at nce sufficiently hmgeneus fr the attributin f risk and sufficiently large t permit a statistically reliable assessment f mrtality differentials is necessary. On the ne hand, such a classificatin will be cnstrained by the nature f the data surce available t investigate mrtality differentials; typically, the ppulatin census r a ppulatin register is used t cnstruct categries fr investigatin. On the ther, the infrmatin available will nt generally be a sufficiently cmplete accunt f an individual's sci-ecnmic circumstances t adequately describe the cntributin f varius factrs t the bserved inequalities in health status. Furthermre, the ppulatin sub-grups t which the census characteristics refer may nt be identical t thse grups fr which mrtality data are available. Leaving aside such statistical cnsideratins fr the mment, it is f much greater cncern t determine what a particular sci-ecnmic classificatin des and des nt reveal abut the nature f the factrs leading t inequalities in health. Fr example, in emplying, as is cmmnly dne, a classificatin f the adult male ppulatin f wrking age based n ccupatinal categries t investigate sci-ecnmic differentials, ne is faced with parcelling ut the cntributin f specific ccupatinal factrs, general ccupatinal factrs related t the envirnment within which the ccupatin is generally lcated, the rle f selective transfers frm ne ccupatin t anther, and ther mre pervasive cnsideratins such as variatins in life-style and verall health cnsciusness amng ccupatinal grups. This latter grup f determinants can be expected t reflect a variety f sci-ecnmic characteristics which influence health behaviur t varying degrees including educatin, assimilatin int sciety, incme, marital status, and the like. The prblem is further cnfunded by the fact that strng intercrrelatins exist amngst these variables which renders the attributin f excess mrtality amngst them extremely difficult. In an attempt t better define the cmplexity f assciatins which are likely t give rise t differentials in ill-health in industrialized scieties, a simple schematic representatin f the causal chain underlying the s-called "diseases f civilizatin" is given in Figure 1. This schema is far frm an exhaustive accunt f the causal prcess but it des serve t illustrate the nature f the interactins underlying the transitin frm a state f gd health t ne f manifest ill-health, and, ultimately, death. Typically, investigatins f sci-ecnmic differentials have fcussed n the final utcme variable, namely death, and have attempted t explain these differences in terms f their assciatin with sme f the factrs listed under the set f micr-health determinants, mst ntably ccupatin. Clearly, hwever, imprtant sci-ecnmic differentials can and d exist at ther stages f the causal chain, especially with regard t individual health behaviur, including the use f health services and respnsiveness t health educatin campaigns. Cnsequently, it is unlikely that bserved variatins in mrtality accrding t any ne variable such as ccupatin will prvide a great deal f insight int the

true nature f the underlying frces which lead t inequality in survival chances. Yet the fact remains that the statistical apparatus and epidemilgical tls necessary fr decmpsing the causal chain underlying these differentials are nt generally available and hence there appears little alternative but t cntinue t specify and "explain" sci-ecnmic variatins in ill-health n the basis f eclgical analyses and hetergeneus descriptrs such as ccupatin which may ften be little mre than a prxy fr a hst f ther sci-ecnmic influences. 33 Classificatin f Sci-ecnmic Status in Australia With these caveats in mind, sme f the mre recent attempts t classify sciecnmic status in Australia are described belw. T begin with, it is wrth emphasizing that there wuld appear t be n generally accepted methdlgy fr defining scial strata in industrialized scieties. Mst attempts t delineate the structure f sciety have been impressinistic. Encel,< 2 > fr example, has develped a stratificatin f Australian sciety in terms f class, status and pwer, using ccupatin, incme, and educatin as indicatrs f the principal frces f scial differentiatin that cntribute t this stratificatin. At the same time, there is general agreement that ccupatin is prbably the best single indicatr f an individual's psitin in the scial rder. Occupatinal prestige scales are widely used t reflect differences in standard f living, pwer and influence in the cmmunity, and value t sciety. Furthermre, incme and skill differentials amng ccupatins are cmmnly used as either direct (in the case f incme) r indirect (e.g. skill as a prxy indicatr fr educatin) measures f factrs likely t influence health behaviur and health status. Althugh ccupatinal characteristics f the Australian wrking ppulatin have been published after each census, n attempt has been made by the Australian Bureau f Statistics t define scial classes alng the lines f what has been dne in England and Wales, fr example, since 1910-12. Hwever, there are at least sme studies by individual researchers which have attempted t define scial strata in Australia and, in ne case at least, t use the strata s defined t investigate scial class differentials in mrtality. Perhaps the first such study was that f Taftw wh ranked twenty ccupatins n a five-pint scale f "scial standing" based n a self-administered questinnaire amng subjects living in bth urban and rural areas f Western Australia. The selectin f ccupatins was chsen s as t be representative f thse lcal ccupatins best knwn t the public, t affrd cmparisns with ther studies and t avid an ver-emphasis n white cllar ccupatins. The mst imprtant determinants f what were perceived as "high status" ccupatins (physicians, civil engineers, clergymen, schl teachers) were the educatin and intelligence required, the interest f the wrk and its imprtance t the cmmunity. Interestingly, incme and wrking cnditins were nt

34 cnsidered as majr determinants f scial class by the respndents. Drawing n the findings f Taft's study, DasvarmaO») allcated minr ccupatin grups frm the 1961, 1966 and 1971 Australian Censuses int fur scial classes as shwn in Table 1. The resulting standardized mrtality rates (SMRs) fr each f the three perids arund the census are shwn in Figure 2. During bth perids 1961 and 1965-67, the differences in mrtality amng the three higher scial strata were negligible althugh death rates fr the lwest scial class (Grup IV) were clearly significantly higher than the remainder. In 1970-72, a similar pattern was evident althugh in this case the classical increase in mrtality with lwe'r scial class beginning with Grup II is mre evident. Hwever, as n test f statistical significance between the SMRs fr Grups II and III was reprted, it is pssible that this differential may have arisen due t chance. Nnetheless, the markedly higher mrtality f wrkers in Grup IV is clearly evident and, as Dasvarma suggests, the explanatin is likely t centre arund differences in life-style. Prfessinal and Managerial wrkers, wh enjyed the lwest SMRs at all three dates, als had the highest levels f incme althugh incme itself is unlikely t exert a direct effect n survival (except perhaps thrugh rare cases f the need fr specialized and expensive medical care) since material impverishment precluding basic needs is nt a cnsideratin in Australian sciety. A natin-wide survey n expenditure patterns did, hwever, reveal that Prfessinal and Administrative wrkers spent mre mney per week n medical and health care than ther ccupatinal grups which may in part accunt fr their better health prfiles cmpared with Grup IV. A mre likely explanatin, thugh, is that persnal health mismanagement accunts fr much f the bserved difference in mrtality rates amng scial classes. Tw causes f death fr which cigarette smking is a, if nt the, principal causal factr are lung cancer and ischaemic heart disease. Standardized mrtality rates frm lung cancer in 1970-72 amng Prfessinal Wrkers (64) and Farmers, Fishermen and Related Wrkers (80) were significantly lwer than the verall Australian average. This is in accrd with the fact that abut 29 and 39 per cent f male wrkers in these categries currently (1973-74) smke cigarettes cmpared with abut 50 per cent f Transprt and Cmmunicatin Wrkers, Craftsmen, etc., and Laburers whse SMRs fr the disease were significantly higher than average (147 and 137 respectively). Miners and Quarrymen, 71 per cent f whm are cigarette smkers, als had a higher than average SMR (137), but because f their relatively small size in the labur frce, the significance f the result culd nt be demnstrated. Miners and Quarrymen, Transprt and Cmmunicatin Wrkers, Craftsmen, etc., and Laburers als had significantly higher mrtality frm ischaemic heart disease than thers, lending further supprt t the dminant rle f life-style in the determinatin f scial class differentials in mrtality. A smewhat mre elabrate prcedure t identify scial strata in Australia is

that f Brm and Jnes.< 5 > Based n a representative survey f 1921 male wrkers aged 21 years and ver carried ut in 1965, the authrs adpted three scales (educatin, ccupatin, and incme) each with six categries* t define a ttal f 216 pssible prfiles which were gruped int ten clusters r stratum, the characteristics f which are shwn in Table 2. The figures in the table indicate the average scre fr men in each particular stratum fr each f the three variables, the maximum pssible scre being 6 indicating that all men in the stratum had the highest value f the variable and the lwest, 1, being attained when all men in the stratum had the lwest pssible value. The strata are listed in rughly descending scial rank frm the highest t the lwest sci-ecnmic status. The labelling f the strata s defined is that f the authrs. The first stratum cnsists predminantly f males in the higher incme brackets wh wrk in prfessinal r managerial jbs and have undertaken higher educatin. Men in this stratum tended t be at the peak f their careers, with 41 per cent in their frties cmpared with nly 29 per cent fr the sample as a whle. Seventy per cent f all upper prfessinals (architects etc., natural scientists, university teachers, physicians, dentists, clergymen, judges etc., accuntants, pharmacists) and 10 per cent f managers were included with this grup. The secnd stratum is similar t the first in that it cnsists primarily f tertiary educated men (althugh few had cmpleted tertiary studies cmpared with Stratum 1), but in this case the members were drawn frm a wider range f ccupatins and earned significantly less (in part because they tended t be yunger). The next tw Strata (3 and 4) are termed ld middle class since they cntain ccupatins which require mre entrepreneurial skills rather than frmal educatin (nte the cmparatively lw ccupatinal scre). Nne f these men had had a tertiary educatin. Sme 20 per cent f the sample fell int these tw categries, including tw-thirds f graziers, ne-third f the managers, twfifths f shp prprietrs and tw-thirds f farmers. The tw strata cvered a wide range f rural and urban ccupatins characterized by relative independence in emplyment status and a cmparatively high incme: what distinguishes the tw Strata frm ne anther is the higher average earnings f men in Stratum 3 cmpared with Stratum 4. Strata 5 and 6 are much mre difficult t interpret. On average, men in Stratum 5 have higher status ccupatins than thse in Stratum 6 even thugh the latter tend t be better educated. Half f the men in Stratum 6 had freign brn fathers cmpared with 18 per cent in Stratum 5 and 10 per cent in the sample verall. Brm and Jnes cnsidered that the tw strata cnsisted f 35 Educatin was categrized as: Sme Primary, Cmpleted Primary, Sme Secndary, Cmpleted Secndary, Sme Tertiary, Cmpleted Tertiary. Occupatins were gruped accrding t: Unskilled, Semi-skilled, Skilled, Clerical, Managerial, and Prfessinal. Incme (annual) was classified accrding t the fllwing intervals: less than $1800, $1800-52599, $26OO-$3399, $34O0-$4199, $4200-54999, and $5000 and ver.

36 "marginal men" in the sense that their educatinal achievements had nt been matched by expected ccupatinal attainment and financial rewards. The demarcatin amng the remaining fur strata (7, 8, 9 and 10) tends t be less well defined than fr the higher status categries. The main difference between the tw pairs f strata (7, 8) and (9, 10) is largely the result f chrt effects in educatin. The s-called "middle mass" strata (7 and 8) tgether accunt fr abut ne-third f the sample. Rughly half f their members are skilled manual wrkers, with lwer white-cllar wrkers (ne-fifth) and less wellff farmers and managers making up the remainder. Males in Stratum 7 tend t be yunger than thse in Stratum 8 (48 and 36 per cent respectively were aged between 25 and 39 years). Twice as many men in Stratum 8 were aged 55 r lder cmpared with Stratum 7 which in part accunts fr the lwer average incme in this stratum. Als, men in Stratum 7 were better educated, reflecting the increasing age at leaving schl during the first half f the century; the lder men grew up when leaving schl after cmpleting primary educatin was the nrm whereas fr yunger men the nrm (and the law) was t leave schl after cmpleting sme secndary schling. The tw bttm strata (9 and 10) cnsist verwhelmingly f semi-skilled and unskilled wrkers. A principal difference between the tw is their age structure; 56 per cent f men in Stratum 9 were under 40 years f age cmpared with 31 per cent in Stratum 10. As a result, there are mre service wrkers and shp assistants in Stratum 9, ccupatins which tend t be held by thse just starting their wrking lives. Brm and Jnes have termed this "life-cycle effects". Interestingly, all men in Stratum 9 had had sme secndary educatin whereas nne f thse in Stratum 10 had prgressed beynd primary schl. Cnclusins Frm these studies, it is apparent that Australia, at least during the 1960s, was indeed a stratified sciety accrding t such variables as ccupatinal psitin, incme, and educatin. It is nt, hwever, a "class" sciety in the sense f largescale transmissin f scial and ecnmic inequalities frm generatin t generatin, nr, by internatinal standards, des it exhibit grss inequalities in incme distributin. Nnetheless, significant differences in life chances d exist and the challenge fr health authrities is t adequately assess the extent f, and mechanisms underlying, these inequalities s as t frmulate mre effective scial and health plicies t minimize their impact. In the Australian cntext at least, the use f ccupatin alne as an indicatr f scial class has nt prved terribly successful fr delineating gradients in mrtality. In a sciety where entrepreneurial skills abund, where mineral resurce develpments have prliferated, and where large-scale inmigratin has drastically altered the ecnmic and scial expectatins f many citizens,

pprtunities fr individual advancement with regard t such classificatry variables as educatin and incme are substantial and, as Brm and Jnes' study reveals, can be expected t exert a majr influence n sci-ecnmic standing. Occupatinal differentials in mrtality may therefre be expected t explain nly a part f the underlying differentials in health status in the ppulatin. Strategies designed t reduce and, if pssibile, t eliminate these inequalities must fcus mre n the health-behaviur f wrkers in thse ccupatins which appear t experience higher mrtality. Studies which seek t identify the variatins in life-style and use f health services amng ccupatin grups, and the attitudinal beliefs underlying such practices, are undubtedly f much greater relevance fr health plicy than the mere descriptin f ccupatinal differentials in mrtality. Finally, it is wrth mentining that a better understanding f the extent and causes f sci-ecnmic differentials in ill-health in the industrialized cuntries is likely t g a lng way twards accunting fr ther bserved differentials as well. The 6 t 8 year gap in life expectancy at birth between the sexes in many f these cuntries fr example may well be attributable t large sex differentials in lwer sci-ecnmic grups cmpared with the sex difference amng prfessinals and ther higher status ccupatins. Clearly, the mst apprpriate future curse fr the investigatin f inequalities in health must be a simultaneus research effrt acrss the several differentials in mrtality and mrbidity which exist in lw mrtality cuntries and which hinder the attainment f mre equitable life chances fr all. 37

38 Table 1. Scial grades in Australia shwing their cnstituent ccupatinal grups Scial Grade Occupatins (minr grups) I Architects, Draughtsmen and Surveyrs, Medical Practitiners, Dentists, Scientists, Prfessinal Engineers, Clergy and related, Teachers, Law Prfessinals, Ship and Aircraft Officers. II III IV Other Prfessinal medical wrkers and technicians. Nurses, Administrative, Executive, etc. (whle majr grup 1), Artists, etc., Other Prfessinal wrkers, Farmers and Farm Managers. Clerical, Sales wrkers, Timbercutters, etc., Fishermen, etc., Farm wrkers, etc. Miners and Quarrymen, Bus, Tram, etc. wrkers, Railway, etc., Deck-hands, etc., Other wrkers nt elsewhere indicated, Laburers. (Nte: Members f the Armed Frces are excluded frm the abve classificatin because daia in sufficient detail was nt available fr them). Surce: Dasvarma, 1980, p. 298.

39 Table 2. Characteristics f strata f wrking age males, Australia, 1965 Average status a Stratum Educatin Occupatin Incme 1. Upper middle class A 2. Upper middle class B 3. Old middle class A 4. Old middle class B 5. Marginal? A 6. Marginal? B 7. Middle mass A 8. Middle mass B 9, Wrking class A 10. Wrking class B 5.89 5.68 2.98 2.52 4.15 4.39 2.90 2.53 3.07 1.69 5.72 4.99 5.26 4.79 4.31 2.63 3.31 3.28 1.55 1.64 5.44 3.40 5.66 3.70 3.38 2.41 3.22 2.17 1.94 1.88 ' The average scres are calculated by giving a scre f six t the highest categry, five t the secnd highest and s n dwn t ne t the lwest. Surce: Brm and Jnes, p. 111.

40 COMMUNITY (OR MACRO) HEALTH DETERMINANTS e.g. Quality f envirnment, Scietal pressures, Cnsumptin patterns and their inculcación. Scial and ecnmic structure INDIVIDUAL (OR MICRO) HEALTH DETERMINANTS e.g. Marital status. Educatin, Incme, Degree f health Cnsciusness, Occupatin, INDIVIDUAL HEALTH BEHAVIOUR e.g Smking, Diet, PRECURSORS OF DISEASE/VIOLENCE Hypertensin, Abnrmal serum chlesterl distributin, MANIFEST ILL HEALTH e.g. Heart attack, Strke, Cancer (esp. f lung, breast, bvel prstate), Emphysema, Cirrhsis f liver, Driving under the influence (DUD, Suicidal behaviur DEATH Level f ecnmic develpment FIGURE 1 : Factrs influencing health status in industrialized cuntries* Adapted frm Pwles,(«1977, p. 47. a Impact thrugh preventive health services, including health educatin. b Impact thrugh therapeutic prcedures and medicatin. c Impact thrugh surgical interventin, intensive care, and ther curative measures. d Theretically, race r ethnicity shuld nly exert an impact n mrtality thrugh genetic endwment.

41 SMR 200 SMR SMR 190 1961 1965-67 150 1970-72 IV 100. III II III 100. I I II 50 0 50 0 50 0 FIGURE 2: Standardized Mrtality Ratis (all causes) by Scial Class, A ustralia, 1961, 1965-67, 1970-72 Surce: Dasvarma, I960, pp. 112-114.

42 References 1. These are reviewed in Lpez, Alan (1982) "Occupatinal and scial class differentials in mrtality in Australia: A Review", pp. 25-30 in UN/WHO/ CICRED, Sci-Ecnmic Differential Mrtality in Industrialized Scieties, Vl. 2, CICRED, Paris. 2. Encel, Sl. (1970), Equality and Authrity: A Study f Class, Status and Pwer in Australia, Cheshire Press, Melburne. 3. Taft, Rnald (1953), "The scial grading f ccupatins in Australia", British Jurnal f Scilgy, 4(2): 181-188. 4. Dasvarma, Guranga (1980), Differential Mrtality in Australia with Special Reference t the Perid 1970-72. Unpublished Ph.D. thesis, Department f Demgraphy, The Australian Natinal University, Canberra. 5. Brm, Lenard and Jnes, F. Lancaster (1976), Occupatin and Attainment in Australia, Australian Natinal University Press, Canberra. 6. Pwles, Jhn (1977), "Sci-ecnmic health determinants in wrking age males"; pp. 31-51 in Mark Diesendrf and Bryan Furnass (eds.), The Impact f Envirnment and Lifestyle n Human Health, Sciety fr Scial Respnsibility in Science (ACT), Canberra.

43 CLASSIFICATION OF SOCIO-ECONOMIC STATUS Sme remarks n the discussin in Nrway Lars B. KRISTOFERSEN Central Bureau f Statistics f Nrway 1. intrductin In Nrway we have n lng traditin, like in England and Wales, in classifying mrtality by sci-ecnmic status. In general, The Central Bureau f Statistics f Nrway has, fr the last fifty years, had very little f its ppulatin statistics published by categries f sci-ecnmic status. Data frm the censuses have fr instance mainly been published in tables by age, sex, main surce f livelihd, educatin, ccupatin, dwelling cnditins and regin. Until the late 1970s there has been made n serius effrt t categrize the Nrwegian ppulatin by sci-ecnmic grups in fficial statistics. 2. "The 1960 SES classificatin" and the criticism t it On the basis f the 1960 Ppulatin Census Kari Skrede at the Institute f Applied Scial Research (Osl) wrked ut a sci-ecnmic status gruping (Skrede 1971). This gruping was based n the classificatin f male ppulatin in the 1960-census. A factr-analysis f different census variables gave different scres fr men in different ccupatins, and ut f the scres fr each ccupatinal field (Nrdic classificatin f ccupatin 1965, clse t ISCO 1958, 2 digit level) she cnstructed fur sci-ecnmic grups. This classificatin (a bit mdified) was used as an additinal part in the Nte: The views expressed in this paper are thse f the authr and d nt necessarily reflect the pinins f the Central Bureau f Statistics f Nrway

44 Nrwegian ccupatinal mrtality analyses (Central Bureau f Statistics f Nrway 1976 and 1979). The gruping based n values fr men in the 1960-census has been much debated in the late 1970s. The gruping has been discussed bth methdlgically and empirically. The methdlgical discussin has tuched whether the gruping used indicatrs valid fr a sci-ecnmic descriptin. It has als been discussed whether it is mre relevant t see a sci-ecnmic gruping in a mre theretical perspective. Thse critics have argued that an empirically based sci-ecnmic gruping nly reflects the surface f peple's place in sciety. Other critics have argued that incme and educatin shuld have been taken mre int accunt, and that ccupatin shuld nt have been the deciding cmpnent fr tracing ne's place in the SES-hierarchy. Mst f the scial scientists have agreed that we are in need f a new sciecnmic gruping that can be used empirically in ppulatin statistics. 3. The theretical way f scial class gruping and its prblems The hardest criticism f the gruping wrked ut by Skrede has been put frward by the mre theretical-based university institutins. Sme researchers there have established ther mre theretical scial class categries. When empirical scilgists and scial statisticians lk upn these mdels fr the purpse f using them in ppulatin analyses, it is, hwever, ften difficult t state peratinal definitins frm the mre theretical categries. 4. The new Nrwegian sci-ecnmic classificatin (1983) In 1978 the Sci-demgraphic Research Unit in the Central Bureau f Statistics started the wrk n a new sci-ecnmic classificatin. First, an internal wrking paper was presented (Album 1979). The paper describes the fficial sci-ecnmic classificatin used in ther cuntries and classificatins used in special well knwn studies. Further, the paper is cnsidering theretical questins n varius ways f thinking abut sciecnmic classes, and it ulines pssible slutins fr a Nrwegian standard. "Difficult" grups, such as students, hmewrking persns and pensiners have been discussed separately in the paper. The use f individual/family as the unit in a sci-ecnmic classificatin has als been discussed. In 1983, the Nrwegian standard will be published in the series Standard fr Nrwegian Statistics (SNS). The sci-ecnmic standard has in its detailed versin 34 basic categries, but they can be aggregated int fewer categries. Five varius levels f aggregatin are suggested frm the CBS. The levels are mre r less graduated. In this SES-classificatin separatin is made between persns gainfully

emplyed (500 wrking hurs r mre last year), and persns nt gainfully ccupied. Fr gainfully emplyed the place in the hierarchy further depends n e.g. type f ccupatin (3. digit level), status as emplyed r independent wrking, whether the persn is in a labur grup r in white cllar ccupatinal grup, level f cmpetence and if the persn has a leading psitin. Fr persns nt gainfully emplyed, place in the hierarchy is defined n base f main type f activity (student, cnscript, huse wrk), status f lng time unemplyment, r type f scial insurance received. 45 5. Sci-ecnmic classificatin in Nrway and in the ther Nrdic cuntries n the basis f the Level f Living Surveys The Nrwegian sci-ecnmic standard has already been "tested" in the results frm the Survey f Level f Living 1980. A cmmn Nrdic classificatin, perhaps mst clse t the sci-ecnmic classificatin in Sweden, has been "tested" n the Danish, Finnish, Nrwegian and Swedish level f living surveys in an analysis published by the Nrdic Cuncil and the Nrdic Statistical Secretariat (1983). The Swedish Sci-ecnmic Classificatin (Statistics Sweden 1982) has in its detailed versin eighteen basic categries referring t the ecnmically active ppulatin. The nn-active ppulatin is brken dwn int six grups. The ecnmically active ppulatin has, in The cmparative Nrdic Study, been brken dwn t nine grups, and the nn-active ppulatin t five grups, as fllws (ppulatin 20-64 years in table 1). As seen frm table 1, Nrway had a much higher percentage f husewives (r male equivalents) with less than 10 hurs paid wrk during the week than any ther Nrdic cuntry in 1980. The percentage f manual wrkers (f the whle ppulatin 20-64 years) was smewhat lwer in Nrway than in the ther Nrdic cuntries. The percentage f salaried emplyees (f the ppulatin 20-64 years) was lwest in Finland (27 per cent), smewhat higher in Denmark and Nrway (31 per cent) and at the highest rate in Sweden (39 per cent). These measures are very much influenced by the type f classificatin used. Anther classificatin wuld quite certainly give a higher per cent age f manual wrkers in Nrway. 6. Age grups and scial grups t be taken specially care f with regard t sciecnmic classificatin in mrtality analyses A brief view n the Swedish and Nrwegian sci-ecnmic classificatins gives me the feeling that mst f the wrk until nw has been grunded n the classificatin n ecnmically active persns 20-64/67 years f age. (The usual

46 O. u 00ON ONfS OOOOVOOON <} N «VD I VO Cl C*J VI ei d <S Cl *O v v VI ON ' O -" «t ON ON r- *O f i Cl VO Cl * «J" r- es CT>r fn«t 3 r~ «S ON CI O ON «S Ci (S ci v r- 8 c Z.c c 13. rs «r i «m «t ci i es CO a ni es ONCifS OOw-i O<N t^ 00 00 ri (S f*l -H VO i t t*~ ON ^^ cn v~t es < fs) ci r^ * t «~* es ON * ci ON * ci r^ "H es ~^ ' ci ^^ ci ^^ ^? es ci " <N*Qt* K-iOOVOOON mtsv ci<s -t^ O -^ino"-^ ^^«n ^ ON N i O C O Z a" 2 ~c E ~ fs NO > ON ts «00 «* * ON «ON ci «Ss «S I X r=3 O D. Z < c Q c C DU M 'S C3 3 d> V) O U 3 D. O eb u O i ó g u M O "8 ï % 111 iil 11 c a ci < S- ' a E M 3 J2 C «E.2 3 U U C 0 5 u 'es Q 1 * *,2 c 3.y h s '- C Xñ O C O <L> UJ Cu 7â II cd > 1 i 8ÊE '5.1 g 1 Ü S -J en S S5E a S ï.2 a v 3 C O O 12 11 ill il u O

age fr ld pensin is 65 in Sweden and 67 in Nrway). This limitatin will be cnvenient fr cmparing ccupatinal mrtality with the mrtality pattern f varius sci-ecnmic grups. But I feel that a mre prblematic discussin starts when we shall divide the ecnmically nn-active ppulatin by sci-ecnmic grups. Shuld they be placed accrding t their present status as e.g. ld age pensiners accrding t their age in 1976-1980, as e.g. disability pensiners, reprted in the 1970-census, r by their status as e.g. skilled factry wrker in the 1960-census? I feel we have t make varius mrtality analyses fr parts f the nn-active ppulatin depending n what type f histric data are available n the individual level. (This shuld f curse als be dne with respect t change f ccupatin in the active ppulatin frm ne census year t anther. This has partly been dne in Nrway already. I feel, hwever, that change in sci-ecnmic status ften is mre substantial fr peple changing frm an ecnmically active t an ecnmically nn-active psitin). As a first step the nn-active ppulatin shuld f curse be analysed accrding t the sci-ecnmic psitin in the last census (e.g. student, ld-age pensiner, hme-wrking, cnscript). Pensiners Old-age pensiners and disability pensiners ught t be analysed als accrding t their ccupatin, if any, in an earlier census and t the crrespnding sci-ecnmic grup (in cuntries having persnal identificatin number and census files where persns can be traced frm ne census t anther). I think this shuld be essential in ccupatinal mrtality studies because f the existence f lng time expsure in many wrking places befre the manifestatin f illness and mrtality frm e.g. cancer and heart diseases. Spuses If wn ccupatin is nt fund, neither in the last nr in the earlier census(es), a pensiner r ther nn-active adult may be classified in the sci-ecnmic grup accrding t his/her spuse, if any, and analysed accrding t this "brrwed" psitin. Children and yuth In Nrway peple 16 years and mre are gruped by main surce f living and wn ccupatin, if any. In the planned Nrwegian ccupatinal mrtality analysis 1970-1980 we will classify peple 16-19 years (and f curse 20 years f mre) by wn sci-ecnmic psitin. There is f curse a prblem cnnected with classifying peple 16-19 years by wn psitin, because a very high number in this age grup is engaged in educatin, and is living (r registered) tgether with their parents. Their sci-ecnmic status is in reality still the same as that 47

48 f their parents. Anther prblem with this age grup is that during a ten year fllw-up (1970-1980) persns enter int an wn psitin n which we have n data (befre the linkage f the census recrds 1970 and 1980 is finished). Children 0-15 years in the 1970-census and children brn in the perid between the 1970- and the 1980-census (if they are t be included) will be classified in the same sci-ecnmic grup as ne f their parents. Children 0-15 years will presumably be placed in the same sci-ecnmic grup as the "head persn" in the husehld in the 1970-census. (Head persn is generally the father. If the child lived tgether nly with the mther, she wuld be "head persn"). Children brn between the 1970- and the 1980-census will (if included int the prject) be assigned t the same sci-ecnmic grup as that f the mther in the 1970-census. 7. Why are we using sci-ecnmic grups as an imprtant variable in mrtality analyses? The traditinal ccupatinal medicine and medical epidemilgy was perhaps the imprtant "trigger" fr ccupatinal mrtality analyses mre than a hundred years ag. This traditin has in Great Britain been fllwed up, and has partly been summarized in Fx and Gldblatt (1982). In Great Britain the scial statisticians early develped a five-gradient sciecnmic classificatin, using ccupatin as the basic determinant. It is interesting that William Farr wrked ut his detailed descriptins f hw t classify ccupatins, sci-ecnmic grups, and évidents imprtant t vital statistics lng befre Karl Marx (1867-) and Max Weber (1922) began their theretical wrk n scial classes and scial stratificatin. The theries f Marx and Weber have later n been built upn and quted by hundreds f scial scientists int the mre mdern scial class thery f amng thers C. Wright Mills (1956), Rbert K. Mertn (1957), Ralph Dahrendrf (1959), Stanislaw Osswski (1963) and Nics Pulantzas (1974). Scandinavian scial scientists have given cntributin t the literature in e.g. Svalastga (1959), Allardt and Littunen (1962), Kleven (1965) Zetterberg (1966), Allardt (1967), Therbrn (1971), Aubert (1975), Alldén (1981), Clbjrnsen, Hernes and Knudsen (1982). Detailed descriptin f type f wrk and the place f a persn in the ccupatinal hierarchy has nt been imprtant in itself in scilgical research n scial classes and scial stratificatin. The field f labur is the central "arena" in theries n classes and stratificatin mainly because this is the arena where use f pwer, scial hierarchies and central ecnmic distributins are mst visible. In the functinalist theries f stratificatin the divisin f labur and thereby differences in achieved scial status are cnsidered meaningful and necessary in a scial system that struggles t be in balance r in scial integratin.

The labur and making f values are als central in the marxist and newmarxian theries n classes and class cnflicts, but there frm anther perspective: The wrking classes are suppressed and the value frm their labur is explited. The sciety is underging scial change thrugh class cnflicts and the class struggle. Frm the view-pint f medical epidemilgy the "pure" ccupatinal mrtality analyses may be interesting. Hwever, frm a scilgical pint f view it is perhaps mre interesting t have mrtality analyses by sci-ecnmic classificatin, and thus include the nn-active ppulatin. We cannt trace medical r ccupatinal causes f high mrtality thrugh sci-ecnmic grup analyses. Hwever, such analyses demnstrate hw lifechances and medical causes f death are distributed thrugh a scial hierarchy that includes all members f a sciety. Thus scial scientists may incrprate lifechances and causes f death in ther analyses f sci-ecnmic classes. This will be necessary if cmparisns f the distributin f incme, wealth, educatin, pwer and life-chances fr the whle ppulatin are t be undertaken. Since I feel that sci-ecnmic mrtality analyses still are in the early stages in Nrway, we may necessarily cntinue studies n ccupatinal mrtality. It will be imprtant fr scial scientists t keep themselves infrmed abut mrtality analyses n sex, age, medical causes, marital status and gegraphic regin. Until nw I have felt that the results frm the Nrdic ccupatinal mrtality analyses in the 1970s (Haldrsen and Glattre 1976 (Nrway), Lynge 1979 (Denmark), Kristfersen 1979 (Nrway), Sauli 1979 (Finland)) are unfamiliar fr many pliticians and scial scientists in Nrway (and in ther Nrdic cuntries t?). The Nrwegian analyses were in a sci-medical seminar in Nrway January 1983 stated as "nt detailed enugh t trace causative factrs in ccupatinal medicine". I feel that results frm the Nrwegian ccupatinal mrtality analyses have been mst asked fr by the trade unins. This is all very well, but at the same time it is a pity that the results are little knwn amng pliticians, scial scientists and "nt gd enugh" fr sme medical researchers. This situatin is ne f the reasns why I feel that the right way fr Nrway t g nw (and perhaps fr ther Nrdic cuntries?), shuld be t widen the scpe a bit further, frm the strictly ccupatinal mrtality apprach, and direct it twards the sciecnmic epidemilgy apprach and the scial indicatr apprach. This was clearly suggested by Tapani Valknen in the Nrdic Demgraphic Sympsium 1979 (Valknen 1979). Thus the frthcming analyses may be mre useful in the applied scial research and may be a better basis fr plicy making in the field f scial and health plitics. 49

50 References Album, D. (1979): Ssitfknmisk gruppering. Wrking paper. Central Bureau f Statistics, Osl Allardt, E. and Y. Littunen (1962): Scilgi. Uppsala Allardt, E. (1967): Knflikt ch knsensusteretiker. In Asplund, J. (ed): Scilgiska terier. Stckhlm Alldén, L. (1981): Det nrske klassesamfunnet. Kntrast nr. 1-2, Osl Arbeidsdirektratet (1965): Nrdisk yrkesklassifisering. (Nrdic classificatin f ccupatin). Osl Aubert, V. (1975): Ssiale klasser g lag. In Ramsey, N.R. & Vaa, M (ed): Det nrske samfunn. Osl Central Bureau f Statistics (under publicatin 1983): Standard fr inndeling etter ssiicnmisk status, Standard Classificatin f Sci-Ecnmic Status, Standard fr Nrwegian Statistics, n. 2, Osl/Kngsvinger Clbjrnsen, T., Hernes, G., Knudsen, K, (1982): Klassestruktur g klasseskiller. Bergen-Osl-Trms Dahrendrf, R. (1959): Class and Class Cnflict in Industrial Sciety. Lndn Fx, A.J. and P.O. Gldblatt (1982): Lngitudinal Study. Scial Demgraphic Mrtality Differentials. Lndn Haldrsen, T. and Glattre, E. (1976): Yrke g dddelighet 1970-1973 (Occupatinal Mrtality). Central Bureau f Statistics, Osl Kleven, H.I. (1975): Klassestrukturen i det nrske samfunnet. Osl Kristfersen, L. (1979): Yrke g dp'delighet (Occupatinal Mrtality). Central Bureau f Statistics, Osl Lynge, E. (1979): DySdelighet g erhverv 1970-1975. Denmark Statistics. Cpenhagen Marx, K. (1867-): Das Kapital (A shrt editin in Nrwegian is published in Osl 1971) Mertn, R.K. (1957): Scial Thery and Scial Structure. Illinis Mills, C.W. (1956): The Pwer Elite. New Yrk Nrdic Cuncil and The Nrdic Statistical Secretariat (1983): Levnadsniva ch Ojämlikhet i nrden. En kmparativ analys av de nrdiska levnadsnivaundersökningarna. Cpenhagen - Stckhlm Osswski, S. (1963): Class Structure in the Scial Cnsciusness. Lndn O

Pulantzas, N. (1974): Den mderna kapitalismens klasstruktur. Stckhlm. (Swedish editin (1977) f: Les classes sciales dans le capitalisme aujurd'hui. Paris 1974) Sauli, H. (1979): Occupatinal mrtality in 1971-1975. Central Statistical Office f Finland. Helsinki Skrede, K. (1971): Ssidknmisk klassifisering av yrker i Nrge, 1960. INASrapprt 71/1. Osl Statistics Sweden (1982): Swedish sciecnmic classificatin. Reprts n Statistical C-rdinatin, 1982:4. Stckhlm Therbrn, G. (1971): Klasser ch eknmiska system. Stckhlm Valknen, T. (1979): Cmment. Sessin II Occupatinal mrtality. Pages 143-150 in Scandinavian Ppulatin Studies. The Fifth Demgraphic Sympsium, June 1979, Nrway. The Scandinavian Demgraphic Sciety, Osl Weber, M. (1922): Wirtschaft und Gesellschaft (Parts f it in the American Editin: The Thery f Scial and Ecnmic Organizatin. New Yrk, 1964) 51

53 SOCIO-ECONOMIC CLASSIFICATION IN SWEDISH STATISTICS Rbert ERIKSON Department f Scilgy University f Stckhlm Sweden Occupatin has since lng been recrded in varius branches f Swedish statistics. The infrmatin thus gathered has been cded and gruped in several ways. We will here cnsider sme f these classificatins with special reference t the pssibilities f studying sci-ecnmic mrtality differentials. Scial grups Fr the general electin 1911, a system f ccupatinal classificatin was cnstructed, t be used in the statistical accunt and analysis f the electin utcme. The ppulatin was, in this system, separated int three main "scial grups", which at that time were called "the upper class", "the middle class" and "the manual wrkers class". The three majr grups were, respectively, separated int varius ccupatinal grups. Emplyers and thse that wrk n their wn accunt were distinguished frm emplyees, farmers frm ther selfemplyed, publicly emplyed frm privately emplyed and fremen frm ther emplyees. This system was subsequently used in electin statistics, but als in many ther studies where a distinctin int scial class was needed. This classificatin system was cnstructed withut guidance frm any thery f sciety. It seems mainly t have been based n the cnceptin f the Swedish scial structure f the civil servants that cnstructed it. The clsest theretical cunterpart t the categries delimited, is prbably Weber's "status grups", as cding persnnel had t cnsider that "the main emphasis shuld nt always lie n the individual's psitin in his ccupatin, but rather t put him in the scial layer he can be assumed t belng t".

54 Table 1. Sweden's ppulatin in ages 15-75 (1968) distributed by scial and ccupatinal grups. Mrtality ratis (SMR) standardized fr age and sex fr the deaths in the 1968-1978 perid Percent f SMR ppulatin 1968-1978 Senir executive, large entrepreneurs, free prfessins 2.0 1.20 Senir civil servants and prfessinals in public service Husewives withut emplyment University students Pensiners withut emplyment Scial grup I Farmers and farming wives Small entrepreneurs with wives wrking in the firm Fremen in private sectr Technical and clerical persnnel in private sectr Salaried emplyees in public sectr Husewives withut emplyment High schl students Pensiners withut emplyment Scial grup II Smallhlders, wrkers in fishing, frestry and agriculture Metal wrkers Wrkers in ther industrial branches Cnstructin wrkers All wrkers in manufacturing Cmmerce, htels, rest. Other private service All private service wrkers Wrkers emplyed by lcal gvernments Wrkers emplyed by the state All publicly emplyed wrkers Disabled Husewives withut emplyment Other students and pupils Pensiners withut emplyment Scial grup III Ttal Number f cases * Significant deviance n 5 per cent level 1.9 1.4 1.2 0.6 7.2 3.0 4.7 2.3 8.1 6.3 5.5 2.8 2.6 35.2 3.7 6.1 6.7 3.7 16.5 3.6 4.2 7.8 5.0 2.5 7.5 1.5 9.5 4.1 6.9 51.5 100.0 5.922 0.66 1.00 0.90 0.94 0.79 1.04 0.79 0.71 0.54* 0.78 0.99 0.85* 0.70 1.13 0.74 0.73 0.86 1.25 1.16 1.20 0.69 0.82 0.73 2.12* 1.07 0.46 1.13* 1.09 0.97

The divisin f scial grups became s well knwn that many Swedes, when asked abut their psitin in the scial structure, answer in terms f scial grups (Scase 1976). When the classificatin has been used in varius surveys, it has prduced rather clear distinctins in terms f incme, educatin, interests and activities. By the end f the 1950s, the Central Bureau f Statistics finished t use the classificatin f scial grups, partly because f the unclear criteria fr classifying ccupatins. It was, hwever, used in many ther cntexts, fr sme additinal ten t twenty years, but is nwadays mre and mre cming ut f use. One f the, perhaps, last majr studies in which this classificatin was used, is the level f living survey cnducted in 1968, 1974 and 1981. The surveys are based n a randm sample f abut 6 000 persns aged 15-75. Frm the survey 1968, we can give data abut the Swedish ppulatin's distributin ver scial and ccupatinal grups. Sci-ecnmic gruping, SEI In the years after Wrld War II the Central Bureau f Statistics gt critique f varius kinds fr its use f the classificatin in scial grups. This critique was ne f the reasns fr taking the classificatin ut f practice. But the bureau then lacked any sci-ecnmic classificatin (except fr ne used in the censuses, t which we will return sn) and was heavily criticized fr this as well. T make a new classificatin a wrk grup was set up. It suggested a classificatin in the early 1970s (Carlssn et. al. 1974). This classificatin was used prvisinally fr several years and in 1982 a mdified versin f it was decided upn as the sci-ecnmic classificatin t use in Swedish statistics fr the years t cme (SCB 1982). In this classificatin several distinctins are made t frm the categries in it. Thse that wrk n their wn accunt are distinguished frm emplyees. Amng emplyees manual wrkers are separated frm ther emplyed n the grund f whether thse wrking in the ccupatin nrmally are rganized within in the blue cllar trade unin cnfederatin r nt. Bth white and blue cllar emplyees are separated after skill level. Blue cllar wrkers are als separated int thse that wrk with gds prductin and thse that wrk with service prductin. Amng white cllar emplyees thse with supervising tasks are put in separate categries. Amng self-emplyed, farmers are distinguished frm thers. Bth farmers and ther self-emplyed are separated int different grups depending upn the size f the enterprise. Students are put in ne f three different grups, which ne depends upn educatinal level. The categries thus frmed are assumed t cntain ccupatins where the incumbents are in similar wrk and market situatins (Lckwd 1966:15, 55

56 Table 2. Sci-ecnmic grups fr gainfully emplyed used in the Swedish census f 1980. Sci-ecnmic grups 11-22 MANUAL WORKERS 11 Unskilled emplyees in gds prductin 12 Unskilled emplyees in service prductin 21 Skilled emplyees in gds prductin 22 Skilled emplyees in service prductin 33-57 NON-MANUAL EMPLOYEES 33 Assistant nn-manual emplyees, lwer level 36 Assistant nn-manual emplyees, higher level 46 Intermediate nn-manual emplyees 56 Prfessinals and ther higher nn-manual emplyees 57 Upper-level executives 60-89 SELF-EMPLOYED 60 Self-emplyed prfessinals 79 Other self-emplyed 89 Farmers Delineatins Occupatins nrmally rganized by LO (the blue-cllar trade unin cnfederatin). Occupatins invlving the prductin f gds and nrmally requiring less than tw years f pst-cmprehensive schl educatin Occupatins invlving service prductin and nrmally requiring less than tw years f pst-cmprehensive schl educatin Occupatins invlving the prductin f gds and nrmally requiring tw years r mre f pst-cmprehensive schl educatin Occupatins invlving service prductin and nrmally requiring tw years r mre f pst-cmprehensive schl educatin Occupatins nrmally rganized by tradeunins nt affiliated t LO Occupatins nrmally requiring less than tw years f pst-cmprehensive schl educatin Occupatins nrmally requiring tw, but nt three, years f pst-cmprehensive schl educatin Occupatins nrmally requiring three, but nt six, years f pst-cmprehensive schl educatin Occupatins nrmally requiring at least six years f pst-cmprehensive schl educatin Upper-level executives in private enterprises r rganizatins with at least 100 emplyees r upper-level executives in public service Self-emplyed persns in ccupatins nrmally requiring at least six years f pstcmprehensive schl educatin Self-emplyed nt including farmers r prfessinals

Gldthrpe 1980:39). By this, the classificatin ught t be suitable fr the study f life chances and differential behaviur. It culd als wrk as a general indicatr f variatins in the immediate envirnment. A versin f this classificatin is used t cde the ccupatins f the gainfully emplyed in the census f 1980. In table 2 the categries f this versin are listed (the distributin f individuals ver the categries is nt yet available). The classificatin system is used in its mre elabrate frms in surveys, where much infrmatin can be cllected. In such cases it is als pssible t classify persns utside the labur frce. Apart frm students, the tw main categries f peple utside the wrk frce are husewives and retired persns. They are put int sci-ecnmic categries n the basis f the husband's ccupatin and the previus ccupatin respectively. 57 Classificatins used in the censuses since 1960 In the census f 1960, infrmatin n ccupatin was cllected frm all gainfully emplyed. It was cded in a three digit cde, (NYK = Nrdic ccupatinal classificatin), which was clsely related t the Internatinal Standard Classificatin f Occupatin (ISCO), published by ILO 1958. The same classificatin with minr alternatins was used in the censuses f 1965 and 1970. ISCO was revised in 1968 and the ccupatinal classificatin used in the Swedish census was likewise revised t the census in 1975. The altered classificatin is, hwever, rather clsely resembling the earlier ne. A classificatin int five statuses was als dne 1960 and 1965. The categries were self-emplyed, emplyers, blue-cllar wrkers, white-cllar emplyees and family wrkers. This classificatin was als used in the censuses f 1970 and 1975 althugh the distinctin between blue-cllar and white-cllar emplyees was nt made these years. In 1975 the self-emplyed were neither separated int thse with r withut emplyees. The classificatin was nt used at all in 1980. By cmbining the ccupatinal and the status classificatins the gainfully emplyed ppulatin and their family members were cded int what was called sci-ecnmic grupings, ten in all: Self-emplyed in agriculture etc Emplyed in agriculture etc Self-emplyed in manufacturing, cmmerce, transprt, and service ccupatins Self-emplyed prfessinals Managers Emplyed in technical, cultural, ffice and cmmercial ccupatins Emplyed in manufacturing and transprt Emplyed in service ccupatins Military persnnel Unclassifiable

58 The categries in this classificatin were, hwever, generally regarded as rather hetergeneus and the classificatin was nly used t a very limited extent. It has, hwever, been reprted in the censuses f 1960 t 1970. In Nrway an attempt has been made t frm a sci-ecnmic classificatin by merging categries in the NYK (Statistisk Sentralbyra 1983). Andersn (1983) has crss-tabulated the utcme f this merging with SEI-cdings n Swedish survey data. Table 3 shws hw emplyed persns in the merged NYK-categries are distributed ver what is suppsed t be crrespnding sci-ecnmic (SEI-) categries. We find that thse that are cded as manual wrkers in the NYK cde practically all are cded likewise in SEI. The distinctin between skilled and unskilled wrkers is rather blurred, hwever. A majrity f thse that are cded in the tw lwest nn-manual categries in NYK are cded as manual wrkers in SEI. There is als a cnsiderable verlap between the different nn-manual categries. The cnclusin must evidently be that the NYK-categries are rather hetergeneus in sci-ecnmic terms, at least when SEI is used as the criterin. Occupatinal classificatins and mrtality data Only recently has infrmatin abut ccupatins been matched t mrtality data. The censuses f 1960 and 1970 have been matched t the registers ver the causes f all deaths in the fllwing ten years. S far nly data frm the 1960 census have been published (SCB 1981). N sci-ecnmic cde has been used in the analyses f variatins in mrtality rates. The ccupatinal cde used is a tw-digit versin f the previusly mentined ISCO-related classificatin. The level f living surveys have als been matched t the causes f death register. The surveys are based n a randm sample f abut 6 000 persns s pssibilities fr analysis are limited because f size restrictins. On the ther hand is it pssible t relate mrtality risks t a vast mass f infrmatin abut living cnditins, nt accessible in the censuses. Standard mrtality ratis fr the scial and ccupatinal grups are given in table 1. The ccupatins f the respndents in the level f living survey cnducted in 1968 were cded accrding t an earlier versin f the sci-ecnmic classificatin (SEI). In table 4 SMR's fr the years 1969 t 1978 fr these grups are given bth fr gainfully emplyed and fr thers i.e. mainly husewives and retired persns.

59 60 '. 60 E2 00 *O fo ^^ O\ <O O\ t** Cl ^O ^D C*J fí ^D 00 fo 88888888 O 60 O si cu M >í v s 2 i i isr» i <s r- is Tf I fs TJ- Tf c3 Ü * s c ë rt i i C - - 2 «2 ^ i r^* r^ r** O u 'S OO * CI O -" - N O Z "8 00 -* t~ CN n 60 4> c3 O ged -64 s"8 I- 60 W O (3 1) ;>> VO mply W I cu Í2

60 c 1. u 's g 00 2 S S garni iply S >NTJ r- «s -H r- v «O t m m «s 00 v 00 00 <1- i O\ ON G i 5 c '5 Ü >> ". UI3 r- mo «s v O VO O <s 00 r» H O O\ ««d CN VO vq d t- c \ q N ri d d «d H 00 «2 T3 CCS O 00 cd Ut «2 "SN 't es 13 Ces C ill 3 C >N 13 3 >» «S a "S 5» O N 00 O ON ON 00 00 dd d es «N O in n r- r~ 00 n f-> cs es O O O -H -H O -* 00 d «3 r-_ q d ' 00 d tí m is ent es 11 rtal s O C O Ë "5. u! 3 C 'ês 60 T3 es ^ sï -a 1> S ri es > es : u 3 " P c c _ es u es a> O c - - îs ^ S J= a.2 S -S -a S S ^ =!2 'S!2 C r; -v «c un p DMM< g< g c s '-S 5 S sî es 13 u 8.2 g! a «> S g S E c «O <L> C i^ a 4> flj *-" Wî rr ut g- E "

61 References Anderssn, Lars-Gunnar: 1983 "Jämförelse av nrska ch svenska scieknmiska indelningarna", mime, Statistics Sweden Carlssn, Gösta, Eriksn, Rbert, Löfwall, Christina and Wärneryd, B: 1974 "Sci-eknmiska grupperingar", Statistik Tidskrift Gldthrpe, Jhn H.: 1980 Scial Mbility and Class Structure in Mdern Britain, Oxfrd: Oxfrd University Press Jhanssn, Sten: 1973 "The Level f Living Survey: A Presentatin", Acta Scilógica Lckwd, David: 1966 The Blackcated Wrker, Lndn: Unwin University bks (1958) Scase, Richard: 1976 "Hur industriarbetare i Sverige ch England ser pa makten i samhället", Scilgisk Frskning Statistics Sweden: 1981 Dödsfallsregister 1961-1970, Stckhlm 1982 Scieknmisk Indelning, Stckhlm Statistisk Sentralbyra: 1983 Standard för inndelning etter sciöknmisk status, Osl

SOCIO-ECONOMIC CLASSIFICATIONS USED IN FINNISH MORTALITY STUDIES 63 Tapani VALKONEN Department f Scilgy, University f Helsinki, Finland This cntributin is a selectin f tables frm Finnish mrtality studies. The tables shw what kind f sci-ecnmic variables and classificatins have been used in Finland. All tables are based n death recrds fr the perid 1971-75 which were linked with the 1970 census recrds by the Central Statistical Office f Finland. Scial grups (Table 1) are frmed n the grunds f ccupatin and educatin. Ecnmically active and frmerly ecnmically active persns are classified by present r frmer ccupatin, and ecnmically dependent persns (husewives, children etc.) by their supprter. Upper white cllar wrkers include higher administrative r clerical emplyees, emplyees cmparable with them, and persns with academic degrees. Lwer white cllar wrkers include lwer administrative r clerical emplyees and emplyees cmparable t them. Students (467 men and 496 wmen) have been classified int the lwer white cllar grup in the study frm which Table 1 is taken. Persns f unknwn scial grup (6,624 men r 0.9% f the male ppulatin, and 45,869 wmen r 4.5% f the female ppulatin) have been included in the unskilled grup.

64 Table 1. Mrtality 1971-75 by scial grup in Finland: Standardized mrtality ratis fr men and wmen aged 35-64 at the census f 1970 Scial grup SMR Deaths SMR Deaths Upper white cllar wrkers Lwer white cllar wrkers Skilled wrkers Unskilled wrkers Farmers All 69 90 105 135 88 100 2,624 7,926 18,981 10,639 11,662 51,791 81 93 102 119 92 100 1,216 4,717 6,926 6,107 5,522 100 Surce: Tapani Valknen: Sciecnmic mrtality differentials in Finland. Department f Scilgy, University f Helsinki, Wrking Paper N: 28, 1982. Occupatin (Table 2) means the activity r wrk a persn undertakes t receive incme irrespective f his field f activity, ccupatinal status r level f educatin. In ccupatinal classificatin the principle is t cmbine similar activities irrespective f the perfrmer f a jb, his educatin, ccupatinal status r psitin r field f activity. In the census an ccupatin is recrded nly fr persns wh are ecnmically active, cnscripts (mst recent ccupatin) r unemplyed (mst recent ccupatin) during the time perid f the survey. Occupatins are classified n the basis f the Nrdic Classificatin f Occupatins f 1964. Nine main grups f ccupatins are distinguished in Table 2. Results with a mre detailed ccupatinal classificatin (63 ccupatinal grups) have been presented by Sauli in Occupatinal mrtality in 1971-75, Central Statistical Office f Finland, Study N. 54, 1969. Table 2. Age-standardised mrtality (direct standardizatin) by ccupatin in 1971-1975. Persns aged 35-64 Occupatin S M MF Deaths W S MF en Deaths Ecnmically active Technical, physical science, scial science, humanistic and artistic wrk Administrative, managerial and clerical wrk Sales wrk Agriculture, frestry, fishing Mining and quarrying Transprt and cmmunicatin Manufacturing wrk, etc. Services Ecnmically nn-active 100 76 84 108 97 132 99 109 107 340 28,789 1,933 1,460 1,443 8,223 214 2,613 11,521 1,248 15,097 100 88 109 101 90 100 101 111 189 Surce: Statistical Reprt VA 1979:3. The Central Statistical Office f Finland. 1979. 7,223 755 850 671 1,644 238 1,293 1,740 12,176

The classificatin f sci-ecnmic status (Table 3) is based n infrmatin n main activity, ccupatin, ccupatinal psitin and industry. Family members are classified with the supprter f the family. The classificatin f the level f educatin (Table 4) is based n the institutinal structure f the Finnish educatinal system. Ambigius cases are classified accrding t the length f educatin. 65 Table 3. Age standardised mrtality (direct standardizatin) by sci-ecnmic status in 1971-1975. Persns aged 30-69 Sci-ecnmic status SMF Deaths SMF Deaths Emplyers Farmers n wn accunt Other wn-accunt wrkers Managers and higher administrative r clerical emplyees Lwer administrative r clerical emplyees Skilled r specialized wrkers Laburers Pensiners and ther ecnmically inactive independent persns All 78 70 84 53 61 73 94 237 100 1,876, 8,160 1,936 2,069 3,785 14,046 3,462 27,638 64,780 77 66 79 58 61 67 69 200 100 739 3,080 654 766 2,824 3,689 1,397 18,473 32,122 Surce: Statistical Reprt VÄ 1979:3. The Central Statistical Office f Finland. 1979. Sme ther scidemgraphic classificatins have als been used in Finnish studies. Fr example, the article Psychscial Stress and Scidemgraphic Differentials in Mrtality frm Ischaemic Heart Disease in Finland (Acta Med. Scand. (Suppl.) 660, 1982) by Tapani Valknen includes results n mrtality by regin, marital status, language grup and rural-urban divisin. Data n husing are nt available in the linked data files cmpiled by the Central Statistical Office.

66 Table 4. Age-standardised mrtality (direct standardizatin) by level f educatin in 1971-1975. Persns aged 30-69 T i r j Men., Wmen _, Level f educatin _. Deaths., Deaths SMF SMF Lwer level f basic educatin and unknwn (flk schl r less, 0-8 years) 109 54,255 107 26,287 Upper level f basic educatin and lwer level f secndary educatin (e.g. junir secndary schl r cmprehensive schl, vcatinal schl, abut 9-11 years) 79 5,714 79 4,118 Upper level f secndary educatin (e.g. matriculatin examinatin, technical schl, abut 12 years) 77 2,600 77 801 Higher educatin (examinatins at institutes and universisties, at least 13 years) 61 2,211 72 916 All 100 64,780 100 32,122 Surce: Statistical Reprt VÄ 1979:3. The Central Statistical Office f Finland. 1979.

67 SECTION II CENSUS - BASED PROSPECTIVE STUDIES La mrtalité seln le milieu scial en France (Guy DESPLANQUES) Census-based prspective studies in Nrway (Lars B. KRISTOFERSEN) Essai de cnfrntatin de quelques études prspectives de mrtalité (Guy DESPLANQUES)

69 LA MORTALITÉ SELON LE MILIEU SOCIAL EN FRANCE Guy DESPLANQUES Institut Natinal de la Statistique et des Etudes Ecnmiques, Paris, France Dans les sciétés industrialisées, la mrtalité masculine est beaucup plus élevée que la mrtalité féminine: en 1980, en France, l'espérance de vie à la naissance des femmes excède de 8 années celle des hmmes. Un tel écart s'explique certainement davantage par les cnditins de vie, les mdes de cnsmmatin que par une résistance supérieure de l'rganisme de la femme. Les différences de mrtalité entre des pays qui nt un dévelppement écnmique visin u, dans un même pays, entre des prvinces u des régins, cnfirment cette influence des mdes de vie. Une étude de l'insee, dnt les derniers résultats publiés prtent sur la péride 1955-1971, a dnné alrs la mesure de l'inégalité devant la mrt en fnctin du milieu scial: l'écart entre les maneuvres et les instituteurs u les cadres supérieurs était plus imprtant que celui qui séparait les hmmes des femmes. Au curs des 25 dernières années, des prgrès écnmiques imprtants nt été réalisés; dans différents dmaines, les différences sciales se snt amenuisées: l'échelle des revenus s'est légèrement réduite; sur un plan matériel, les catégries défavrisées nt accédé à des équipements que d'autres pssédaient auparavant: l'autmbile, la télévisin, la machine à laver. On peut se demander si l'inégalité devant la mrt a cnnu une évlutin analgue. D'autre part, les cnditins de vie snt lin de s'expliquer entièrement par la prfessin et la catégrie sci-prfessinnelle, telle qu'elle est définie en France. Elles snt liées aussi à bien d'autres facteurs: le lieu de résidence, les cnditins de lgement, la situatin matrimniale u familiale. Si les statistiques habituelles mettent bien en évidence les différences gégraphiques de mrtalité, elles ne disent que peu de chse sur l'influence des autres caractéristiques. Pur ces raisns, l'insee a entrepris une nuvelle étude à partir du recensement de 1975: un échantilln d'envirn 1 millin d'individus, hmmes et

70 femmes, âgés de 30 à 64 ans a été tiré de ce recensement. Les pages qui suivent apprtent les premiers résultats de cette étude: elles prtent sur la mrtalité de Français nés en France, au curs de la péride 1975-1980. La première partie s'attache à la mrtalité masculine des actifs suivant la catégrie sciale. Est ensuite analysée la mrtalité des hmmes inactifs: chômeurs, inactifs nn retraités, retraités. L'inactivité des femmes a une significatin très différente de celle des hmmes: leur mrtalité a dnc été étudiée un peu différemment. La suite de l'article cherche à décrire l'influence de 2 facteurs sans lien direct avec l'activité: le niveau de frmatin et la situatin familiale et matrimniale. La fin de l'article, revenant aux différences de mrtalité suivant la catégrie sciale, cherche à mesurer l'évlutin des écarts, ceux-si se snt plutôt amplifiés en une vingtaine d'années. La mrtalité masculine suivant le milieu scial Sur l'ensemble de la péride 1975-1980, parmi les hmmes actifs, c'est le grupe des cadres supérieurs et prfessins libérales qui cnnaît la mrtalité la plus basse entre 35 et 60 ans. Les instituteurs avaient acquis la réputatin de détenir la plus grande lngévité: au curs de la péride 1955-1971, les hmmes qui exerçaient ce métier en 1954 précédaient ceux qui étaient cadres supérieurs. 20 ans plus tard, cette situatin a dnc un peu changé. L'image sciale des instituteurs s'est détérirée: ils ne snt plus les ntables qu'ils furent pendant de lngues années en dehrs des agglmératins. Les parents d'aujurd'hui ne rêvent plus de faire de leur enfant un instituteur, ce qui, il n'y a pas si lngtemps, représentait une ascensin sciale. En haut de la hiérarchie, en matière de mrtalité, figurent les prfesseurs* 1 > dnt la prbabilité de décéder entre 35 et 60 ans dépasse à peine 7% (tableau 1 et graphique 1). Viennent ensuite les ingénieurs, les prfessins libérales, les cadres administratifs supérieurs (un peu mins de 10%), puis les instituteurs (10%). A l'autre extrémité, les plus défavrisés des actifs snt tujurs les maneuvres: un quart d'entre eux meurent entre 35 et 60 ans, 3 fis plus que les prfesseurs et les ingénieurs. Un peu mins mal ltis, n truve les salariés agricles et le persnnel de service, puis le grs des uvriers: un peu mins d'un uvrier de 35 ans, qualifié u spécialisé, sur 5 meurt sans atteindre 60 ans. Entre ces ensembles, l'un cnstitué par les cadres supérieurs, les prfessins libérales et les instituteurs, l'autre par les persnnels d'exécutin qui exercent un métier manuel, les autres catégries se distribuent de manière cntinue. Les industriels et grs cmmerçant viennent d'abrd: leur mrtalité dépasse celle des cadres supérieurs, mais elle est un peu inférieure à celle des techniciens et des cadres myens. Les agriculteurs snt au niveau de ces derniers, ainsi que les cntremaîtres et les artisans. Restent les emplyés et les petits cmmerçants et la catégrie «Armée-Plice» (les sus-fficiers de l'armée et le persnnel subalterne

de la plice) qui précèdent d'assez peu les uvriers qualifiés. Dans l'ensemble, la hiérarchie qui se dessine en matière de mrtalité n'est pas très élignée de la hiérarchie sciale: les cadres snt les mins tuchés, le persnner d'exécutin est le plus expsé; et, entre les deux, ceux qu'n appelle maintenant «les prfessins intermédiaires» et les catégries qu'n qualifie de «myennes» (artisans et petits cmmerçants). Le classement qui paraît le plus surprenant est celui des agriculteurs: leur mrtalité est visine de celle des techniciens u des cadres myens, alrs que leurs cnditins de vie, leur niveau de frmatin, les rapprchent plutôt des uvriers. Parmi les catégries de faible mrtalité, la liaisn entre niveau de mrtalité et niveau culturel paraît étrite: ce snt les grupes ù les diplômés d'études supérieures et les bacheliers snt les plus nmbreux qui nt la plus grande lngévité. Sur ce plan, les instituteurs snt très prches des cadres supérieurs et des prfessins libérales: ils snt plus suvent titulaires du baccalauréat que les cadres administratifs supérieurs (tableau 2). Cette liaisn est mins nette dans les catégries ù la mrtalité est un peu plus élevée. Les industriels et les grs cmmerçants nt, en myenne, fait mins d'études que les cadres myens; quant aux agriculteurs et aux artisans, leur niveau de frmatin est très bas: mins de 3% nt le baccalauréat u un diplôme plus élevé. Les travailleurs nn-salariés nt, il est vrai, mins besin de diplômes lrsqu'ils reprennent l'entreprise paternelle. Mais les cntremaîtres n'nt pas nn plus une frmatin pussée et n les retruve purtant avec une faible mrtalité. Par cntre, s'ils nt mins de diplômes que les instituteurs, les cadres administratifs supérieurs juissent d'un niveau de vie plus élevé; de la même façn, les industriels et grs cmmerçants nt des surces de revenus supérieures à celles des cadres myens. A l'autre extrémité, avec les maneuvres et les salariés agricles, ce snt les catégries qui nt à la fis les plus faibles revenus et les plus bas niveaux de frmatin qui ccupent le bas de l'échelle. Chez les hmmes adultes, avant 40 ans, le risque de décès est faible: la prbabilité de décéder dans l'année pur un hmme de 35 ans est de 2,3 /. En revanche, les écarts relatifs snt très sensibles; de 1 /«, chez les cadres supérieurs, les prfesseurs u les instituteurs, le qutient de mrtalité à 35 ans s'élève à plus de 5 / chez les maneuvres. Ceux-ci snt particulièrement expsés vers cet âge, puisque, chez les salariés agricles, purtant tuchés par une frte mrtalité, la même qutient ne dépasse pas 4%. Dans l'ensemble, la hiérarchie des catégries avant 40 ans est très visine de ce qu'elle est sur l'ensemble de la tranche d'âge 35 à 60 ans. Quelques divergences apparaissent cependant: les agriculteurs et les artisans snt relativement expsés vers 35 ans, par rapprt aux cntremaîtres, aux techniciens et aux cadres myens qui nt une mrtalité visine. De même les emplyés cnnaissent les mêmes risques de mrtalité que les uvriers qualifiés vers 35 ans, mais snt mins tuchés quand ils nt 10 u 15 ans de plus. 71

72 Lrsque l'âge augmente, la hiérarchie des catégries reste à peu près la même, mais les différences se réduisent légèrement: à 55 ans, le qutient de mrtalité va de 5 à l 0 /», sit un rapprt de 1 à 3. C'est un écart qui reste imprtant: il avisine celui qui existe vers cet âge entre hmmes et femmes. Ce n'est qu'au delà de 55 ans que les différences s'amenuisent sensiblement. Entre 55 et 65 ans, chez les actifs, les risques de mrtalité entre les grupes extrêmes ne vnt plus que du simple au duble. C'est ce que traduit le graphique 2 qui furnit une autre illustratin des différences: le maneuvre de 35 ans est sumis au même risque que l'uvrier spécialisé u qualifé d'envirn 45 ans u que le cadre supérieur de 53 ans. L'influence de la prfessin, du niveau defrmatin et de la taille de la cmmune Les différences de mrtalité entre les différentes catégries snt telles qu'elles ne peuvent pas s'expliquer par les seules cnditins de travail. Le métier luimême, le type d'établissement, la lcalisatin gégraphique, tus ces éléments influent sur les cnditins de travail, plus généralement sur le mde de vie, et en définitive, sur la mrtalité. Les écarts qui nt été mis en évidence dans ce qui précède mntrent que les uvriers, même si l'n exclut les cntremaîtres, snt lin de cnstituer un grupe hmgène. Il y avait en 1975, envirn 8,2 millins d'uvriers en France, dnt plus de 3/4 étaient de sexe masculin. Exerçant des milliers de métiers, dans des cnditins très différentes, n imagine qu'ils ne snt pas tus sumis aux mêmes risques. Ainsi peut-n nter, parmi les grupes suffisamment nmbreux, une frte mrtalité des déménageurs (cf tableau 3). Cependant, la qualificatin de l'empli semble primrdiale: l'ensemble des déménageurs est mins expsé que l'ensemble de ceux qui snt classés maneuvres. La frmatin, par cntre, jue un rôle imprtant: la mrtalité de uvriers qui n'nt déclaré aucune frmatin technique est sensiblement plus élevée que celle des autres, quelle que sit la qualificatin de l'empli (tableau 4). Les études précédentes avaient mis en évidence la plus grande lngévité des travailleurs du secteurs public, ceux des grandes entreprises natinalisées en particulier. Cette situatin n'a, semble-t-il, pas changé: à tus les niveaux hiérarchiques, n se truve mieux prtégé si n travaille dans la fnctin publique u les entreprises natinalisées. Cependant, la différence est en général assez mince: elle n'est un peu sensible que pur les uvriers spécialisés (graphique 3). Si le type d'établissement ne jue qu'un rôle réduit, par cntre l'urbanisatin cnserve une grande influence sur la mrtalité u, plus précisément, sur les écarts entre catégries sciales. A ne regarder que la taille de cmmune u d'agglmératin, n ne relève que de faibles écarts: ce snt les hmmes actifs des cmmunes rurales qui snt les mieux prtégés, puis ceux de l'agglmératin parisienne. Ceux qui résident dans

une autre agglmératin snt un peu plus tuchés, mais entre les extrêmes, la différence de mrtalité dépasse à peine 10% (tableau 5). Cette apparente unifrmité cache des écarts très sensibles entre catégries sciales. Elle ne se retruve que dans les catégries myennes: techniciens, cadre myens, dnt la mrtalité est visine en ville u à la campagne. Les cadres supérieurs et prfessins libérales, eux, truvent plutôt avantage à vivre en agglmératin. A l'ppsé, ce snt les instituteurs de la campagne qui snt les mieux prtégés: c'est là, peut être, qu'ils crrespndent encre à l'imagerie traditinnelle du ntable sumis à des règles de vie impsées par la nrme sciale (graphique 4). Dans les catégries sciales qui n'nt dans leur métier qu'un rôle d'exécutin, la mrtalité crît avec l'urbanisatin: c'est déjà vrai chez les emplyés et les uvriers qualifiés, dnt les niveaux snt assez prches. Ca l'est davantage chez les uvriers spécialisés et plus encre chez les maneuvres: l'agglmératin parisienne est particulièrement défavrable à ces deux catégries. Chez les uvriers spécialisés, la surmrtalité des urbains par rapprt à ceux qui vivent en zne rurale est d'envirn 40%. Chez les maneuvres, elle est de près de 100%. On nte d'ailleurs qu'à la campagne les risques de mrtalité des maneuvres et des salariés agricles snt identiques. Ainsi la mrtalité des maneuvres est égale à 2,5 fis celle des instituteurs u des cadres supérieurs à la campagne, mais près de 4 fis dans les grandes agglmératins, et même 5 fis dans l'agglmératin parisienne. 73 La mrtalité des chômeurs La prfessin semble un facteur déterminant dans l'étude de la mrtalité, par les cnditins d'existence qu'elle impse u qui lui snt assciées: cnditins de travail, habitudes de cnsmmatin, chix des lisirs, etc.. Mais l'activité prfessinnelle laisse à l'écart nmbre d'individus. Outre les chômeurs, qui snt mmentanément sans empli, n cmpte un nmbre assez imprtant d'inactifs, nn retraités. 11 y a actuellement plus de 2 millins de chômeurs: ils n'étaient que (!) 800000 en 1975, au mment du recensement, pur lesquels ce dernier indique, en principe, la prfessin exercée antérieurement. On parle fréquemment des méfaits du chômage sur l'état psychlgique des individus, par les phénmènes de déstructuratin qu'il entraîne. Qu'en est-il de leur mrtalité? Les chômeurs nt une mrtalité près de 2 fis plus frte que les actifs des mêmes catégries; plus précisément, cette surmrtalité augmente lrsqu'n descend l'échelle sciale; elle reste limitée chez les cadres supérieurs (graphique 5); chez les cadres myens et les techniciens u parmi les titulaires d'un diplôme au mins égal au BEPC, les chômeurs nt une mrtalité qui est presque

74 le duble de celle des actifs. La surmrtalité est plus frte encre chez les emplyés, les uvriers u les maneuvres, u chez les nn-diplômés (graphique 6). Cette surmrtalité des chômeurs peut s'expliquer en partie par le fait que des persnnes en mauvaise santé peuvent avir plus de peine à retruver un empli: dans ce cas en effet, chômage et décès peuvent avir pur cause la maladie, sans que le chômage ait eu quelque incidence sur le décès. Le fait que la surmrtalité des chômeurs sit plus frte dans les milieux défavrisés mntre cependant que les cnséquences du chômage y snt plus dramatiques qu'ailleurs: ce dernier les laisse plus démunis. La mrtalité des autres inactifs Si la situatin de chômeur s'accmpagne d'une surmrtalité, il n'est pas étnnant que la mrtalité des inactifs sit plus élevée encre. Pur un hmme âgé de 30 à 50 ans, être durablement inactif, est une situatin particulière et rare: envirn 3% des hmmes, à ces âges, snt classés cmme «autres inactifs» en 1975. Cette inactivité est suvent causée par une lngue maladie, une incapacité permanente, récente u ancienne. Entre 35 et 45 ans, le risque de décès des inactifs est 5 fis plus élevé que celui de l'ensemble de la ppulatin masculine et 2,5 fis plus que celui de la catégrie d'actifs la plus expsée: les maneuvres (tableau 6). Vers 60 ans, cette surmrtalité des inactifs nn retraités reste élevée: la prbabilité de décéder ente 55 et 65 ans atteint près de 40% (deux sur cinq) au lieu de 17% (un sur six) pur l'ensemble de la ppulatin masculine. Qui snt ces inactifs, peut-n les situer scialement? A ces questins, le recensement ne répnd que très partiellement. Impssible de savir quelle prprtin n'a jamais exercé d'activité prfessinnelle, du fait d'un handicap ancien, ni quelle était la prfessin de ceux qui nt dû s'arrêter à la suite d'une maladie u d'un accident incapacitants. On peut tut de même nter que la prprtin d'inactifs dans la ppulatin masculine de 30 à 50 ans n'a pratiquement pas changé depuis 1954, qu'en 1975, ce snt, pur plus de la mitié, des célibataires (près des 2 tiers entre 30 et 34 ans, au lieu de 14% pur l'ensemble des hmmes de même âge) et qu'ils nt un niveau de frmatin très bas, visin de celui des maneuvres. Ces éléments rapprchent dnc les inactifs des catégries sciales les plus défavrisées, par leur cmpsitin (tableau 7). A partir de 50 ans, les retraités cnstituent une part de plus en plus élevée des inactifs. Avant 65 ans, ce snt surtut des anciens salariés. Cmme les autres inactifs, les retraités nt une mrtalité plus élevée que les actifs au même âge. Tutefis, si n entre dans le détail, n nte que les retraités du secteur public snt peu expsés: entre 55 et 65 ans, ils cnnaissent les même risques que l'ensemble des actifs; par cntre, les anciens salariés du privé nt une

mrtalité beaucup plus élevée: plus du duble de celle des actifs. L'âge nrmal de départ en retraite est de 60 ans dans la Fnctin publique. Il est même de 55 ans pur bn nmbre de métiers: instituteurs, persnnel rulant de la SNCF, etc.. : prendre la retraite avant 65 ans, pur un fnctinnaire u un travailleur de l'edf, représente la situatin nrmale. Par cntre, dans le secteur privé (ù l'âge de départ en retraite était en général de 65 ans en 1975), prendre sa retraite avant cet âge laisse augurer d'un mauvais état de santé qui peut expliquer un niveau de mrtalité élevé. Avec l'âge, ce décalage entre la mrtalité des actifs et celle des retraités de même âge ne se réduit que lentement: les actifs de 65 ans, du pint de vue de l'état de santé, snt lin de-cnstituer une ppulatin représentative des survivants de leur génératin: ils nt une mrtalité bien plus faible, (graphique 7) Ces remarques faussent partiellement l'analyse des différences de mrtalité suivant la prfessin au delà de 60 ans, c'est-à-dire à des âges ù une sélectin s'père sur des critères de prfessin, mais aussi de santé: seuls restent actifs ceux qui juissent d'une santé suffisante. 75 Mrtalité de femmes et activité prfessinnelle Peu d'hmme snt inactifs entre 35 et 50 ans: n peut dnc se faire une idée de l'influence du milieu scial sur la mrtalité si n cnnaît la prfessin, ne fut-ce qu'à une seule date. Il en va tut autrement pur le sexe féminin, dnt le taux d'activité était en 1975 de l'rdre de 50% entre 30 et 55 ans: le recensement ne permet de saisir l'activité qu'à un mment dnné. Tandis qu'un hmme ne cessera durablement sn activité qu'en cas d'invalidité u de maladie grave, une femme est fréquemment amenée à cesser sn activité, en cas de naissance d'enfant, de déménagement, etc.. Il est pssible qu'elle abandnne sn activité si une maladie vient l'affaiblir, rendant plus pénible la duble jurnée de travail; et cela dépend très certainement de la prfessin exercée. Cmpte tenu de ces difficultés, la mesure des différences de mrtalité féminine seln la prfessin n'apprte que des infrmatins limitées. Le résultat le plus frappant est la faiblesse relative des écarts entre les catégries (graphique 8). Le persnnel de service, qui cnnaît les risques les plus élevés, a entre 35 et 60 ans une mrtalité à peine supérieure de mitié à celle des institutrices, des cadres myens et des emplyées, qui snt le plus épargnées. C'est peu en cmparaisn du fssé bservé pur les hmmes (de 1 à 3!). Les femmes qui snt cadres supérieurs, ne paraissent pas juir d'un avantage décisif par rapprt aux uvrières. En réalité, le fait à suligner est que les actives, même dans les catégries déclassées, telles que les uvrières spécialisées et les maneuvres, nt une

76 mrtalité plus basse que l'ensemble des inactives. La mrtalité des inactives, en effet, est près de 60% plus élevée que celle des actives: la prbabilité de décès entre 35 et 60 ans est de 8,9% pur les unes, 5,4% pur les secndes. Une telle différence s'explique en partie par une liaisn entre l'activité prfessinnelle et l'état de santé: l'activité, mesurée à un mment dnné, sélectinne des femmes qui snt en bnne santé. De fait, l'écart bservé entre actives et inactives est plus sensible en 1975 et en 1976, c'est-à-dire au curs de l'année du recensement et de l'année suivante, que pendant les années ultérieures. Mais, au but de 4 u 5 ans, la différence reste sensible entre celles qui snt actives et les autres. Pur savir un peu mieux cmment cette sélectin peut juer, n peut examiner, du mins pur les femmes qui snt cnjint de chef de famille, le niveau de mrtalité suivant le milieu scial du cnjint; n retruve alrs à peu d'exceptins près, la hiérarchie bservée pur le sexe masculin: ce snt les femmes dnt le cnjint est cadre supérieur u cadre myen qui nt la plus basse mrtalité (graphique 11). Puis n truve plusieurs catégries assez visines: instituteurs, cntremaîtres, techniciens, agriculteurs, artisans et petits cmmerçants. Ensuite, plus n descend l'échelle, plus la mrtalité est élevée: depuis les emplyés jusqu'aux maneuvres: la prbabilité de décéder entre 35 et 60 ans des femmes de maneuvres est duble de celle des femmes dnt le cnjint est un cadre supérieur. A ces écarts, se superpsent ceux qui séparent les actives des inactives: quelle que sit la catégrie sciale du cnjint, la mrtalité des actives reste basse et assez peu liée à ce milieu scial. En revanche, celle des inactives y est très sensible: les femmes inactives de salariés agricles et surtut de maneuvres snt particulièrement expsées. Ainsi les différences de mrtalité entre actives et inactives snt-elles particulièrement frtes dans les catégries défavrisées. C'est là que les taux d'activité féminine snt les plus bas. L'influence du niveau defrmatin La catégrie sciprfessinnelle telle qu'elle est définie à partir de la prfessin est lin de caractériser l'ensemble du milieu scial et du cadre de vie dans lesquels chacun vit, surtut pur le sexe féminin, et il est intéressant d'examiner l'influence d'autres caractéristiques telles que le niveau de frmatin u la situatin matrimniale u familiale: le premier, tut en étant très lié à la catégrie sciale, est indépendant de l'exercice d'une prfessin à un mment précis, la secnde cnditinne bien suvent le mde de vie. La mrtalité masculine apparaît très sensible au niveau de frmatin: elle est,

entre 35 et 64 ans, près de 2,5 fis plus élevée chez ceux qui n'nt déclaré aucun diplôme d'enseignement général que chez les diplômés de l'enseignement supérieur (graphique 12). Et ces derniers snt eux-mêmes mieux prtégés que l'ensemble des cadres supérieurs et des prfessins libérales. Entre ces extrêmes, la mrtalité augmente quand le niveau de frmatin baisse. Ces écarts traduisent les différences entre catégries sciales, mais, n l'a vu pur les uvriers, ils se cnstatent également dans chaque catégrie. A prfessin dnnée, la détentin d'un diplôme élevé se révèle bénéfique en matière de lngévité. La situatin est tut autre pur le sexe féminin: celles qui n'nt déclaré aucune frmatin nt, certes, la plus frte mrtalité, mais ce ne snt pas les diplômées d'études supérieures 'qui se truvent les plus épargnées. L'avantage va aux grupes intermédiaires, titulaires du BEPC u du BAC. Les écarts snt beaucup mins prnncés que pur les hmmes, mais ils snt nets: la mrtalité la plus frte est supérieure d'envirn 60% à celles de bachelières. Ces résultats apparaissent un peu surprenants, même si n a relevé plus haut que les femmes qui étaient cadres supérieurs n'étaient pas les plus épargnées. Ils s'bservent à la fis chez les actives et les inactives et rappelle, pure cïncidence peut-être, la curbe «en U» que prévaut pur la fécndité. 77 Le mariage prtège surtut l'hmme Depuis lngtemps, n sait que le mariage u, en tut cas, une certaine vie de famille, prtège; vers 20 u 25 ans, les hmmes célibataires meurent 2 fis plus que les mariés. A un âge ù les accidents expliquent plus de la mitié des décès, cette mrtalité s'explique prbablement par les risques que des célibataires prennent plus facilement. Jusqu'ici, le manque de chérence entre l'état civil et les recensements empêchait malheureusement des mesures très précises aux âges plus élevés. La présente étude apprte des infrmatins plus sûres, encre qu'imparfaites puisqu'elle ne prend pas en cmpte les changements de situatin qui nt pu survenir à la suite du recensement. La mrtalité des célibataires, des veufs et des divrcés de sexe masculin, entre 35 et 60 ans, est près du duble de celle des mariés; la prbabilité de décéder entre 35 et 60 ans, pur un hmme marié, est de 15%. Elle atteint 28% pur les célibataires, 30 pur les divrcés et plus de 33 pur les veufs. A tut âge entre 35 et 60 ans, les écarts snt du même rdre (tableau 8). Les hmmes qui restent célibataires appartiennent plus suvent au bas de l'échelle sciale (tableau 9). En utre, les persnnes en mauvaise santé nt plus de peine à truver un cnjint. La frte surmrtalité des célibataires n'a dnc rien de surprenant ni le fait que cette surmrtalité est plus marquée dans les catégries défavrisées, que celles-ci sient repérées par le niveau de frmatin u par la

78 catégrie sciale; la sélectin qui s'père au mment d'un recrutement u d'une prmtin cantnne ceux qui snt en mauvaise santé u fréquemment malades dans des emplis déclassés. Plus précisément, la surmrtalité des célibataires est très élevée dans tutes les catégries qui exercent des travaux plutôt manuels, uvriers, maneuvres, mais aussi cntremaîtres et artisans, ainsi que chez les emplyés. Seuls les agriculteurs et les salariés agricles ne cnnaissent pas cette frte surmntalité: le célibat y est mins qu'ailleurs une exceptin; célibataires et mariés nt des cnditins de vie prbablement mins différentes que dans les autres milieux. Dans les autres catégries, en particulier chez les cadres supérieurs u les cadres myens, les célibataires ne cnnaissent qu'une surmrtalité limitée par rapprt aux mariés. Dans l'ensemble, ces écarts rappellent ceux qui séparent les chômeurs actifs: l'absence de vie familiale pur les uns, de vie prfessinnelle pur les autres se traduit par des cnséquences néfastes, d'autant plus marquées que les individus snt déjà défavrisés. La surmrtalité des célibataires et les taux de célibat très variables permettent de cmprendre un peu mieux la place surprenante de quelques catégries, les cntremaîtres en particulier. Leur classement dans la hiérarchie, en matière de mrtalité, est apparu tut à fait favrable: il se truve que le taux de célibat y est remarquablement bas, près de la mitié du taux purtant peu élevé bservé chez les techniciens, catégrie visine. Il s'agit d'une catégrie ù l'n entre par ascensin prfessinnelle: n peut penser que celle-ci sélectinne des persnnes qui juissent d'une bnne santé et, pur le sexe masculin en tut cas, des individus qui ne s'élignent pas de la nrme sciale, plutôt des mariés dnc. La très frte surmrtalité des veufs ne peut évidemment s'expliquer par cette sélectin qui pèse sur les célibataires. Pur une petite partie, elle est due à la mrtalité différentielle elle-même: celle-ci étant plus frte dans les milieux défavrisés, ceux-ci snt davantage représentés parmi les veufs. Mais cet effet de structure ne saurait justifier que le veufs meurent 2 à 3 fis plus que les mariés. Seul le déséquilibre intrduit par la rupture de la vie familiale semble puvir prvquer de tels écarts. Cntrairement à la surmrtalité des célibataires, celle des veufs ne paraît pas liée au milieu; quel que sit le niveau de frmatin, les veufs meurent 2 fis plus que les mariés. A la différence du veuvage, plus fréquent dans les catégries défavrisées, le divrce tuche tus les milieux avec une intensité visine; seuls les agriculteurs y échappent. Par cntre, les effets du divrce sur la mrtalité semblent analgues à ceux du veuvage, pur les hmmes en tut cas. Ainsi, dans tutes les situatins, l'hmme apparaît très prtégé par le mariage, et plus précisément la vie maritale: dans l'ensemble, ceux qui nt un cnjint, nt une mrtalité plus faible que ceux qui, n'ayant pas de cnjint, nt la charge

d'au mins un enfant et ces derniers snt eux-mêmes mieux prtégés que ceux qui vivent hrs famille. L'hmme marié ne cnnaît une faible mrtalité que s'il a un cnjint. Les célibataires, lés veufs et les divrcés les mieux prtégés snt ceux qui nt un enfant (u plusieurs) à charge, ceux qui vivent maritalement viennent ensuite, puis ceux qui vivent hrs famille (graphique 10). La situatin matrimniale ne prvque pas d'écarts aussi sensibles pur les femmes que pur les hmmes. La mrtalité des célibataires n'est que de mitié supérieure à celle des mariées, celle des veuves et des divrcées se situe à michemin de ces 2 grupes. Les caractéristiques des femmes célibataires diffèrent sensiblement de celles de hmmes; les femmes-qui nt suivi de lngues études restent plus suvent célibataires. Pas d'effet de structure, dnc, pur expliquer une frte surmrtalité; c'est parmi les femmes qui n'nt déclaré aucun diplôme que la surmrtalité des célibataires est la plus vive: elles nt une mrtalité presque duble de celle des mariées: n y bserve une prprtin imprtante d'inactives qui snt prbablement, pur une bnne part, des persnnes handicapées u en mauvaise santé. Lrsque le niveau de frmatin s'élève, l'écart se réduit. Les veuves n'nt pas, cntrairement aux veufs, une mrtalité très supérieure à celle des mariées: purtant les milieux défavrisés, cmme n l'a vu, y snt davantage représentés. Les divrcées snt un peu plus expsées que les veuves, mais leur mrtalité ne dépasse celle des mariées que d'un tiers. Surtut, la présence d'un cnjint, pur une femme, ne semble pas la prtéger: dans l'ensemble, les femmes qui nt un cnjint nt une mrtalité visine de celles qui, n'ayant pas de cnjint, nt au mins un enfant à charge, tandis que celles qui vivent seules snt plus expsées. Mais parmi les veuves et les divrcées, celles qui élèvent seules leurs enfants cnnaissent la plus basse mrtalité, puis celles qui vivent hrs famille; celles qui nt un cnjint, nt une mrtalité plus élevée. Sur un plan matériel, le mariage prfite à l'hmme et dessert la femme: le premier se décharge sur sn épuse des tâches dmestiques qu'il devrait assumer s'il vivait seul [1]. En matière de mrtalité, le mariage, et la vie de cuple en général, snt aussi plus bénéfiques à l'hmme qu'à la femme. L'hmme laissé à lui-même est sumis à des risques beaucup plus grands. La femme qui vit seule u qui assume sans cnjint la charge de ses enfants ne parait pas s'en prter beaucup plus mal, même si les difficultés matérielles sn accrues. 79 L'évlutin des écarts entre catégries sciales depuis 1955 Au curs des vingt dernières années, la mrtalité des adultes a cnnu une baisse assez sensible, surtut depuis 1970. La prbabilité de décéder entre 35 et 60

80 ans, pur les hmmes, est passée de 20,9% au curs des années 1955-1959 à 17,6% pur les années 1975-1980, sit une diminutin d'envirn 16%. Les prgrès nt été plus marqués pur le sexe féminin dnt le niveau de mrtalité était purtant plus bas. Une telle baisse a-t-elle prfité à tus les milieux u a-telle été plus sensible dans certains? C'est évidemment la questin qui vient à l'esprit quand n parle de l'inégalité devant la mrt. Dans l'ensemble, la hiérarchie des catégries a subi très peu de changements au curs des 2 décennies passées: cadres supérieurs, prfessins libérales et instituteurs étaient et restent les mieux prtégés. Salariés agricles, uvriers spécialisés et maneuvres cnstituent tujurs les grupes les plus expsés (tableau 10). Cmme n l'a signalé plus haut, les cadres supérieurs d'aujurd'hui nt une plus faible mrtalité que les instituteurs: c'était le cntraire il y a 20 ans. Cete mdificatin ne saurait, à vrai dire, étnner: au recensement de 1954, c'est parmi les instituteurs que la prprtin de bacheliers était la plus frte. Actuellement, nmbreux snt ceux qui vnt au delà du baccalauréat: la prprtin de diplômés d'études supérieures a davantage augmenté chez les cadres supérieurs que chez les instituteurs. Pur le reste des catégries sciales, la hiérarchie est restée pratiquement inchangée; tutefis, les cntremaîtres nt à présent une mrtalité un peu plus faible que les techniciens et les cadres myens. La permanence d'un tel classement cnfirme ce qui a été dit u écrit ces dernières années à prps de l'inégalité devant la mrt; elle mérite cependant d'être examinée de près: la structure sciale a sensiblement évlué depuis un quart de siècle. Le cntenu de certaines catégries s'est mdifié du fait du changement des mdes de prductin et de distributin. Les agriculteurs snt mins nmbreux; à l'inverse, certaines prfessins nt cnnu une large expansin: techniciens, chauffeurs rutiers; d'autres étaient même inexistantes en 1954: les métiers de l'électrnique et de l'infrmatique. Dans ces cnditins, une même appellatin en 1954 et en 1975 peut rassembler des prfessins assez différentes, surtut pur les catégries intermédiaires telles que techniciens u cadres myens. Quand n cmpare la mrtalité entre 35 et 60 ans au curs de la péride 1975-1980 à celle de la péride 1955-1960, n nte une diminutin dans tutes les catégries. Celle-ci est très sensible pur les patrns de l'industrie et du cmmerce, pur les cntremaîtres, pur les cadres supérieurs et les prfessins libérales; c'est pur les uvriers spécialisés, les salariés agricles et les maneuvres qu'elle est la plus réduite. Ces 2 dernières catégries qui cnstituaient 15% des actifs en 1954 n'en représentent plus que 10% en 1975.

Pur des français nés en Franced) être maneuvre en 1975, u salarié agricle, c'est-à-dire appartenir à 2 catégries à frte prprtin d'immigrés, c'est, dans bien des cas, le signe d'une mauvaise intégratin sciale; ce n'était pas aussi vrai en 1954, lrsque ces catégries étaient beaucup plus nmbreuses. L'évlutin a été différente entre uvriers qualifiés et uvriers spécialisés, mais là, c'est peut être le mde de classement différent aux 2 recensements qui est en cause. En 1954, les uvriers étaient classés en spécialisés u qualifiés suivant le libellé de la prfessin; en 1975, la qualificatin était demandée au recensement. Par ailleurs, entre 1954 et 1975, les glissements catégriels nt été fréquents dans certaines branches d'activité. Ces cnsidératins ne facilitent pas la répnse à la questin qui était psée plus haut. Cependant, n peut examiner l'évlutin au sein de grands grupes: l'analyse est alrs mins perturbée par l'incertitude des classements. On ppsera ainsi d'une part les salariés agricles et les uvriers, cntremaîtres exclus, c'est-à-dire les travailleurs manuels exécutants, d'autre part les autres actifs, en grs les cls blancs et les agriculteurs: d'un côté 43% des hmmes actifs, de l'autre 57%, aussi bien en 1954 qu'en 1975. La mrtalité de ces derniers, qui étaient déjà les mieux prtégés vers 1960, a davantage diminué en une vingtaine d'années. Pur eux, la prbabilité de décès entre 35 et 60 ans a chuté de plus de 20%, alrs que la baisse n'a été que de 15% pur les travailleurs manuels: les écarts se snt ainsi accrus (tableau 11). Un cup d'eil au sein de ces 2 grupes cnfirme ce résultat; au sein du mnde uvrier, l'évlutin a été plus favrable chez les uvriers qualifiés que dans les autres catégries: uvriers spécialisés, salariés agricles et maneuvres. A l'autre extrême, c'est chez les cadres supérieurs, prfessins libérales et instituteurs, dnt l'imprtance s'est purtant accrue, que l'améliratin a été la plus marquée: la mrtalité y a baissé de plus d'un quart en vingt ans, au lieu de 22% pur l'ensemble des cls blancs et agriculteurs. 81 (1) pur des raisns techniques l'étude est limitée au per n nés françaises nées en France

82 Prfesseurs Ingénieurs Instituteurs Cadres supérieurs Industriels, grs cmmerçants Cntremaitres Agriculteurs Techniciens Artisans Cadres myens Petits cmmerçants Emplyés de bureau Emplyés de cmmerce Armée, plice Ouvriers qualifiés Persnnel de service Ouvriers spécialisés Salariés agricles Maneuvres 50 60 70 80 100 -t- 150 1 200 I Ensemble des actifs Inactifs nn retraités GRAPHIQUE 1: Mrtalité entre 30 et 64 ans suivant la catégrie sci-prfessinnelle (hmmes)

l 83 Cadre supérieurs et prf, libérales Instltuteur3 Cntremaîtres Techniciens Agriculteurs Artisans Cadres myens Petits cmmerçants Emplyés Ouvriers qualifiés Ouvriers spécialisés Salariés agricles Maneuvres Actifs Ttal 35 40 1 t 1 1 1 1 1 45 i;,;,-,;,-.;, 1 *-: > i h..:."-v: I I 1 : 1 : - t:.:.-. i 1 i 35 1 5 lïjv!.:-.:. lit 40 [ Hi, \ 1 ] l!1 4b 55,1 1 1 t Ai \ 1 J K 0 6( 4 ::!} :; 1 1 i 55 J,1 11 : J, 5î 1 1 tí GRAPHIQUE 2: Qutients de mrtalité ajustés à 35, 40, 45, 50 et 55 ans suivant la catégrie sci-prfessinnelle (hmmes)

84 O 50 I Cadre supérieurs Cadre myens Emplyés Ouvriers quai. Ouvrier spec. 100 I public exédent du privé sur le public GRAPHIQUE 3: Mrtalité des salariés du secteur privé et du secteur public (Indicateur synthétique de mrtalité pur les génératins 1921-1945)

85 Cadres supérieurs et prf, libérales Cmmunes rurales XI CO si 57 63 cv 20000 à 200000 hab 200000 à 2000000hatj Agglmérat parisienne- 47 51 49 Instituteurs 46 46 59 52 58 Techniciens 70 62 68 66 67 Emplyés 80 94 88 97 107 Ouvriers qualifiés 87 99 95 113 108 Ouvriers spécialisés 100 117 132 113 143 Maneuvres 131 178 156 194 261 GRAPHIQUE 4: Mrtalité suivant la catégrie sciale et la catégrie de cmmune (Indicateur standardisé de mrtalité pur la péride 1921-1945)

86 Cadre supérieurs Cntremaîtres Techniciens et Emplyés Ouvriers qualifiés Ouvriers spéc. Maneuvres Ensiçrable des aci 0 50 1 1 1 1 100 1 11 1 1 1 150 200 1 1 250 1 Actifs ayant un empli au recensement de 1975 Chômeurs au recensement de 1975 GRAPHIQUE 5: Mrtalité des chômeurs et des nn-chômeurs seln la catégrie sciale (Indicateur synthétique de mrtalité pur les génératins 1911-1945)

87 50 100 150 ' 200 250 Aucun dipl., déclaré CEP BEPC u plus Ensemble Actifs ccupés au recensement de 1975 Chffleurs au recensement de 1975 GRAPHIQUE 6: Mrtalité des chômeurs et des actifs suivant le sexe et le niveau defrmatin (Indicateur synthétique de mrtalité pur les génératins 1911-1945)

qutient (pur 1000 35 Rétraités Ensemble âge au 1.1 de l'année GRAPHIQUE 7: Qutients perspectifs de mrtalité par âge suivant la situatin (hmmes)

89 Emplyés Techniciennes et cadres myens Institutrices Cadres supérieurs OS et maneuvres Artisans et cmmerçants Ouvriers qualifié Agricultrices Femmes de ménages Persnnel de service Actives Inactives Ttal GRAPHIQUE 8: Prbabilité de décéder entre 35 et 60 ans suivant la catégrie sci-prfessinnelle (femmes)

90 Cadres.sup., prr.iiderales Instituteurs Cntremaîtres Techniciens Agriculteurs Artisans Cadres myens Petits cmm. Emplyés OQ OS Salariés agr. Maneuvres Actifs Ttal ( 3 50 1 1 1 1 1 11 1 1 100 1 1 1 1, 1 1 1 150 200 1 1 1 1 1 1 1 Célibataires Mariés, veufs u divrcés GRAPHIQUE 9: Mrtalité des hmmes suivant l'état matrimnial et la catégrie sciprfessinnelle (Indice synthétique de mrtalité calculé pur les génératins de 1921 à 1945)

91 Célibataires 1 Vivant seuls _ Vivant avec un cnjint^ Ensemble Vivant seuls Sans cnjint,avec enfant Avec cnjint Vivant seüb Sans cnjint,avec enfant Avec cnjint =E Vivant seuls Sans cnjint,! S nfant vec cnjint Ensemble ^' " i 1 Vivant seulss l t 8 Íní J Avec cnjint Ensemble 1Í0 2 0 GRAPHIQUE 10: Mrtalité suivant l'état matrimnial et la situatin de famille (Indice synthétique de mrtalité calculé pur les génératins de 1911 à 1945)

92 Cadres supérieurs et prf. Instituteurs Cntremaîtres Techniciens Agriculteurs Artisans Cadres myens Petits cmmerçants Emplyés Ouvriers qualifiés Ouvriers spécialisés Salariés agricles Maneuvres m " * * * n i i I ' I Ttal _L gfemmes actives [~jensemble des femmes LjFemmes inactives GRAPHIQUE 11 : Prbabilité de décéder entre 35 et 60 ans des femmes ayant un cnjint suivant la situatin de la femme et la catégrie sciprfessinnelle du cnjint

93 HOMMES Aucun diplôme declare CEP BEPC Baccalauréat Etudes supérieures (_ 50 i 1 ] 100 I 1 1 1 FEMMES Aucun diplôme déclaré CEP BEPC Baccalauréat Etudes supérieures 1 11 50 i 100 1 1 1 I] 1 1 GRAPHIQUE 12: Mrtalité suivant le sexe et le diplôme d'enseignement général (Indicateur synthétique de mrtalité pur le génératins de 1911 à 1945)

94 Tableau 1. Qutients de mrtalité à 35 et 55 ans, prbabilité de décès entre 35 et 60 ans, espérance de vie à 35 ans (estimée), nmbre de décès bservé entre 35 et 64 ans suivant la catégrie sci-prfessinnelle au curs des années 1975 à 1980 HOMMES Qutients de mrtalité (' V) à 35 ans à 35 ans Prbabilité de décès entre 35 et 60 ans (%) Espérance de vie à 35 ans (estimée) Nmbre de décès bservé entre 35 et 64 ans 32 Prfesseurs 33 Ingénieurs 41 Instituteurs 34 Cadres supérieurs 32-26 Industriels et grs cmmerçants 60 Cntremaîtres 00 Agriculteurs 43 Techniciens 22 Artisans 44 Cadres myens 27 Petits cmmerçants 51 Emplyés de bureau 53 Emplyés de cmmerce 82 Armée, plice 61 Ouvriers qualifiés 70-72 Persnnel de service 63 Ouvriers spécialisés 10 Salariés agricles 68 Maneuvres 3 Cadres supérieurs, prfessins libérales 4 Cadres myens 0 Agriculteurs 2 Patrns de l'industrie et du cmmerce 8 «Autres actifs» 5 Emplyés 6 Ouvriers 7 Persnnel de service 1 Salariés agricles 0,86 1,05 1,21 1,24 1,57 1,38 1,69 1,53 2,08 2,48 2,19 2,34 3,05 3,87 5,81 1,10 1,36 1,57 1,79 2,41 2,81 3,87 4,9 5,9 7,0 6,8 8,4 8,3 8,4 8,5 8,9 10,3 10,6 10,8 13,0 12,1 14,5 12,8 13,5 16,4 6,4 8,3 8,3 9,3 9,9 10,7 12,5 14,5 13,5 6,9 7,9 10,1 9,6 11,4 11,6 12,0 11,8 12,3 12,4 15,5 16,3 16,0 14,4 17,2 19,1 18,7 20,2 25,4 9,1 11,7 12,0 13,6 14,1 16,3 18,2 19,1 20,2 43,2 42,3 41,1 41,4 39,1 40,2 40,3 40,3 40,2 39,6 38,8 38,5 38,4 36,9 37,5 36,0 37,0 37,5 34,3 42,0 40,3 40,3 39,5 38,5 37,2 36,0 37,5 82 156 436 462 67 689 856 425 383 503 476 819 208 107 2 023 112 1418 179 769 740 1377 856 945 123 1 027 4 976 112 179 Ensemble des actifs Inactifs TOTAL 2,20 2,30 10,3 12,6 15,1 47,0 17,2 38,8 37,2 10 335 1089 11 424

Tableau 2. Prprtin d'hmme de 30 à 34 ans ayant le baccalauréat u ayant suivi des études supérieures dans les catégries sci-prfessinnelles de basse mrtalité, en 1975 95 Catégrie sci-prfessinnelle Prfesseurs Ingénieurs Instituteurs Cadres Supérieurs Industriels et grs cmmerçants Cntremaîtres Agriculteurs Techniciens Artisans Cadres myens nt au mins le baccalauréat 86,6 79,8 71,9 52,3 13,9 5,4 2,1 16,6 2,9 25,9 nt suivi des études supérieures 81,2 72,1 32,9 36,6 7,4 1,8 0,9 6,1 1,2 12,0 Ensemble des actifs 15,2 9,8 Tableau 3. Mrtalité de quelques prfessins uvrières (Indicateur synthétique de mrtalité pur les génératins 1921 à 1945) Prfessin Maçns Peintres en bâtiment Chauffeurs pids lurds Déménageurs Magasiniers Ensemble des uvriers (1) Ensemble de la ppulatin masculine Nmbre de décès bservé 478 135 392 195 174 4.647 Indicateur de mrtalité 118 115 109 143 107,110 100 (1) Cntremaîtres + uvriers qualifiés + uvriers spécialisés + maneuvres

96 Tableau 4. Mrtalité des uvriers suivant la qualificatin de l'empli et le niveau de frmatin (Indicateur synthétique de mrtalité pur les génératins 1921 à 1945) Qualificatin de l'empli Aucune frmatin technique déclarée Nmbre de décès bservé Indicateur de mrtalité Avec une frmatin technique Nmbre de décès bservé Indicateur de mrtalité Ensemble Nmbre IIndicateui de décès de bservé mrtalité Cntremaîtres Ouvriers qualifiés Ouvriers spécialisés Maneuvres Ensemble des uvriers (sauf mineurs et pêcheurs) 374 1 311 1 191 661 3 517 71 106 117 162 116 227 575 190 44 1036 56 87 108 172 87 601 1 886 1 381 685 4 553 65 100 116 163 110 Tableau 5. Mrtalité des hmmes actifs suivant la catégrie de cmmune (Indicateur synthétique de mrtalité pur les génératins 1921 à 1945) Catégrie de cmmune Cmmunes rurales Unités urbaines de mins de 20 000 h. de 20 000 à 199 999 h. de 200 000 à 1 999 999 h Agglmératin parisienne Ensemble (1) Nmbre de décès bservé 2 666 1 532 2 061 1 811 1 593 2 593 Indicateur de mrtalité 84. 94 90 90 87 88 (1) L'indice 100 crrespnd à l'ensemble actifs + inactifs.

Tableau 6. Prbabilité de décès entre divers âges suivant la situatin (hmmes) 97 Situatin au recensement de 1975 35 et 45 ans (en <V) Prbabilité de décès entre 45 et 55 ans (en %) 55 et 65 ans (en %) 35 et 60 ans (en %) Actifs Inactifs nn retraités Retraités: Anciens agriculteurs «Retirés des affaires» Retraités du secteur public Anciens salariés du secteur privé 2,86 16,2 7,1 28,4. 13,4 39,3 26,3 31,1 15,5 34,6 15,1 51,0 Ensemble 3,19 8,3 17,1 17,2 Tableau 7. Taux de célibat et niveau de frmatin des inactifs nn retraités et de l'ensemble de la ppulatin suivant l'âge (hmmes) Age (au 1.1.1976) Taux de célibat (en* 7) Inactifs nn-retraités Ensemble Prprtin d'hmmes n'ayani déclaré aucun diplôme (%) Inactifs nn-retraités Ensemble 30-34 35-39 40-44 45-49 50-54 63,7 57,9 51,0 37,5 33,8 14,1 11,8 10,7 9,4 8,2 72,7 73,0 71,5 66,5 57,6 28,2 32,7 41,2 38,9 35,2

98 Tableau 8. Prbabilité de décès entre divers âges suivant le sexe et l'état matrimnial Prbabilité de décès entre 35 et 45 45 et 55 55 et 65 35 et 60 ans ans ans ans HOMMES Célibataires Mariés Veufs Divrcés 7,32 2,47 7,86 6,60 13,9 7,2 18,6 15,6 25,1 15,2 34,3 28,2 28,4 15,0 33,5 30,4 Ensemble 3,19 8,3 17,1 17,2 FEMMES Célibataires Mariées Veuves Divrcées 2,30 1,36 3,45 2,48 4,74 2,86 4,12 3,63 8,6 6,5 7,5 6,2 9,8 6,7 10,8 8,7 Ensemble 1,52 3,09 6,7 7,2

Tableau 9. Taus de célibat myen des hmmes nés entre 1921 et 1945 suivant la catégrie sci-prfessinnelle et l'état matrimnial (en 7) Cadres supérieurs et prfessins libérales 5,1 Instituteurs 8,4 Cntremaîtres 3,1 Techniciens 5,2 Agriculteurs 19,0 Artisans 6,5 Cadres myens 6,0 Petits cmmerçants 6,3 Emplyés 9,7 Ouvriers qualifiés 9,1 Ouvriers spécialisés 11,3 Salariés agricles 36,6 Maneuvres 29,6 Ensemble des actifs 10,6 Retraités 15,9 Autres inactifs 44,0 Ensemble 11,7 99

100 t CS TJ O ON «Ó t ON <L> ON /"> ON I < >O ON "( QJ T3 O c "8. CO u a 8 cd S < «O u C u u M <** -<J O u ti XU O. ó U -S. a y S Vi p S S OH g 8 8 CS O. > "5 XI C H. Z -a ces x> 2 -a fi -ëg s & 11 U g -sss ent s u S «c CS T «S m f O r~ fs ^H in v O " O O ^t -^ >O "^ 0O O\ 1^ N «««-i «c ^f v^r^r-^c^ O\ O " " (S* ri ci n ^ <S ON ON <O <S O «r-" \ C w" vvvvvï m n h «m in VOVO r~- «ON PI N ««O «M M M <H ri «tn'rn'i-'î'r't'viv n «i t> O 'i ^t~-«r >>i*>-^ Tj-v-Hi^ir-v ri ri v VO -H ON r- O rr, {S 00 ON * I rô 0O VO «- N (S N u as N <t N Oi -H M «fsr mr ON OOOOVOONONO es_ "^ _ m r-^ w» " «-«^ i -H es <s es «s "T. ^ ^ ^. 00 ON ON»-H 8UN U UIUIO u 3 r ON ri N N t^ aalifié: riers ( ilyés. rr U O.Xi Vi 3 Ä a 8 S 1 M riers : ries a > es 3 73 O C/3 t euvi ces ^ *

Tableau 11. Evlutin de la mrtalité entre 35 et 60 ans pur quelques grandes catégries 101 Part de ppulatin Prbabilité de active masculine de décès entre 35 Diminutin 35 à 54 ans et 60 ans (%) (en 7) en 1954 en 1975 1955-1959 1975-1980 Ouvriers salariés agricles et maneuvres 43,8 42,7 22,7 19,4 15 dnt uvriers qualifés 16,9 17,4 20,8 17,2 17 dnt uvriers spécialisés, salariés agricles et maneuvres 26,9 25,3 23,9 20,9 13 Autres catégries (sauf Armée-plice et Persnnel de service) 52,0 53,4 15,8 12,4 22 dnt Instituteurs, cadres supérieurs et prfessins libérales 6,1 11,3 12,6 9,3 26 Ensemble des catégries sciales 19,0 15,6 18

103 CENSUS-BASED PROSPECTIVE STUDIES IN NORWAY Lars B. KRISTOFERSEN Central Bureau f Statistics f Nrway 1. Nrwegian experiences until nw The Central Bureau f Statistics has carried ut three prjects in the field f ccupatinal mrtality until nw. The first ne was carried ut by Björn T^nnesen and published in 1974 as an (internal) wrking paper. He linked male deaths (males 30-81 years f age in 1960) in the perid 1st f Nvember 1960 31st f December 1964 t the Ppulatin Census 1960 and perated with 37 ccupatinal classes«. The secnd study was cnducted by Tr Haldrsen and Eystein Glattre and published as Statistical Analyses N. 21 in 1976< 2 >. Haldrsen and Glattre linked all recrds n deaths in the perid 1st Nvember 1970 t 31st December 1973 amng males and females 16 years and ver in 1970 t the 1970 census recrds. They cnstructed a scheme f 28 ccupatinal classes fr men and 14 classes fr wmen (based n the Nrdic ccupatinal classificatin 1965, ISCO 1958) fr which mst f the cmparisns and analyses were made. In additin they analysed the mrtality pattern fr the nn ccupied, fr the ccupied versus nn ccupied in different regins, and the mrtality pattern fr fur (five) scial grups. This study als brught causes f death int cnsideratin (7 main grups based n ICD 8. revisin). This was nt dne in the 1974-study f male deaths. The third study was cnducted by Lars Kristfersen. This was a repeat s t say, testing the mst imprtant findings in the study by Haldrsen and Glattre, taking 1960 ccupatin and ccupatinal status int accunt (frm the 1960 census) 0). This culd be dne because the tw censuses had been linked n the base f the persnal identificatin number in the Central Bureau f Statistics.

104 2. Characteristics and size f the ppulatin As ppulatin in the ccupatinal mrtality study frm 1979 was chsen all persns 16 years and mre in 1970 living in Nrway and present in bth the 1960 and the 1970 census, and which had incme frm wn wrk as their main surce f livelihd in 1960 and/r 1970. Gainfully emplyed persns at least ne f these tw census years amunted t slightly mre than 1.7 millin persns. Of these 1.7 millin clse t 1.2 millin were men and slightly mre than 500 000 were wmen. As a ttal, clse t 3.9 millin persns were present in the 1970 census, and f these clse t 2.8 millin persns were 16 years r mre. Of the abut 1.4 milin men 16 years and mre in the 1970 census, 84 per cent culd be assigned t an ccupatinal title either frm the 1970 census f frm the 1960 census, (if they were ut f wrk in 1970). The same ccupatinal per cent was 36 fr the slightly mre than 1.4 millin wmen. The ccupied men and wmen (1970 and/r 1960) were linked with the ttal death recrd register in Nrway frm the perid Nvember 1st 1970 t December 31st 1973. This link resulted in abut 44 000 deaths amng the 1 180 000 men, and abut 8 800 deaths amng the 530 000 wmen. 3. Main findings The findings frm this last study strengthened the hypthesis/ cnclusins made hy Haldrsen and Glattre. The female ccupatinal mrtality was mre hetergenus when we brught their 1960 ccupatinal int cnsideratin, and the same can be said fr bth female and male scial grup mrtality. Scial grups and ccupatins with highest status and the best wrking cnditins have fr mst f the age grups a lwer mrtality than scial grups and ccupatins with lw status and prblematic wrking cnditins. All the three analyses (1974, 1976 and 1979) shwed hight mrtality fr males in the fllwing ccupatinal grups: Seamen (deck and engine rm crew wrk) Mining and quarring wrk Fishing The tw last studies als shwed high mrtality fr males in: Htel and restaurant wrk Lw mrtality fr males were fud in: Pedaggical wrk (teachers etc.) The tw last studies fund high mrtality fr females in the fllwing ccupatins: Htel and restaurant wrk

105 Cleaning wrk etc. The studies fund lw mrtality fr females in the fllwing ccupatinal grup: (High skilled) medical wrk, gvernment services, directrs and administratrs Fr further details frm the tw latest analyses, see detailed tables. 4. Difficulties One f the largest difficulties s far has been t interpret mrtality figures frm ccupatinal grups with relatively small number f wrkers, and especially indexes n causes f deaths fr such grups. As this is a cmmn prblem fr all the Nrdic cuntries, c-peratin is established t try t find ut mre abut the mrtality pattern fr sme interesting ccupatinal grups cnsisting f small numbers f emplyed persns when each cuntry is seen separately. Befre this c-peratin (started in 1980) can give results, we have prblems in each cuntry interpreting ccupatinal mrtality data fr sme hetergenus ccupatinal grups. But fr the main findings quted abve, the results are quite clear, and are related t relatively hmgenus ccupatinal grups. When studying ccupatinal mrtality in Nrway we have few prblems with the linking f census data, central persnal register data and death recrds, due t gd register systems. The difficulties are mre related t the small numbers we have in many ccupatins. Anther difficulty, discussed in anther sessin in this meeting, is f curse the classificatin in sci-ecnmic grups. In bth the 1976 and 1979-study fur sci-ecnmic grups were used (farmers kept beside because f their special cnditins.) The cncrete classificatin used is, hwever, hardly debated in Nrway, and a new SES-classificatin will be used fr the next study (see pint 6). A third item fr discussin related t these analyses has been whether t use the CMF (Cmparative Mrtality Figure) r the SMR (Standardized Mrtality Rati) fr age standardizatin. Bth measures were cmputed fr all ccupatinal and sci-ecnmic grups in the 1976 and 1979 study, but nly the CMF-indexes were published. These measures are lying quite clse fr the great majrity f the' grups, and the SMR will be the measure cmputed and published in the next analysis. In that way we will als have cmmn measures published fr the Nrdic cuntries. 5. Our wrk since the Wiesbaden meeting Our wrk since the Wiesbaden meeting in this field is restricted t participatin in tw Nrdic expert meetings (in Gthenburg June 1982 and Stckhlm January 1983).

106 In accrdance with the cperatin initiated as a result f these meetings, the planning f a new research prject n ccupatinal mrtality has just started in the Central Bureau f Statistics f Nrway. 6. Plans fr ccupatinal mrtality statistics Intrductin The Central Bureau f Statistics f Nrway in nw planning a new statistical analysis n ccupatinal and sci-ecnmic differentials in mrtality. The purpse f such analyses is t prvide a statistical base fr demgraphers and epidemilgists t generate hyptheses abut causative factrs. Further, they indicate changes in patterns, and thus can prvide a base fr evaluatin f health and scial plicies. Main methds fr the prject The prject will be based n linkedfilesfr all the deceased persns in Nrway the ten years after the 1970-census. This new file will be linked with the Nrwegian 1970-census file n the base f the persnal identificatin number. Age adjusted mrtality indexes fr each sex will be calculated fr ccupatinal grups and fr sci-ecnmic grups. Calculatins will be made fr general mrtality and fr cause specific mrtality. Calculatins will be made fr chrts f persns thrugh the tw perids 1971-1975 and 1976-1980 separately. If enugh resurces are available, the linkage will als include the 1960- and 1980-censuses. This will be dne in rder t state the change f ccupatins and sci-ecnmic status thrugh the perid between tw pints f time fr the persns wh died 1971-1980, and fr three pints in time fr adults living at the 1980-census date. Occupatin The surce (in bth the numeratr and the denminatr) will be the censusdata. Occupatin in the censures are cded accrding t the Nrdic classificatin f ccupatin 1965 (clse t ISCO 1958/3. digit level). Mrtality will be analysed fr persns staying in the same ccupatin 1960 and 1970, as well as fr persns having changed their ccupatins r being ut f ccupatin at ne f the census years. Occupatinal data frm 1980-census will be used t evaluate the results in relatin t changes f ccupatinal grups. Sci-ecnmic grup The Central Bureau f Statistics has been wrking n a new classificatin system fr scial classes (sci-ecnmic grups in the Nrwegian terminlgy). If this new classificatin system is available in 1983, we will try t use ne f its versins fr the mrtality analysis. The system has in its mst detailed basic versin 27 categries. An aggregatin f categries will be made accrding t

107 what will be cnsidered mst fruitful fr ur purpse. In this SES-classificatin separatin is made between persns gainfully emplyed (500 wrking hurs r mre last year), and persns nt gainfully ccupied. Fr gainfully emplyed the place in the hierarchy further depends n e.g. type f ccupatin (3. digit level), status as emplyed r independent wrking, whether the persn is in a labur grup r in white cllar ccupatinal grup, level f cmpetence and if the persn has a leading psitin. Fr persns nt gainfully emplyed, place in the hierarchy is defined n base f main type f activity (student, cnscript, huse wrk), status f lng time unemplyment, r type f scial insurance received. Persns nt gainfully emplyed (dependents) can als be cnnected with the status grup f the main supprter f the family. Cause f death Cause f death is cded in accrdance with the ICD, 8 th revisin. The files have infrmatin at 4. digit level, but the analysis will be made fr aggregated grups. Fr cardi-vascular diseases and cancer part f the analysis may be carried ut fr specified subgrups. ; Reginal variatin As mrtality in Nrway shws great reginal differences, a gegraphical divisin will be cnsidered in the analysis. Time schedule - The prject is nw in its planning perid. The data prcessing will take place frm autumn 1983, and the analytic wrk will start late 1983. The final reprt frm the prject is planned t be published late 1984. Staff The prject will be carried ut mainly by an actuary, a medical epidemilgist and a scilgist at the Office f Health Statistics. Bibligraphical references 1. Tnnesen, Bjrn (1974: Enkelte trekk ved dpdelighetsmnsteret i Nrge 1970-1964 sammenliknet med andre land. Arbeidsntat (Wrking Paper) 10 nr. 15, 1974. Statistisk Sentralbyra, Osl. 2. Statistisk Sentralbyra (1976): Yrke g dpdelighet 1970-1973 (Occupatinal mrtality). Statistiske analyser (Statistical Analysis) n 21. 1976, Osl. 3. Kristfersen, Lars (1979): Yrke g dpdelighet (Occupatinal mrtality). Tilleggsberegninger til tidligere analyse. Rapprter (Reprts) n 19, 1979, Statistisk Sentralbyra, Osl.

108 «"ç^ S 835 271 602 S t n 858 844 N S 107 _ -S " x, 3-2 00 -< O N n S 5 00 0% 11 I «I -a s 1 s»n ON «m «V) M h r M r O ~ ON m» N O "*r Q «v m ^ >r> <r> «t «* m *n «ri «-* S8 2 Ñ p- S 8 O IN ON «r~ en «M >n t (7> s H S 2 * -> S ai I 7Ï a * B 9. «T3 # Ji S C ^ tï "> ^ «1J1.S iïllî S '8-O l S _ à! S S g 0 O i? O b. le.si n î " II c u rt. ii!! a. a 8 ^ -a > ut *- >. Ö g gl 9 C.î» 3 «u t; «H if a ea >. 5 S S 11

109 I s 00 f^\ NO NO» N75 ON «n e s TÍ- n»o i-» ON rn r~ m s r- 824 443 552 NO ON 116 584 017 ON t 849 984 «S 669 ^> -< O 00 O m ^ \ O *N OO ON e4 s <N rn r» *-» m» t^- v CM m ~- NO m SO ON rn <N -^ \O m S _* M r* * NO O Vl 00 VI O ôô ON VI O s O NO 3 NO = a r» N \c ON ~* «N M ON «f* 00 ON m fn -^ lííjll X * s s» NO NO S goo r- s vo g 00 m ONO M < N «O -^ ONOOCÏ t"»n»n M r» c a s * M ai. M C a 1 a cn Cu v <5. i " û M g.s 5 «II s c i 2 S "S il II 1? i S O s M 1 s s s!! a

110 O "O *O 3 OO 00 00 so <N Tf I- (N O m *N i OO IN SO so <S SO «s m w-i \O OO <N r- vu ~H» r- m «-» v O <N t - \ r^ <N "1 O\ r-- r-l IN t 3 s <N < r^ <t v fi IT» «-^ V-> OO so O r» c r-t Q *t 1 O 00 fs I O \ v~> <+i r* *t s **» r- s «n r-4 -» -* 5 N n OS \O «O ^H ^ s - r< r- OO SO *t Vi ~ \ O N h vi N lull t- 00 vi O v> _ vi sc ^> c a s a u > V. M -.* (S v> ^ U O J L^ 5 _ D, 60 S 'S. '5> ~ ^ 2 Ü ^ 1 2 -a -g & i c 3 s S C ï g Si SS.9 <T O C3 r i TÎ *n s r^ rj N N M 5 2 it " a?. 'i 1 E e I -S -g "S s. a s «s f C Olí a-as -S-g *- iä ^ ni g g G lis 1 C u 0 : = * "5 u S-g D. ni s & D.»S.5 II E«E.y O E «g a E «s ; i a S

Ill IN ÍN OO O 00 OO \O m S 5 ON ON OO i «* 3 rn m ON N 2 3 6 S! S S S s m ft <N 3i - 1 z~ S fl> l» O> 00 O O IN O «5 IN 1^ VO <N J» *û «O m O io O t r~ t> IN c 3 6 waning ant wr u caí etc j -i ccd le "estai grap _/ i rk -prcess leaning kaig and c e ucti s. Nursii Htel Electrica verage Other laundi Buildi pstal Textih Other Y a icd j; retak essenge c >, 00 B E cj O m 3< Q ggo«-" «N «>»

112 t- 8 Tf 00 S; = 2 8 0 00 00 8 I D. a 8 CÜ 3 5.5 S 5 3 i.s -a sg g > g a, - IS 8 8 3 2 i et 8 v m c c s a a CD CL if " 2 "(3 ï a> rt 5 -g il ;-1» "S^ ^ gj! S il 'Si w I -s 8 cd C» crt -g-s s 11 N m <s t Cleric Wrki frm i Pstal precisi S les wrl /rk tin w rk, etc. pr priel rs ices and ret id telec :han ica M C S > '3 cd 'S 3 CD S Ü e iterairy ravelier 1cdrk Artisti cm m ercial t; manul ureí Shipciffiicers a c u r- D C VI Vi u es 00 micall c c~~ her The tt

113 -* (-4 «««««4 O I/-1I--M OC O O O ' C~ * O e> 4 CO OO 8 c- ÎJfiïl.S " '* 1/1 ^* T3 ^ S ' ** : a g. c -a ü ó 'S ns &< S e t m ü «O a c a.* T3.1 5 S- ^- * S." 2 K u w c - * 2 {* Ef! c jt * O cd u "3 u 2 'S -j «p ü > c S a S g I «"3 S e ' w '3 Ü 3 O S 5 fe O O S "* *N CQ a H S <2 c u S O M» O a ts O X 00 s 53 a a u a O w> s «

114 H.E O.S O.! 8 8 2 2, > c.5 S^p 2 8 8 *rt Q ^^ S 10 r- es 8 <^ 8 8 S S e "3. 3.E E T3 C O i!!1 ti O «3 'S c c & 2 -a c u c 13 c i: c < s!ë "5 1 'e ^ E A r. 5 u u act iive, tt :ntific i >-. m cal c U u V J O % vi n u etc b O ggiical edical nis ter n -a ^ cil nisti 'i blic adi n f pr ganizal 3 O O > i: E T3 C a c.2 c S D. c 0 73 erii O S etc# rs, sal retail vv nmunic:atin i & riet,ing & C T3. c«. ices " O f Sá tlar sin a. "5 1 E u.

115 " Si?

116 Appendix 1 DETAILED OCCUPATIONAL CLASSIFICATION (Fr ccupatinal titles f Standard Classificatin numbers, see Appendix 2) Occupatinal class in the prject MALES FEMALES 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 01 02 Occupatin by Standard f Occupatinal Classificatin (tw-digit grups) used in the 1970- census 00, 01, 02, 07, 08, OX, 31 06 03, 10, 11,05 20,21, 29 30, 33 66, 67, 74, 96, 97, 98 09, 32 60 62, 63, 65, 90, XI 69, 76, 80, 82, 99, 84, 86 78,94 93, 42, 68, 89 70,71,72 40 64, 87 75 77 91, 92, 04 81,85,95 41 88 43 61 44 50,51,52,59 73 83 79 00, 01,02, 07, 08, OX, 31 06

117 n,, Occupatin by Standard f Occupatinal Occupatinal class,._..,....,.,,,._..,. Classificatin (tw-digit grups) used in the 1970-111 the prject census 03 03,10,11,05 04 20,21,29 05 30, 33 06 66, 67, 74, 96, 97, 98 07 40,41 08 04,92 09 91 10 69, 76, 80, 82, 99, 84, 86 11 81, 85,95,78, 84 12 93, 42, 68, 89 13 70, 71, 72 14 Remainder 00-99, XI The 1960 ccupatinal census cdes are recded t the crrect 1070-cdes fr thse ccupatins that had different cdes in the tw censuses.

118 Appendix 2 STANDARD OF OCCUPATIONAL CLASSIFICATIONS IN THE NORVEGIAN 1970-CENSUS 00 Technical wrk 01 Chemical and physical wrk 02 Bilgical wrk 03 Medical wrk 04 Nursing care 05 Other prfessinal health and medical wrk 06 Pedaggical wrk 07 Religius wrk 08 Juridical wrk 09 Artistic and literary wrk OX Other wrk in majr grup 0 10 Public administratin 11 Administratin f private enterprises and rganizatins 20 Bk-keeping and cashier wrk 21 Stengraphy and typing wrk 29 Other clerical wrk 30 Wrking prprietrs 31 Salesmen f real estate, securities, business-services, insurance etc. 32 Cmmercial travellers and manufacturers' agents wrk 33 Sales wrk frm ffices and retail sales wrk 40 Management in agriculture and frestry 41 Farmwrk and livestck wrk 42 Game supervisrs and game hunters 43 Fishing, whaling and sealing wrk 44 Frestry wrk 50 Mining and quarrying wrk 51 Well drilling and related wrk 52 Mineral treating wrk 59 Other mining and quarrying wrk 60 Ship fficers and pilts 61 Deck and engine-rm crew wrk 62 Air transprt wrk 63 Railway engine drivers and firemen 64 Rad transprt wrk 65 Cnductrs, dispatchers and freigt assistant wrk 66 Traffic supervising wrk 67 Pstal and telecmmunicatin wrk 68 Pstal and ther messenger wrk 69 Other transprt and cmmunicatin wrk 70 Textile wrk 71 Cutting and seam wrk 72 She and leather wrk 73 Smelting, metallurgical and fundry wrk 74 Precisin mechanical wrk 75 Irn and metalware wrk 76 Electrical wrk 77 Wd wrk 78 Painting and paperhanging wrk 79 Cnstructin wrk nt elsewhere classified 80 Graphic wrk 81 Glass, ceramic and clay wrk 83 Chemical and related prcess wrk 84 Tbacc wrk

119 85 Other prductin-prcess wrk 86 Packing and wrapping wrk 87 Statinary engine and mtr-pwer wrk 88 Lngshremen and related freighthandlers 89 Laburing wrk nt elsewhere classified 90 Public safety and prtectin wrk 91 Htel, restaurant and dmestic wrk 92 Waiting wrk 93 Building caretaking and charwrk 94 Hygienical and beauty treatment wrk 95 Laundering, dry-cleaning and pressing wrk 96 Prfessinal athletes, and sprtsmen etc. 97 Phtgraphical wrk 98 Funeral service 99 Other service wrk XI Military wrk

121 ESSAI DE CONFRONTATION DE QUELQUES ÉTUDES PROSPECTIVES DE MORTALITÉ Guy DESPLANQUES Institut Natinal de la Statistique et des Etudes Ecnmiques, Paris, France Dans plusieurs pays dévelppés, surtut à partir de 1970, des études prspectives nt été mises en place pur mesurer les différences de mrtalité suivant des caractéristiques sci-écnmiques. Ces pays snt les pays Scandinaves, la Grande-Bretagne et la France. En quelques mts rappelns que les études prspectives cnsistent à définir un ensemble de persnnes dnt n suit individuellement la situatin à l'aide d'un répertire u d'un fichier de ppulatin ù snt ntés les décès. Le principal avantage de ces méthdes est d'assurer l'hmgénéité des numérateurs et des dénminateurs dans le calcul des qutients de mrtalité. Plusieurs publicatins relatives à ces études nt vu le jur depuis 1979: la dernière, semble-t-il, est celle de l'opcs (Gldblatt et Fx). Cnnaissant bien l'étude française, j'ai tenté de cmparer quelques résultats des différentes études ainsi que quelques aspects méthdlgiques, du mins lrsque la dcumentatin dnt je dispse m'en dnnait la pssibilité. Cntrairement à ce qui purrait sembler la démarche scientifique, je cmmence par une cmparaisn des résultats. I. Mrtalité suivant la catégrie sci-prfessinnelle La cmparaisn de la mrtalité différentielle suivant le milieu scial entre plusieurs pays se heurte à plusieurs difficultés. La principale de ces difficultés vient de la différence des structures sciales. Histriquement, certains grupes sciaux u prfessinnels nt pris une place particulière. En Grande-Bretagne, les uvriers snt traditinnellement nmbreux; par cntre, les agriculteurs cnstituent un grupe assez minritaire,

122 au cntraire de la France et de la Finlande. Des nmenclatures des catégries sci-prfessinnelles nt été définies dans chaque pays: elle tiennent cmpte évidemment des structures sciales lcales et présentent d'un pays à l'autre des divergences sensibles, particulièrement en ce qui cncerne des catégries difficiles à classer, tels que les cls-blancs, les techniciens. Chaque langue s'est mdifiée en fnctin des usages du pays et une traductin mt-à-mt des termes utilisés pur désigner un grupe cnduit à bien des erreurs. Malgré cela, il est tentant de chercher à cmparer la situatin de différents pays. L'étude publiée en Grande-Bretagne par Gdblatt et Fx (Sci-demgraphic differences in mrtality, Ppulatin Trends 27 Spring 1982) prte sur un échantilln au 1/100 tiré du recensement de 1971, ù nt été relevés les décès survenus avant 1976. Pur la France, les résultats prtent sur un échantilln tiré du recensement de 1975: n y prend en cmpte les décès survenus avant le 1er janvier 1981. Cmpte tenu de l'évlutin assez lente de la mrtalité adulte et des différences de mrtalité entre milieux sciaux, ce décalage des pérides d'bservatin n'apparait pas gênant pur une cmparaisn. 1. Les difficultés de cmparaisn dues aux nmenclatures utilisées Les Angl-saxns, ainsi que les Scandinaves, utilisent fréquemment un decupage en 5 grupes sci-prfessinnels. Dans ce décupage, il est assez difficile d'isler les grupes II et III, qui snt hétérgènes et se recupent par ailleurs. D'autre part, le grupe I est très réduit. Dans ces cnditins il faut descendre à un niveau plus fin pur mettre en évidence des écarts plus significatifs. En utilisant la nmenclature plus détaillée, il est pssible de cnstituer, à la fis pur la France et la Grande-Bretagne, un décupage en une quinzaine de grupes qui rassemblent à peu prés les mêmes prfessins. 2. Quelques dnnées Pur la Grande-Bretagne, l'bservatin prte sur les individus de 15 à 64 ans. Tus snt classés suivant leur catégrie sciale, sauf les étudiants. En France, n s'est limité aux persnnes actives de 30 à 64 ans, ayant un empli u chômeurs. Les retraités et les inactifs jeunes ne snt pas pris en cmpte. Ce qui suit ne prte que sur le sexe masculin. Pur chacun des grupes sciaux cnstitués et pur chaque pays, nt été calculés:

123 le nmbre de décès bservés, qui dnne une idée de l'aléa qui pèse sur le calcul de l'indicateur de mrtalité, le nmbre de décès «attendu» btenu en appliquant les qutients de mrtalité de l'ensemble de la ppulatin à la structure par âge de chaque catégrie. Pur la France, ce nmbre attendu tient cmpte des cefficients de pndératin qui diffèrent d'un grupe à l'autre et dépendent de l'âge, le «SMR» (taux de mrtalité standardisé). Ce SMR indique la surmrtalité u la sus-mrtalité d'une catégrie par rapprt à la ppulatin du pays crrespndant. Les grupes d'âge envisagés n'étant pas les mêmes, les indicateurs ne snt pas directement cmparables: cependant, les décès de 15 à 30 ans snt assez peu nmbreux (envirn 15% des décès qui surviennent entre 15 et 64 ans, pur le sexe masculin, en France, en 1980) et ne cmptent pas trp dans le calcul du SMR. La répartitin des décès «attendus» suivant la catégrie sciale dnne une idée de la structure sciale, vue cmme répartitin de la ppulatin suivant le milieu scial; du fait que la mrtalité des persnnes âgées est plus frte, entre 2 catégries de même effectif, celle qui a la plus frte myenne d'âge sera plus représentée. La cmparaisn de répartitins dans chaque pays permet de vir que la cïncidence des catégries est à peu près bnne: les agriculteurs snt beaucup plus nmbreux en France. Par cntre, les uvriers qualifiés («Skilled manual wrkers») frment plus de 1/4 des décès attendus en Grande-Bretagne et 12% seulement en France, les uvriers spécialisés («Semi-skilled manual wrkers») et les maneuvres («Unskilled manual wrkers») snt aussi plus nmbreux. Cette cnstatatin rejint une réalité: la classe uvrière est très imprtante en Grande- Bretagne; mais il est pssible que certains individus, classés en France crne cntremaîtres u techniciens, sient des «skilled manual wrkers» seln la définitin Angl-Saxnne. La cmparaisn entre les 2 pays de la mrtalité par catégrie sciale cnduit à plusieurs cnstatatins. Tus d'abrd les écarts snt beaucup plus sensibles en France. Le SMR va de mins de 50 chez les ingénieurs à près de 150 chez les maneuvres, si n ne cnsidère que les actifs. En Grande-Bretagne, la gamme des SMR s'étend de 60 pur les agriculteurs à 120 chez les maneuvres et 130 parmi le persnnel de service. En France les agriculteurs nt une mrtalité beaucup plus faible que les uvriers alrs que leurs cnditins de vie, leurs niveaux de frmatin snt visins. Les agriculteurs («farmers») anglais snt prbablement plus cmparables aux grs agriculteurs. Leur faible mrtalité n'est dnc pas étnnante. Mais les salariés agricles de Grande-Bretagne snt aussi mieux prtégés que ceux de France: n peut penser que dans un pays ù l'agriculture utilise depuis lng-temps des techniques industrielles, la qualificatin des uvriers agricles peut être élevée.

124 A ces exceptins près, la hiérarchie des catégries apparaît assez visine dans les 2 pays avec, n l'a déjà dit, des écarts plus réduits. II. Prblèmes méthdlgiques Les études prspectives dnt les résultats snt cmparés ci-dessus utilisent le même principe. Cependant les instruments qui les permettent diffèrent sensiblement. En Grande-Bretagne, «l'identificatin» et le relevé des décès des individus de l'échantilln se fnt à l'aide du NHSCR (Natinal Health Service Central Register) ù tus les individus résidant en Grande-Bretagne snt inscrits, y cmpris les persnnes nées hrs du Ryaume-Uni. En France, le répertire qui permet cette identificatin et ce relevé de décès ne cmprte que les individus nés en métrple. Ceci cnduit à des différences ntables: les recherches pur identifier un échantilln abutissent plus suvent à un échec en France puisqu'il faut exclure les nés hrs de France; par cntre, lrsqu'une persnne a été retruvée, il est rare que le décès ne sit pas transcrit et relevé, en tut cas si elle est française. Entre les qutients de mrtalité mesurés au sein de l'échantilln (qui prtent sur les Français nés en France) et ceux qu'n mesure avec les instruments traditinnels (qui prtent sur l'ensemble de la ppulatin), il y a effectivement très peu de différences. Pur la Grande-Bretagne, ces deux séries révèlent une sus-estimatin sensible de la mrtalité masculine aux âges actifs, dans l'échantilln suivi, de 15% envirn. Une telle sus-estimatin sulève quelques questins.

«H» 125 and ass 3 S + H 3 g 8 tu i m eu a 2O c c..2 ' O O HL) S c ci > O cl O. E U Ui u.0 ' 3 0 e- 3 0 CO z ela - Ë Z n. 3 200 0 "Ê 0c0 c, CD 1 0 Sci rie 60 "22 c5 U tu a s a "tu i [OISS tu 4-i 0 0. ó G0 CO 3 a s v" 1 S CO «E UÍ a c tu li n cd ll O M U DO M U c ^ C u E eu S tu '0 ntr hni I 'S. c 8u 03 le 8 S»'S tu a) < ««N -^ ri 3 )'<N cn a^vt-v-hv «c M 'S S B I CO t/i </i y Ils,0 S «4- ^ j ^ S E * ß «ci = TS«S2 «fil e Ç "X CO l 2 E "S 2 t G? I i 00 si a-ta O 3 S.E * 132 e 13 = 3 TJ S eu S ^2 C c.û 3. l_ c " Ë tu 11! "5 g '5 "5

126 c 4> u I m u Im w Q i a v> 3 si OO M - - «O <M* O g T3 g O 4> C O î s óg CO MU u il (A a I ". 8 u e fe C e ITÏ w-j * t-.» < s. «* h 'S * * * * * r^ O ^M *** s ^ «i? ï «i h 1? 2 ^2 -= i J 1153 Hi S..52 s «a *T O r«r-l "3 *~^ Ï-«s "^ *^ "" ti O < H *» E 2 u O O vi "S O, Ë Ô «s u» '0 " Sí "-E Í2 n 3 ui O.îi» «13 B ÎJ SCO g«3 H "ö ri «ils su5< e fe agi 111 1 âîllï E C 3 fe 3 u < O cu O Ï < c H

127 (JU í 3 8 es < ub PQ U a GRA i bser Oí ffl m u "O SO g B O O t.si? 5 2 2P 8 S? G 60 ca s I I ó s MU <u -a î a C l-i! S a O U ' g h O «A n tu u i I 2 g D. >> i«lg d> 3 3-S «3 CA 1 E Q O _ «E u fiés "Ï3 pli rier: ersnneld O 1 > 3 O > u u a. Vi C/3 "a )_.Sá UV] O les. agri ivres riés el "ri C/3 S ctives c 6

128 Taux de mrtalité seln le sexe et l'âge en France et en Grande-Bretagne (pur 1000) (aux âge d'activité) Age Hmmes FRANCE Femmes GRANDE-BRETAGNE Hmmes Femmes 25-34 25-44 45-54 55-64 1,6 3,0 8,1 16,7 0,7 1,4 3,3 6,6 1,0 2,0 6,6 18,8 0,6 1,4 4,1 9,9

129 SECTION III PROBLEMS AND OPPORTUNITIES FOR RESEARCH ON THE BASIS OF LIMITED DATA New research directins n sci-ecnmic differential mrtality in the United States f America (Harry M. ROSENBERG and Marilyn M. McMILLEN) Develpments in research n sci-ecnmic determinants f mrtality since 1981 in the Netherlands (Jeren K.S. van GINNEKEN) Recent mrtality change amng wrking vis-à-vis nn wrking ppulatin at age f ecnmic activity and agricultural vis-à-vis nn-agricultural wrkers in Pland (Marek OKOLSKI) Prblems and pssibilities f research in cuntries with limited data (Wilfried LINKE and Jan Van REEK)

NEW RESEARCH DIRECTIONS ON SOCIO-ECONOMIC DIFFERENTIAL MORTALITY IN THE UNITED STATES OF AMERICA 131 Harry M. ROSENBERG and Marilyn M. McMILLEN Natinal Center fr Health Statistics, United States f America Increasing interest in the United States is fcusing n sciecnmic and lifestyle factrs assciated with mrtality. Amng the reasns fr the increased attentin has been the rapid dwnturn in death rates frm heart disease, the leading cause f death in the United States. As f 1981, prvisinal data fr the United States shwed that this cause, which accunts fr abut fur f every ten deaths, had declined by ver 36 percent since 19500). While the reasns fr the dwnturn are nt fully dcumented r understd, it is widely believed that sciecnmic and life-style factrs have played an imprtant rle in mrtality reductins frm heart disease and a number f ther majr chrnic cnditins* 2 ). What data bases are available in the United States t study the relatinship f sciecnmic factrs t levels and trends in mrtality? The mst recent cmprehensive results are thse frm the 1960 landmark study by Kitagawa and Häuser. That study, which fcusses n mrtality differentials by incme, educatinal attainment, and ccupatin, was based n matched 1960 census data and death certificates fr the same individuals^). Since the Kitagawa-Hauser study, a number f ther studies have been undertaken; these have used a variety f methds, data bases, and variables. Sme have been micranalytic, that is, based n bservatins fr individuals, as is the Kitagawa-Hauser study, while thers have been «eclgical», that is, based n bservatins fr gegraphic areas rather than individuals. The limitatins f eclgical studies are wellknwn(4). Studies based n individual bservatins, while far mre preferable, are generally mre cmplex and mre cstly that eclgical studies. Necessity being the mther f inventin, in recent years the absence f needed data based fr investigatin f sciecnmic differentials stimulated use f inferential prcedures which are applied t available data sets t prvide knwledge abut sciecnmic differentials. Irnically, sme f the techniques, in use in the

132 United States were develped principally fr demgraphic investigatins in cuntries with extremely limited data, mainly the develping natins. Stimulated largely by epidemilgical interest in factrs assciated with differentials and trends in cause-specific mrtality, there is currently a resurgence f interest in the United States in the subject that is the fcus f this meeting. There has als been a lng-standing and cntinuing interest amng scial scientists and sme wh are cncerned with scial plicy in issues f equity as they relate t bth health and mrtality. They ask whether the likelihd f death is distributed differentially amng scial grups and amng sciecnmic strata. And they are interested in whether the sustained reductins in mrtality in the United States have been accmpanied by a narrwing r a widening f mrtality differentials by sciecnmic status. This paper prvides a brief verview f U.S. mrtality differentials by sciecnmic status illustrated by salient but selected Findings frm majr studies. This, by way f backgrund, prvides fr a catalg f data bases that have recently been develped r analyzed r are nw in the develpmental stages. These include the fllwing: 1. The U.S. natinal lngitudinal study f mrtality differentials. 2. Cding ccupatin and industry reprted n the death certificate. 3. The natinal mrtality fllwback Survey. 4. Administrative recrds studies. 5. Indirect estimatin methds. In additin, this paper prvides a cmprehensive set f references t recent studies f sciecnmic differentials in mrtality in the United States. Backgrund The mst cmprehensive infrmatin n sciecnmic differentials in mrtality in the United States is based n data well ver tw decades ld, namely, the study by Kitagawa and Häuser which utilized matched recrds frm the 1960 Census f Ppulatin and death certificates. That study revealed pervasive assciatins between incme and educatin separately n the life chances f males and females f bth majr race grups-white and persns f ther races. The data in Table 1 and 2 shw that in the United States in 1960 mrtality f the white ppulatin varied inversely with level f educatinal attainment and incme. These mrtality differentials can be translated int relative gains in years f life; fr example, a white male at age 25 years with 12 years r mre f schling culd expect t live ver tw years lnger, n the average, than a white male f that age with less than a high schl educatin (Table 3)(5). That a negative assciatin existed between educatinal attainment and mrtality was an imprtant finding, because years f schling wuld nt be affected by adult

133 health status, whereas incme culd be. Duleep ntes, «the effect f educatin estimated by Kitagawa and Hauser was the first certain indicatin that sciecnmic status des in fact affect adult chances»* 6 ). The Kitagawa-Hauser study made it pssible t examine bth the effects f incme cntrlling fr educatin and the effects f educatin cntrlling fr incme; each was fund t have an independent effect n mrtality. Kitagawa and Häuser cncluded that «educatin is prbably the single mst imprtant indicatr f sciecnmic status fr mrtality analysis»* 7 ). With regard t the incme effect, they asked if it might be due in part t a «reverse causal effect», whereby pr health (assciated with a higher prbability f death) culd als be respnsible fr lwer incme. Their crss-selectinal data did nt permit analysis f this effect. One culd nt knw, therefre, what it was abut higher sciecnmic status that appeared t cntribute t lnger life. Infant mrtality in the U.S. is als assciated with sciecnmic status. Results f the NCHS Natinal Survey f Infant Mrtality fr 1964-66 shwed that the educatinal attainment f mthers strngly affects the prbability f survival f their infants: thus, fr wmen with less than a high schl educatin, infant mrtality rates were ver 50 percent higher than thse fr wmen with at least a high schl educatin (Table 4)* 8 ). Until recently, n natinal data were available that culd dcument the extent f sciecnmic differentials amng children aged 1 t 20 years. In the Kitagawa-Hauser study, the attributes f the husehld were nt assigned t persns in that age range. Hwever, using 1975 data Mare prvided estimates f childhd mrtality differentials based n indirect estimatin prcedures applied t data frm a representative sample f the United States ppulatin* 9 ). He fund that, like adult mrtality, childhd mrtality is hightly assciated with differentials in family incme and educatinal attainment f parents. Thus, survival rates f children whse mthers had less than a high schl educatin were as much as a third lwer than thse whse mthers had graduated frm high schl (Table 6). The findings are similar t thse frm the Kitagawa and Häuser analysis f adults; fr children Mare fund that educatin affects mrtality, cntrlling fr incme, and that incme affects mrtality, cntrlling fr educatinal attainment f the parent (Table 7). Kitagawa and Häuser, and mre recently Therriault and Lgrill, shwed that the assciatin between mrtality and factrs such as incme, educatin, and ccupatin varies by cause f death. Using vital statistics data fr upstate New Yrk in 1980 Therriault and Lgrill fund, fr example, a psitive assciatin between educatinal attainment and cancer mrtality amng wmen (standardized prprtinal mrtality ratis), but a negative assciatin between educatinal attainment f these wmen and the likelihd f death frm mycardial infarctins (Table 8)* 10 ).

134 These selected findings shw the persistence f sciecnmic differentials in mrtality in the U.S. and hint at the magnitude f thse differentials. In the ver 150 years since Crbaux first dcumented the inverse relatinship between sciecnmic status and mrtality in an urban-industrial sciety* 1 >, the Western wrld has experienced substantial reductins in mrtality. These reductins have been attributed t imprvements in medical care, public health, and the general standard f living. Expectatins that recent imprvements experienced in mrtality wuld eliminate sciecnmic differences in the risk f dying have, bviusly, been unfulfilled. The present dimensins f these differentials in the United States are, hwever, nt well knwn. While ur present knwledge is still defined largely in terms f the Kitagawa-Hauser study f 1960, sme imprtant cntributins have been made since then, including Mare's wrk n childhd mrtality differentials. In additin, a number f researchers have attempted t unravel the casual structure between selected sciecnmic factrs and mrtality. Fr example, in attempting t interpret the statistical assciatin between incme and mrtality, a majr questin that has been raised, and examined empirically by a number f researchers, is whether what ne sees is the casual influence f incme n the likelihd f death r whether the assciatin really represents just the ppsite in a causal sense; that is, the influence f health r disability n incme. This prblem f «reverse causality» has been examined by, fr example, Rsen and Taubman* 12 >, Caldwell and Diamnd* 13 ', and Duleep* 14). Using lngitudinal data bases, which are essential t study this prblem, the mst recent findings by Duleep indicate that the relatinship between incme and mrtality remains negative even when health status is taken explicitly int accunt. Fr example, in an analysis f incme differentials and mrtality f white males, Duleep stated «Taking int accunt the effect f disability n incme, incme cntinues t have a large and significant negative effect n mrtality. The relatinship is nt linear ver the whle range; rather, mre incme is assciated with reduced mrtality risk up t the average incme level, thereafter its effect is insignificant»* 15 ). In cnclusin, then, we are beginning t understand the independent effects f a selected set f sciecnmic variables n mrtality in the United States. The smewhat fragmentary nature f past studies in the U.S. des nt lend itself readily t a cmprehensive understanding f the situatin nr des it enable us t trace patterns ver time. Fr example, are the assciatins becming weaker? Are differentials diminishing r intensifying? Are new factrs cming int play? Are new public plicies affecting thse aspects f survival that are assciated with sciecnmic factrs? New data bases are emerging, and new tls are being develped in the U.S. that will allw us t explit existing data that heretfre were nt cnsidered part

135 f the research repertire fr studying these questins. The fllwing discussin reviews current and emerging appraches t the study f sciecnmic differentials mrtality in the United States. The U.S. Natinal Lngitudinal Study f Mrtality Differentials Cmprehensive studies f mrtality differentials almst always require bringing tgether at least tw different data bases. Mrtality data certainly by cause f death-will be drawn largely r exclusively frm the certificate f death, while the infrmatin n sciecnmic status is mst likely t be frm a different data base such as a census r a survey r a set f administrative recrds. Establishing the linkage between tha mrtality file and the crrespnding recrds fr individuals in a file that includes sciecnmic variables has prbably been a majr deterrent t studies using micrdata in the United States. Even in the Kitagawa-Hauser study, the very high unit cst f manually matching files led t decisins t substantially reduce the sample size< 16 ). Lngitudinal studies have been undertaken elsewhere: Fx and Gldblatt have cnducted a lngitudinal study f mrtality differentials in England and Wales using a ne-percent sample f the 1971 Census f England and Walesd?). A mechanism has nw been develped that prmises t cnsiderably reduce the cst and t increase the feasibility f creating linked files f the srt that are essential t studying differential mrtality. This mechanism, recently implemented by the Natinal Center fr Health Statistics, is called the Natinal Death Index (NDI)< 18 >. The NDI is a centralized, cmputerized index f death recrd infrmatin cmpiled frm magnetic tapes submitted t NCHS by the State vital statistics ffices. These tapes-beginning with deaths ccurring in 1979-cntain a standard set f identifiers fr each decedent, which can be matched against similar identifying infrmatin frm an entirely different set f recrds-such as a survey, r an administrative file r even-theretically a census. The NDI makes it pssible fr investigatin t cnduct prspective studies in which they can determine if persns in their file may have died, and, if s, the NDI prvides the names f the States in which thse deaths ccurred and the crrespnding death certificate numbers. This enables a researcher t prcure cpies f death certificates frm State vital statistics ffices, where recrds are maintained. The death certificates can then be used t abstract infrmatin such as cause f death f the decedent. Use f the NDI is restricted t statistical studies in medical and health-related research; it cannt be used fr legal r administrative purpses. The NDI prmises t reduce cnsiderably the high csts f linkingfileswith death certificates. In additin, because it is a cumulative file, it can be run repeatedly n a prspective basis in rder t measure attritin (by

136 death) in a starting ppulatin. It is this new resurce-and the lgic f repeated prspective matches--that prvides the basis fr the U.S. natinal lngitudinal, r prspective, study f mrtality differentials. This study is nw in the early implementatin stages, as a cllabrative prject f the Natinal Center fr Health Statistics; the U.S. Bureau f the Census; and the Heart, Lung, and Bld Institute (f the Natinal Institutes f Health). The initial plan is t link a series f eight natinal prbability surveys f the United States nn-institutinal ppulatin (the Current Ppulatin Survey f the Census) t crrespnding identifiers f decedents in the NDI. The surveys span a perid extending frm the early 1970's thrught 1981. Since the NDI thus far includes nly deaths fr 1979, 1980, and 1981, the time perid f expsure t death f successive natinal sample ppulatins will differ. The ttal size f the eight chrts is almst 1,000,000 persns; individual samples vary in size frm abut 46,000 t 189,000. The Appendix cntains a list f the questins that are inlcuded in the cre questinnaire f the Current Ppulatin Survey. Asterisked are thse items that are being cnsidered as candidates fr examining sciecnmic differentials in mrtality. The first results f this study have been n the feasibility f linking Census samples with death certificate identifiers in the Natinal Death Indexe«). A majr strength f the U.S. study is its large sample size f almst 1,000,000 persns. Furthermre, additinal chrts will be added t the base ppulatin ver time. In cntrast, ther files such as the CPS-IRS-SSA Exact Match File, discussed subsequently (see «Administrative recrds studies»), are limited by their relatively small sample size. A ptential strength f the U.S. lngitudinal study is the pssibility f linking the base chrts with ther data surces that can be used t update the characteristics f the ppulatin n a peridic r cntinuus basis. Amng ptential surces f lngitudinal augmentatin culd be the Scial Security Administratin Summary Earnings Recrds, which include such infrmatin as annual earnings, sex, race, age, age at death; and the Master Beneficiary Recrds, which include infrmatin n age, race, sex, disability related infrmatin, hspital insurance, pattern f wrk, military service, marital status, and dependents). Such an augmented file wuld be a vehicle apprpriate fr studying questins such as reverse causality that can nly be addressed effectively with lngitudinal data. The cncept f using representative natinal data based fr lngitudinal studies f mrtality can, f curse, be applied t available samples ther than the CPS. Sme f these natinal samples, such as the NHANES I Epidemilgie Fllwup Survey f the Natinal Center fr Health Statistics, can prvide infrmatin regarding sciecnmic differentials in mrtality. In this Fllwup Survey the mrbidity and mrtality experience f sme 14,000 individuals wh had participated in the NCHS 1971-1975 Natinal Health and Nutritin

137 Examinatin Survey are being fllwed thrugh interview and linkage with death certificates thrugh the Natinal Death Index. The availability f physical examinatin, medical histry, and dietary intake data fr the baseline perid shuld prvide evidence regarding certain f the mechanisms thrugh whith sciecnmic differentials in mrtality develp. The U.S. natinal lngitudinal study f mrtality differentials will prvide a data base that can be used fr a number f ther types f investigatins such as examining the reliability f items cmmn t bth the death certificate and the survey schedule. Such studies were als assciated with the Kitagawa-Hauser research* 20 ). In additin, a variety f health-related and epidemilgical studies can be carried ut that will explre the extent t which mrtality reductins in diseases such as heart disease and strke in the United States may be assciated with sciecnmic and labr frce variables. Cding Occupatin and Industry Reprted n the Death Certificate Occupatin has been widely used bth in the United States and abrad as an indicatr f sciecnmic status. Indeed, in Great Britain ccupatinal mrtality studies, using infrmatin frm the death certificate, in cmbinatin with infrmatin frm decennial censuses, have been a statistical traditin frm 1851 thrugh 1971 with nly a single interruptin, the war year 1941. In the United States the recrd is less cmplete. Our mst recent natinal study was in 1950< 2 '); n studies were carried ut in cnjunctin with the 1960, 1970, r 1980 censuses. The main stimulus fr develpmental wrk n cding ccupatin and industry during the mst recent perid has been nt principally an interest in sciecnmic differentials in mrtality but rather a cncern abut the relatinship between the envirnment and health, where the envirnment is bradly defined as the ambient envirnment as well as thse hazards believed t be specific t certain ccupatins. The wrk f the Natinal Center fr Health Statistics was prpelled by a reprt f a Technical Cnsulting Panel f the U.S. Natinal Cmmittee n Vital and Health Statistics which identified ccupatinal mrtality statistics as an imprtant ptential data base fr studying issues related t envirnmental health* 22 ). The mst recent initiatives by NCHS in this area began in 1978 with an evaluatin study f the «cdability» f ccupatin and industry infrmatin reprted n the death certifícate«23 ). In this jint study by NCHS, the U.S. Bureau f the Census, and the Natinal Institute fr Occupatinal Safety and Health (NIOSH), a sample f 5,000 death certificates fr all resident deaths in the United States in 1975 was drawn randmly within fur age-race strata separately fr the tw age grups 20-64 years and 65 years ld and ver. In this

138 evaluatin study, the ccupatin and industry entries n the death certificates were cded by the Census Bureau t ne f the 424 ccupatinal categries and ne f the 215 industry categries that are identified in the Census Bureau's current versin (1980) f the Alphabetical Index f Industries and Occupatins. Results f the study indicated that an estimated 91 percent f the recrds cntained ccupatinalentries that were cdable. This included 32 percent f the decedents wh were reprted as nt being in the labr frce, mst f whm were husewives. Fr the 59 percent f the deaths that were reprted as being in the labr frce, abut 45 percent were cdable t a detailed ccupatinal categry. Stated differently, ver three quarters f the recrds fr persns in the labr frce were cdable t a detailed ccupatin (3-digit level), such as «electrical engineer». Results f tw previus studies can be cmpared with thse f the mst recent evaluatin, namely, that f Guralnick and f a small-scale study by NCHS fr 1973. Results f all three are cnsistent: fr the U.S., the cdability f the ccupatinal infrmatin n the death certificate has remained cnsistently high at abut 90 percent since 1950. And abut three f fur certificates cntinue t have sufficient infrmatin t permit ccupatinal cding at the mst detailed level f the Census Bureau's ccupatin and industry classificatin scheme. The evaluatin revealed, mrever, that the cding prcedures used by the Census Bureau culd, with sme mdificatin, be adapted t entries reprted n the death certificate. The study als prvided infrmatin relevant t prductin utput shuld these prcedures be incrprated int the data systems f the NCHS r f the States, NCHS has cntinued t mve this prgram frward since 1978 in cllabratin with the tw ther Federal agencies. Thrugh a series f interagency agreements, financed by NIOSH, the cding prcedures used by the Bureau f the Census have been refined. Anther majr evaluatin has been cnducted t determine the feasibility f incrprating ccupatinal cding prcedures int the rutine prcessing f vital statistics. In the United States this rutine prcessing f vital statistics is increasingly decentralized t the State level, such that, ultimately, NCHS wuld receive nly magnetic tapes cntaining precded data rather than receiving actual cpies f the vital recrds which are filed with the States. At the present time, fr example, abut 80 percent f the registratin areas in the United States send t NCHS precded demgraphic data n magnetic tapes. In cntrast, NCHS still cdes medical data fr well ver half the registratin areas. The thrust f the cding peratins, hwever, is clearly tward decentralizatin. The mre recent evaluatin study determined the feasibility f having ccupatin and industry items f the death certificate cded by the States rather than by NCHS. The results, which indicated a high level f cncrdance between cdes assigned by States and cdes independently assigned fr a sample f these recrds by the Bureau f the Census, demnstrated that ccupatin and industry cding culd be dne by the States. Special training,

139 hwever, is required fr ccupatin and industry cding, which in cmplexity falls smewhere between cding the standard demgraphic items n the death certificate and cding causes f death frm the medical certificatin n the death certificate. The interagency prgram is mving ahead by prmting the cding f these items by the States. Several training curses have been held; and an estimated 15 States have begun cding ccupatin and industry reprted n the death certificate using unifrm cding prcedures that are cnsistent with the Alphabetical Index used by the Census Bureau fr cding these items n censuses and surveys. A number f States have prduced reprts n ccupatinal mrtality as special studies; the States include Washingtn State, Califrnia, and Rhde Island. Table 9 illustrates results fr the recent Rhde Island special study based n deaths during 1968-72. The study, directed by David Gute, prduced results that were generally cnsistent with ther studies, such as that f Guralnick, which shw elevated mrtality ratis by cause f death fr a number f ccupatins* 24 ). The State f Wiscnsin has prduced ccupatin and industry mrtality data rutinely fr a number f years as part f its vital statistics prgram. Remaining steps in adapting ccupatin and industry cding int the vital statistics data system f NCHS cnsist f assuring that State-cded data meet the NCHS quality cntrl requirements fr incrprating them int the NCHS vital statistics data set. Finally, inasmuch as the U.S. vital statistics system is a cperative statistical prgram in which bth the Federal gvernment and the States are in partnership fr prducing a cre set f natinal statistics, cst sharing arrangements have t be agreed t and resurces identified fr institutinalizing ccupatin and industry data int the natinal mrtality statistics data set. Use f ccupatin data as indicatrs f sciecnmic status While ccupatinal infrmatin has lng been used in Great Britain as a measure f sciecnmic status, its use fr that purpse has been far mre limited in the United States, where it has been viewed by health statisticians mre as an indicatr f expsure t envirnmental hazards that as a measure f scial class. Hwever, ccupatin can als be viewed as an intervening variable that translates the educatinal advantage int an incme advantage. Guralnick and Mriyama in their 1950 study and Therriault and Lgrill in their 1980 study aggregated ccupatinal data int classes that are similar t thse used in Great Britain. Part f the uniqueness and imprtance f the Therriault-Lgrill study is the cmparisn f mrtality differentials based n ccupatinal aggregatins

140 with thse based n educatinal attainment, which is an item that is unique t the upstate New Yrk death certificate; this item des nt appear n the death certificate recmmended as mdel t the States by the NCHS, nr is it used by ther States. Therriault and Lgrill shw a fairly high degree f agreement between the mrtality gradients assciated with educatinal attainment classes and thse assciated with the brad ccupatinal classes, with greater cnsistency fr females that fr males. They suggest that, f the tw indices, educatinal attainment has a number f advantages, including:* 1 ) ease f cding and* 2» ease f aggregating int brader categries. Hwever, the authrs nte that the peratinal advantages f using educatin shuld be cntrasted with the «argument that educatin shuld be cnsidered mre as an indicatr f ptential than achieved status. In this sense, ccupatin wuld appear t be mre meaningful* 25 )». Others, such as Kitagawa argue that educatinal attainment is the mre meaningful indicatr f sciecnmic status* 2 «. Mare als pts fr educatinal attainment which he characterized as «a mre r less permanent status than ne-sht measures f incme r ccupatin». Arguments abut which variable is mre meaningful, he cntends, shuld be embedded in an explicit mdel f hw sciecnmic differentials cme abut* 27 *. The Natinal Mrtality Fllwback Survey Anther means used in the U.S. t generate data n sciecnmic variatins in mrtality is called a «fllwback» survey. Such surveys have been used t augment the limited infrmatin n the birth and death certificates with data n sciecnmic status. The term «fllwback» refers t ging back t an institutin r infrmant identified n the birth r death certificate fr additinal infrmatin. Fr cnstructing measures f relative risk such as as death rates, fllwback surveys need a «cmpanin» data surce t describe the ppulatin at risk. Hence, the numeratr f the rate is a sample f the fllwback decedents, and the denminatr is a cmpanin ppulatin, which may be derived frm anther set f vital recrds, a census, r an independent ppulatin survey, such as the Current Ppulatin Survey f the Census Bureau r the Natinal Health Interview Survey f NCHS. A number f natinal mrtality fllwback surveys were undertaken by NCHS during the perid 1961-68. In additin, a fllwback survey was carried ut in cnjunctin with the Kitagawa-Hauser study fr estimatin f bias. Kvar and Weed described the earlier NCHS surveys, as fllws: «The prcedure in cllecting the numeratr data in this survey tk advantage f the Current Mrtality Sample, a 10-percent sample f deaths submitted by

141 each State each mnth. This 10-percent sample was subsequently subsampled at a sampling rate f ne ut f 33, prducing an verall rate f 1 ut f 330 deaths registered in the United States. A mail survey then was the principal methd f data cllectin. The primary surce f infrmatin was the persn wh prvided the funeral directr with the persnal infrmatin abut the deceased fr recrding n the death certificate. The mailing address f the death recrd infrmant is usually reprted n the death recrd but each primary surce infrmant, attending physician, funeral directr was asked t identify ther persns wh might be able t cmplete the questinnaire. Therefre, infrmatin was als cllected frm a secndary surce if the primary surce culd nt prvide all f the requested infrmatin. There were als prvisins fr cllecting missing infrmatin by ther means; these included telephne and persnal interviews which were carried ut by the Bureau f the Census... The respnse rates fr these surveys were abut 90 percent«28 ). Kvar and Weed underscre the great advantage f fllwback surveys, which is that the surveys can ask questins in precisely the same way n bth the numeratr and the denminatr. Als, the dates f the numeratr and denminatr surveys can be synchrnized, thereby minimizing classificatin prblems, such as thse that exist in ccupatinal mrtality studies where the items n the death certificate (numeratr) differ cnceptually frm thse n the census r surveys (denminatr). The type f synchrnizatin that has ccurred in past fllwback surveys has been f tw types:(i) in the 1964-66 Natinal Infant Mrtality Survey, a cncurrent fllwback survey f births was taking place-the Natinal Natality Survey-which prvided the needed denminatr data.») In the 1966-68 Natinal Mrtality Survey, which fcussed n smking, the same questins n smking were asked n the Current Ppulatin Survey t prvide crrespnding ppulatin data. < The great advantage f fllwback survey fr studies f sciecnmic factrs assciated with mrtality is the great ecnmy in sampling frm the universe f vital events, which are relatively rare events. Because a death ccurs with a relative frequency f less than ne-percent n a ppulatin basis, a prspective ppulatin-based survey wuld capture a death with relative infrequency. In cntrast, using the fllwback technique ne can identify a specific sample f interest, such as deaths frm a particular cause f lw frequency, and can include all f them in the survey. Alternatively, ne can als fcus n an ccupatin f relatively lw frequency, again including, if ne wishes, every death in a year assciated with that specific ccupatin. Premilinary plans are being develped fr a Natinal Mrtality Survey t be carried ut by NCHS in 1985. Under cnsideratin as the subject matter fci f the 1985 survey are the fllwing:(i) the ptential fr preventin f premature

142 death by inquiring int the assciatin between risk factrs and deaths frm preventable causes;* 2 ) health care services needed and prvided fr lder persns in the last year f life; and< 3 > sciecnmic differentials in mrtality. Research Based n Administrative Files Administrative recrds that can be used fr demgraphic research are maintained in a number f Federal prgrams. Of these files, that f the U.S. Scial Security system is extensive in ppulatin cverage, is cntinuusly updated, includes a number f demgraphic characteristics such as industry and earnings, and generally cntains infrmatin n the fact f death. That such a data base culd lend itself t a variety f research applicatins, including the analysis f mrtality, has been recgnized» 9 ). The Cntinuus Wrk Histry Sample f the Scial Security Administratin is a ne-percent sample f f the Scial Security files, which includes date f birth, sex, and race-btained frm a persn's applicatin fr a Scial Security number. Earning infrmatin as well perids f wrk during the year (in quarters), emplyment status, and gegraphic lcatin f wrk and industry are all included in the file. Infrmatin n health status is available frm recrds f the applicatin fr disability benefits administered under the System. Given the link between benefit payments and mrtality, the Scial Security Administratin cllects death infrmatin thrugh several paths. This administrative data base prvides a unique lngitudinal file that lends itself t studying selected aspects f mrtality differentials that require lngitudinal data bases, as the prblem f reserve causality believed t clr the assciatin between incme and mrtality. The data base has the ptential, als, f being linked with statistical infrmatin frm the death certificate, including ccupatin and cause f death. This is being explred by the Scial Security Administratin in a number f studies. The file is mst cmplete in terms f ppulatin cverage and cmpleteness f mrtality reprting fr white males. The Scial Security files have been used in studies t ascertain the assciatin between incme and mrtality. Results f these studies have nt been cnsistent. Early results suggested that there might be a u-shaped assciatin between incme and mrtality, when health status was taken int accunt. Hwever, Duleep, wh has critiqued the earlier wrk and undertaken her wn, argues that a reasn fr the incnsistencies stems frm incmplete use f all majr surces f death reprting in the Scial Security Administratin files. By accessing all surces f mrtality infrmatin and limiting the study ppulatin t thse fr whm death reprting has been fund t be clse t perfect, Duleep cncluded that higher incme is strngly assciated with lwer prbabilities f dying, cntrlling fr educatin»o0).

143 Indirect Estimatin Methds Except fr England and Wales, sciecnmic effects n child mrtality have been a largely neglected tpic thrughut the develped wrld, accrding t Rbert Mare, wh has used indirect estimatin methds t fill this lacuna fr the United States^1). These methds, irnically, were develped and have largely been used fr develping natins where data bases fr demgraphic research are ften acutely limited. Fr the United States, sciecnmic infrmatin n child decedents has been absent. Occupatin infrmatin sught n the certificate f death has n relevance fr children wh have nt entered the labr frce. Mrever, this age grup was nt included in the Kitagawa-Hauser study, because n link was established between the sciecnmic characteristics f the husehld and the children in the husehld. In the Natinal Mrtality Surveys f NCHS number f children in the sample have generally been t few t permit reliable estimates.. Mare used infrmatin frm the 1975 Current Ppulatin Survey (CPS) t btain estimates f the relative mrtality f children (1 t 20 years). The CPS, mentined earlier in cnnectin with the U.S. Natinal Lngitudinal Study f Mrtality Differentials, is a large prbability sample f the U.S. nninstitutinalized ppulatin. The 1975 survey included questins abut the survival status f wmen's children, which culd be transfrmed int relative mrtality rates, and culd be, in turn, related t infrmatin in the CPS n family incme and characteristics f the mther such as her educatinal attainment. Mare's data set included a ttal f ver 40,000 children f whm almst 800 had died by the time f the survey. Despite what is suspected t be cnsiderable underreprting f mrtality n this survey (if it is like ther surveys that have attempted t elicit survival data) Mare develped relative mrtality gradients by sciecnmic status described earlier. His results are cnsistent with thse f Kitagawa and Hauser in revealing independent effects f incme and educatinal attainment n mrtality. It is ntewrthy that ther available data bases wuld be amenable t the same types f analyses that Mare applied t the CPS data. Amng the mre prmising files are thse f the NCHS Natinal Survey f Family Grwth, a peridic survey f the reprductive and family histries f natinal sample f American wmen- Cnclusin. Renewed interest in sciecnmic differentials in mrtality in the United States has been inspired in recent years by epidemilgical inquiries int the surces f the rapid decline in majr chrnic disease mrtality; it is als a result

144 f grwing interest in envirnmental factrs that may pse hazards t health. These interests have given rise t nt nly mre intensive and creative use f existing data bases but als t develping new data bases. This paper reviewed a number f these that are in varius stages f planning, implementatin, and use in the U.S. tday. It can be anticipated that the 1980's will witness cnsiderable expansin f knwledge abut differences in mrtality in the U.S. assciated with variatins in bth sciecnmic status and life-style; the 1980's may als be a perid when a data base is created that will allw cntinuus tracking f sciecnmic variatin in mrtality amng Americans. Appreciatin Appreciatin is expressed t Harriet Duleep, Office f Research and Statistics, Scial Security Administratin, Rbert Mare, Department f Scilgy, University f Wiscnsin-Madisn, and Diane Makuc, Divisin f Analysis, NCHS, fr their cnstructive cmments n an earlier draft f this paper. Ftntes 1. Natinal Center fr Health Statistics (NCHS), «Annual Summary f Births, Deaths, Marriages, and Divrces: United States, 1981», Mntiy Vital Statistics Reprt, Vl. 30, N. 13, December 20, 1982. NCHS, Vital Statistics f the United States, 1950, Vlume 1. 2. Gillum, Richard F., Henry Blackurn, and Manning Feinleib, «Current Strategies fr Explaining the Decline in Ischémie Heart Disease Mrtality», Jurnal f Chrnic Disease, Vl. 35, 1982, pp. 467-474. Patrick, Cliffrd H., Yuk Y. Palesch, Manning Feinleib, and Jacb A. Brdy, «Differences in Declining Chrt Death Rates frm Heart Disease, American Jurnal f Public Health, Vl. 72, N. 2, February 1982, pp. 161-166. Havlik, Richard J. and Manning Feinleib, Editrs, Prceedings f the Cnference n the Decline in Crnary Heart Disease Mrtality, U.S. Department f Health, Educatin, and Welfare, Natinal Institutes f Health, May 1979. 3. Kitagawa, Evelyn and Phillip Häuser, Differential Mrtality in the United States: A Study f Sciecnmic Epidemilgy, Cambridge, Harvard University Press. 1973. 4. Stckwell, E.G., J.W. Wicks and D.J. Adamchak, «Research Needed n Sciecnmic Dirrerentials in U.S. Mrtality», Public Health Reprts, Vl. 93, Nvember-December 1978, pp. 666-672. 5. Kitagawa, p. cit., p. 17. 6. Duleep, Harriet, «The Examinatin f Mrtality Differentials by Sciecnmic Status Using Scial Security Administrative Recrd Data», paper presented at the 1982 Annual Meeting f the Ppulatin Assciatin f America, p. 6. 7. Kitagawa, p. cit., p. 179. 8. NCHS, «Infant Mrtality Rates: Sciecnmic Factrs, United States», Vital and Health Statistics, Series 22, N, 14, March 1972, Table 21.

145 9. Maree, Rbert D., «Sciecnmic Effects n Child Mrtality in the United States», American Jurnal f Public Health, Vl. 72, N. 6, June 1982, pp. 539-547. 10. Therriault, Gene D. and Vit M. Lgrill, «Sciecnmic Status and Mrtality: An Applicatin Using Death Certificates», Paper presented at the 1982 Annual Meeting f the Ppulatin Assciatin f America. 11. Crbaux, F., On the Natural and Mathematical Laws Cncerning Ppulatin, Vitality and Mrtality, Lndn, 1833. 12. Rsen, Sherwin and Paul Taubman, «Changes in the Impact f Educatin and Incme n Mrtality in the U.S.» in Linda Delbene and Fritz Scheuren, Editrs, Statistical Uses f Administrative Recrd with Emphasis n Mrtality and Disability Research, Washingtn: Office f Research and Statistics, U.S. Scial Security Administratin, 1979, pp. 61-65. 13. Caldwell, Steven and Thedre Diamnd, «Incme Differentials in Mrtality: Preliminary Results Based n 1RS-SSA Linked Data», in Linda Delbene and Fritz Scheuren, Editrs, Statistical Uses f Administrative Recrds with Emphasis n Mrtality and Disability Research, Washingtn: Office f Research and Statistics, U.S. Scial Security Administratin, 1979. 14. Duleep, Harriet, «Sciecnmic Status and Mrtality: The Rle f Incme», Office f Research and Statistics, U.S. Scial Security Admnistratin, 1983 (unpublished paper). ' 15. Duleep, ibid., p. 30. 16. Kitagawa. p. cit., p. 16. 17. Fx, Jhn and Peter Gldblatt, «Sci-demgraphic differences in mrtality, Ppulatin Trends, N. 27, 1982. 18. NCHS, Users' Manual, The Natinal Death Index, Semptember 1981. 19. Rgt, Eugene, Meanning Feinleib, Kathleen A. Ockay, Sidney H. Schwartz, Rbert Bilgrad, and Jhn E. Pattersn, «On the Feasibility f Linking Census Samples t the Natinal Death Index fr Epidemilgical Studies: A Prgress Reprt, American Jurnal f Public Health (in press). 19. Fx, Jhn and Peter Gldblatt, «Sci-demgraphic differences in mrtality», Ppulatin Trends, N. 27, 1982. 20. NCHS, «Cmparability f Age n the Death Certificate and Matching Census Recrd, United States, May-August 1960», Vital and Health Statistics, Series 2, N, 29, June 1968. 21. Guralnick, Lillian, «Mrtality by Occupatin and Industry, Amng Men 20-64 Years f Age:, United States 1950», Vital Statistics-Special Reprts, Vl. 52, Ns. 2-5, 1962-63. 22. NCHS, «Statistics Needed r Determining the Effects f the Envirnmenta n Health», Vital and Health Statistics, Series 4, N. 20, July 1977. 23. Rseberg, Harry M., Drusilla Burnham, Rbert Spirtas, and Victr Valdisera, «Occupatin and Industry Infrmatin frm the Death Certificate: Assessment f the Cmpleteness f Reprting, in Delbene and Scheuren, Editrs (p. cit.), pp. 83-89. 24. Gute, Davd M., «The Assciatin f Occupatin and Industry with Mrtality in Rhde Island, 1968-1972», Technical Reprt N. 23, Rhde Island Department f Health, July 1981. 25. Therriault, p. cit., p. 13. 26. Kitagawa. p. cit., p. 179. 27. Mare, persnal crrespndence. 28. Kvar, Mary Grace and James A. Weed, «Cnsideratin in Using Individual Sciecnmic Characteristics in the Analysis f Mrtality», Paper presented at the 1977 Annual Meeting f the American Statistical Assciatin. 29. Delbene and Scheuren, Editrs, p. cit.. 30. Duleep, p. cit. (unpublished paper). 31. Mare, 1982, p. cit.

146 Appendix Item n CPS Mnthly Interview Schedule 1. Interviewer Check Item 2. Sample 3. Cntrl Number 4. Type f Living Quarters 5A. Land Usage 5B. Farm Sales 6. PSUN. 7. Segment N. 8. Serial N. 9. Husehld N. 10. Interviewer Cde 11. Date Cmpleted 12. Line N. f H'hld Resp. 13. Type interview Nninterview 14. Type A -Reasn -Race 15. Type B, Type C 16.-17. Seasnal Status 18. Line Number 19. What was... ding mst f LAST WEEK? -wrking, lking fr wrk..., unable t wrk, retired 20. Did... d any wrk at all LAST WEEK, nt cunting wrk arund the huse? 20A. Hw many hurs did... wrk LAST WEEK at all jbs? 20B. Interviewer Check Item. 20C. Des... USUALLY wrk 35 hurs r mre a week at this jb?? 20D. Did... lse any time r take any time ff LAST WEEK fr any reasn such as illness, hliday, r slack wrk? 20E. Did... wrk any vertime r at mre than ne jb LAST WEEK? 21. Did... have a jb r business frm which he was temprarily absent r n layff LAST WEEK?? 21A. Why as... absent frm wrk LAST WEEK? -wn illness, n vacatin, bad weather,... * Asterisked items are under cnsideratin fr analyses.

147 21B. Is... getting wages r salary fr any f the time ff last week? 21C. Des... usually wrk 35 hurs r mre a week at this jb? 22. Has... been lking fr wrk during the past 4 weeks? 22A. What has... been ding in the last 4 weeks t find wrk? 22B. Why did... start lking fr wrk? Was it because... lst r quit a jb at that time r was there sme ther reasn? 22C. Hw many weeks has... been lking fr wrk? 22D. Has... been lking fr full-time r part-time wrk??* 22E. Is there any reasn why... culd nt take a jb LAST WEEK? -already has a jb, temprary illness,... 22F. When did... last wrk at a full time jb r business lasting 2 cnsecutive weeks r mre? * 23. Descriptin f Jb r Business-yields industry and ccupatin 23A. Fr whm did... wrk? 23B. What kind f business r industry is this? 23C. What kind f wrk was... ding? 23D. What were... 's mst imprtant activities r duties? 23E. Was this persn an emplyee f...? 24. Interview Check Item * 24A. When did... last wrk fr pay at a regular jb r business, either fullr part-time? -years t 5 + * 24B. Why did... leave that jb? -persnal, family; health; retirement r ld age,... 24C. Des... want a regular jb nw, either full r part-time? * 24D. What are the reasns... is nt lking fr wrk? lacks nee. schling; t yung r t ld; ther persnal handicap; ill health, physical disability;... * 24E. Des... intend t lk fr wrk f any kind in the next 12 mnths? 25. Line Number * 26. Relatinship t head f husehld *27. Age * 28. Marital Status *29. Race * 30. Sex and Veteran Status *31. Highest Grade Attended * 32. Grade Cmpleted * 33. Origin * 47. Ttal Family Incme

148 Since 1976 / think that fur questins 25A-D have been added fr hurs wrked and wages * 25A. Hw many hurs per week des... USUALLY WORK at this jb? * 25B. Is... paid by the hur n this jb? * 25C. Hw much des... earn per hur? * 25D. Hw much des... USUALLY earn per week at this jb befre deductins?

149-0.2 1950 1955 1960 1965 1970 1975 SOURCE: Natinal Center fr Health Statistics, Divisin f Vital Statistics. 1990

150 S ñdónrl is (M ««00 O\ M M S S vi 1/1 O O 00 * O n N d O t - - M ri p. ^ O O O n «- 13 "i h O ó ísísi«^ 1-1 00 N«C9 s 3 52 ri \é d (S r-; s d 00 v 00 «p \ r- a C300000-MS» O'O-'Oah m «v ic n 00 m tn O ON OO OO w 1 p 00 00 "S u 'S. E 3 sch 1960 «*- 0Vi yeai >» ^ CO 1 >. 3 3 GO <<< W ü 2 rt ted 2 S «1 E ai es "3 II E *- tu M S 8 N O O SI OO -» - " O O O N Û O O\0O O O ON ON P O N O O N C S O O N O N O N O in ^t r~ f - «c "tr ~-«Q m v 't N - O - - O O 0 i 0 0 h «l ^ "ON «Si Ö» O p ON OO g PpOOONON OOO O Ol rn Q <N ON O O O O ON ON cd u cd ú. u es e g 2 S 52 S e E 8 «S O O O JZ JZ u Í2 *= u) «U) U) S è e 00 I a-.^ aiaöö ö s C/î g 52 ^ g "3 "3 JC JZ u e M U U U M H g X! JZ >, 00 60 : ii O U

3.O C 4-i 3 :ent 0,0; a 10: es 1 O OH les es i IS 3 es Eu is es ^ a? S 10 u tn > ««b E 0 3 es " 0 J3 0 " CO tu es u S S 2 vq^f i vq «Scts vm c5«<s Svn -H ve n «O j -- 5; q - 5 v O O0 Ci O va\ «00 O H Ö a\ d m t O 0O * OTJ- i 00 ON O to ON O 00 g 83 g 2 î S 8SS en t~ S S 83 'S ai 8.0 '3 "3 5 -s T. g x $ -.Si, r 8 I " I S - > feg«00.? ^ 00.? "3 ^ 00.? ó se ó se u x es «J3 "g 11 E + > c «3 a 3 "^ < rt S es <» u O "O l 1/1 ^g in ï 3 S g. "5 «s a f < ñ - 0 U en g 5 ** Q> *J 'tî -c n î ** S e g. ^ 2 u 'S ^"3 Hl 2 C 'C D. <u S " S 1 Ä e.a g H.8 5 5 & S fi - S S -c fi W rrt Vî Elu c S S «.2 I- 3 Si«s «*-.S es O - "" >, V 3 1) «S ^ 3&* rt i«ü «C ^-* Tj 3 H 5 151

152 Table 2. Mrtality ratis by incme level, fr white family members and unrelated individuals, by sex and age: United States, May-August, 1960 Family status and incme in 1959 Family members by family incme White male family members Under $2,000 $2,000-3,999 $4,000-5,999 $6,000-7,999 $8,000-9,999 $10,000 r mre Under $4,000 $8,000 r mre White female family members Under $2,000 $2,000-3,999 $4,000-5,999 $7,000-7,999 $8,000-9,999 $10,000 r mre Under $4,000 $8,000 r mre Unrelated individuals by persnal incme White male unrelated individuals Under $2,000 $2,000-3,999 $4,000 r mre White female unrelated individuals Under $2,000 $2,000-3,999 $4,000 r mre 25 & ver 7.00 1.14 1.03.97.91 1.00.89 1.09.93 7.00 1.05 1.02 1.00 1.01.95.92 1.04.93 7.00.97 }l.05 7.00 1.06 /.80 Mrtality ratis* 25-64 years 1.00 1.51 1.20.99,.88*.93,.84 ' 1.32.88 1.00 1.20 1.12 1.00).98 * Sl\.86 > 1.15.88 1.00 1.25 1.02%.77) 1.00 1.27.73»}.79*' 65 & ver 1.00 1.10.99.92.96* 1.05.96* 1.00.96.96 1.05 1 r\i 1.01.96 1.01 1.00 1.00 1 /It 1.01 1.00 1.05 QA*.80 Ppulatin (percent distributin) 25 & ver 100.0 9.3 14.8 22.8 21.0 13.2 19.0 24.1 32.2 100.0 10.8 15.4 22.2 20.3 12.9 18.4 26.2 31.3 700.0 40.5 23.4 36.1 100.0 59.3 22.0 18.8 25-64 years 100.0 6.3 12.8 23.9 22.6 14.2 20.2 19.1 34.4 100.0 8.5 14.1 23.0 21.5 13.7 19.3 22.6 33.0 100.0 28.7 25.5 45.8 100.0 42.8 29.2 28.1 65 & ver 100.0 27.6 27.0 16.3 10.9 6.6 11.6 54.6 18.2 100.0 25.7 24.2 17.1 12.2 7.8 13.0 49.9 20.8 100.0 68.8 18.4 12.8 100.0 79.0 13.3 7.6 * Des nt meet reliability requirement specified in Table 2.1. "See nte a, Table 2.1. fr definitin f ratis. SOURCE: Kitagawa and Häuser, (p. cit.), Tables 2.1. and 2.5.

153 Table 3. Selected life tables functins fr the white ppulatin by sex and years f schl cmpleted: United States. 1960 Sex and years f schl cmpleted Prbability f dying 8 between agees: 25 &45 45 &65 65 &75 life 25 average years f remaining Íit age 45 65 White males 0-4 years 5-7 years 8 years High schl, 1-3 years High schl, 4 years Cllege, 1 year r mre White females 0-4 years 5-7 years 8 years High schl, 1-3 years High schl, 4 years Cllege, 1 year r mre.0680*.0878.0634.0562.0431.0345.0838*.0407*.0332*.0323.0239.0289*.3086.2944.2863.2777.2637.2284.2123*.1667.1569.1247.1297.1099.4156.4051.3997.3757*.3919.3803.3004*.2660.2599.2319*.2435.1833* 43.9 43.6. 44.8 45.6 46.0 47.1 46.8 50.5 51.1 53.4 52.2 56.4 26.2 26.7 27.1 27.6 27.5 28.4 30.0 32.1 32.4 34.8 33.2 37.7 12.7 12.9 13.0 13.5 12.9 13.1 14.8 16.0 16.2 18.0 16.3 20.8 * Des nt meet reliability requirement specified in Table 2.1 a Cmputed frm e x clumn f abridged life table. SOURCE: Kitagawa and Häuser, [p. cit.], Table 2,4.

154 Table 4. Estimated infant deaths per 1,000 legitimate live births, by family incme and race and birthweight f infant: United States, 1964-65 Educatin f mther Race and birth weight in grams All levels 8 years r less 9-11 years 12 years 13-15 years 16 years r mre Ail races Deaths per 1,000 live births All birth weights 23.5 36.6 30.0 18.6 16.5 19.7 2.500 grams r less 2.501-3.000 grams 3.001-3.500 grams 3.501-4.000 grams 4.001 grams r mre 185.5 19.4 7.3 6.6 9.2 205.9 23.4 13.7 15.4 16.3 197.5 24.8 9.5 8.4 9.1 167.5 14.1 5.8 5.1 7.6 171.8 19.7 3.0 3.3 5.5 22.9 5.9 3.4 11.8 White All birth weights 21.0 32.8 26.0 17.5 15.7 19.0 2.500 grams r less 2.501-3.000 grams 3.OO1-3.5OO grams 3.501-4.000 grams 4.001 grams r mre 184.0 18.2 6.8.5.9 7.7 198.3 28.9 11.5 14.0 13.9 183.7 21.3 9.1 7.6 7.7 177.3 13.0 5.8 4.5 6.2 19.1 3.0 2.9 4.4 21.7 5.1 3.7 12.0 Black All birth weights 40.7 48.9 47.7 29.4 32.7 2.500 grams r less 2.501-3.000 grams 3.001-3.500 grams 3.501-4.000 grams 4.001 grams r mre 188.7 24.6 11.3 14.0 10.7 20.8 35.8 11.7 15.7 20.3 5.1. SOURCE: NCHS, 1972, Table 21

Table 5. Estimated infant deaths per 1,000 legitimate live births, by family incme and race and birthweight f infant: United States, 1964-65 155 Race and birth weight in grams All incmes Under $3,000 Family incme $3,000- $4,999 $5,000- $6,999 7.000-$ 10.000 $9,999 and ver All races Deaths per 1,000 live births All birth weights 23.5 34.0 25.0 17.6 19.7 20.3 2.500 grams r less 2.501-3.000 grams 3.001-3.500 grams 3.501-4.000 grams 4.001 grams r mre 185.5 19.4 7.3 6.6 9.2 205.1 25.9 10.5 12.3 16.6 205.9 17.0 8.5 7.1 6.9 135.1 14.1 5.4 4.6 6.8 203.8 19.2 6.1 4.8 7.2 22.4 5.4 4.7 12.0 White All birth weights 21.0 30.2 21.2 17.3 19.0 19.9 2.500 grams r less 2.501-3.000 grams 3.001-3.500 grams 3.501-4.000 grams 4.001 grams r mre 184.0 18.2 6.8.5.9 7.7 205.5 27.0 10.6 9.8 12.9 186.6 16.0 7.6 6.4 5.2 143.3 14.7 5.2 4.7 6.3 221.4 16.6 5.7 4.7 7.4 20.0 5.3 4.8 10.8 Black All birth weights 40.7 41.3 53.0 20.4 2.500 grams r less 2.501-3.000 grams 3.001-3.500 grams 3.501-4.000 grams 4.001 grams r mre 188.7 24.6 11.3 14.0 201.8 23.8 10.1 19.3 22.9 12.4 SOURCE: NCHS, 1972, Table 22

156 Table 6. Percent f children dying by June 1975 and number f births by mther's schling, years between birth and June 1975, race, and sex: United States Mther Schling Race and Sex Years between Birth and June 1975 Less Than 12 Grades Number f Births Percentage Dead 12 Grades r Mre Number f Births Percentage Dead White Males 0 4 5 9 10 14 15 19 1034 1172 1429 1547 1.94 2.98 3.36 3.81 3018 3173 3441 3528 1.53 1.96 1.94 2.18 White Females 0 4 5 9 10 14 15 19 970 1134 1399 1428 1.24 1.85 1.79 2.31 2816 3059 3426 3304 ().99.34.52.66 Black Males 0 9 10 19 427 621 2.34 3.22 638 532 1.41 1.50 Black Females 0 9 10 19 405 579 1.72 2.94 643 567 2.18 2.47 Table 7. Percent f white children dead by ttal family incme, mther's schling, years since birth, and sex: United States Sample Mther s Schling Annual Family Incme Less than $10.000 $10.000 r mre Ttal Males 0 9 <12 ^12 Ttal 2.16 2.09 2.45 2.14 1.62 1.70 2.15 1.74 1.96 Males 10 19 <12 >n Ttal 4.64 2.75 3.74 2.87 1.99 2.18 3.68 2.13 2.59 Females 0 9 < 12 ^ 12 Ttal 1.54 1.77 1.67 1.69 1.04 1.13 1.60 1.23 1.32 Females 10 19 <12 ^12 Ttal 1.98 2.10 2.04 2.16 1.48 1.63 2.08 1.59 1.74 SOURCE: Mare, Tables 2 and 4

Table 8. Standardized prprtinal mrtality ratis fr selected causes f death by sex, persns aged 18-64 years: Upstate New Yrk, 1980 157 Cause: Ttal Cancers SES Indicatr Males Females Cause: Mycardial Infarctin SES Indicatr Males Females Cause: Mtr Vehichle Accidents SES Indicatr Males Females Cause: Suicide SES Indicatr Males Females Lw i High Lw I High Lw i High Lw J High Lw J High Lw I High Lw I High Lw 1 High SOURCE: Therriault and Lt-rilll. Tables 4A and 4B Educatin 0.97 0.96.02.11 C1.84.01.10.21 Educatin 0.96 1.03 1.08 1.05 1.28 0.94 0.82 0.70 Educatin 0.85 1.16 1.01 1.00 D.79 1.06 1.00 1.29 Educatin 0.92 1.08 0.97 1.38 0.49 1.10 1.26 1.43 Occupatin 0.93 1.02 1.01 1.02 0.92 0.99 1.14 1.12 Occupatin 0.90.03.05.11.10.23 0.84 0.80 Occupatin 1.03 1.14 1.08 1.04 1.10 1.17 1.14 1.54 Occupatin 0.94 1.14 1.07 1.02 0.70 0.86 1.22 1.38

158 Table 9. Mrtality by ccupatin fr causes f death fr which standardized mrtality ratis are significantly raised (p less than 0.05), fr males aged 16-64 years: Rhde Island, 1968-72 OCCUPATION TITLE CA USE (ICD NUMBER) Prfessinal, technical, and kindred wrkers Cln Cancer (153) Managers and administratrs, except farm Residual cancer (all ther 140-209) Acute mycardial infarctin (410) All causes (0-999) SMR 161 125 134 115 OBSERVED DEATHS 28 126 304 1013 Carpenters Accidents (800-949) 186 19 Cnstructin caftsmen Lung cancer (162) Accidents (800-949) All causes (0-999) Metal craftsmen Residual cancer (all ther 140-209) Lung cancer (162) Acute mycardial infarctin (410) Cerebrvascular dsease (430-438) Influenza and pneumnia (470-474, 480-486) Residual All causes (0-999) Transprt peratives Lung cancer (162) All causes (0-999) Cnstructin labrers Acute mycardial infarctin (410) Accidents (800-949) All causes (0-999) Other labrers Residual cancer (all ther 140-209) Acute mycardial infarctin (410) Cerebrvascular disease (430-438) Gute, [p. cit.], Table 21. 151 197 122 140 158 138 206 288 151 146 137 111 161 241 134 200 143 232 38 35 367 44 36 96 28 10 91 398 47 460 36 16 122 30 46 15

OCCUPATION TITLE CAUSE (ICD NUMBER) Influenza and pneumnia (470-474, 480-486) Cirrhsis (571) Accidents (800-949) Residual All causes (0-999) Cleaning service wrkers Lung cancer (162) Chrnic ischémie heart disease (412) Accidents (800-949) Residual All causes (0-999) Prtective service wrkers Acute mycardial infarctin (410) All causes (0-999) SMR 488 368 285 268 202 155 154 167 176 142 144 122 OBSERVED DEATHS 8 20 26 78 264 40 40 21 109 415. 57 193 Other service wrkers Residual. 136 88 159

160 Bibligraphy Adamchak, D.J., R.E. Siegel and E.G. Stckwell. «Infant Mrtality and Sciecnmic Status.» Ohi's Health, 28 (1976): 8-9 Adamchak, D. J. and E.G. Stckwell. «Trend in the Relatinship Between Infant Mrtality and Sciecnmic Status.» Scilgical Fcus, 11 (1978): 47-52. Altenderfer, M.E. «Relatinship Between Per Capital Incme and Mrtality in Cities f 100,000 r Mre Ppulatin.» Public Health Reprts, 62 (Nvember, 1947): 1681-1691. Altenderfer, M.E. «Relatinship Between Infant Mrtality and Sciecnmic Factrs in Urban Areas.» Public Health Reprts, 64 (March, 1949): 331-339. Antnvsky, A. «Scial Class, Life Expectancy and Overall Mrtality.» Milbank Memrial Fund Quarterly, 45 (April, 1967): 31-73. Antnvsky, A. and J. Bernstein. «Scial Class and Infant Mrtality.» Scial Science and Medicine, 11 (1977): 453-470. Armstrng, R.J. «A Study f Infant Mrtality frm Linked Recrds by Birth Weight, Perid f Gestatin and Other Variables.» Natinal Center fr Health Statistics, Vital and Health Statistics, 20:12 (May, 1972). Bedger, J.E., A. Gelperin and E.J. Jacbs. «Sciecnmic Characteristics in Relatin t Maternal and Child Health.» Public Health Reprts. 81 (September, 1966): 829-833. Brks, C.H. «The Changing Relatinship Between Sciecnmic Status and Infant Mrtality: An Analysis f State Characteristics.» Jurnal f Health and Scial Behavir, 16 (September, 1975a): 291-301. Brks, C.H. «Path Analysis f Sciecnmic Crrelates f Cunty Infant Mrtality Rates.» Internatinaljurnal f Health Services, 5 (1975b): 499-514. Caldwell S. and T. Diamnd «Incme Differentials in Mrtality: Premilimary Results Based n IRS-SSA Linked Data.» In Statistical Uses f Administrative Recrds with Emphasis n Mrtality and Disability Research, ed. Linda Delbene and Fritz Scheuren. Washingtn: Office f Research and Statistics. U.S. Scial Security Administratin, 1979. Chabt, M.J., et. al. «Urbanizatin and Differentials in White and Nn-white Infant Mrtality.» Pediatrics, 56 (1975): 771-781. Chase, H.C. «A Study f Infant Mrtality frm Linked Recrds: Cmparisn f Nenatal Mrtality frm Tw Chrt Studies,» Natinal Center fr Health Statistics, Vital and Health Statistics, 20:13 (June, 1972).

Crbaux, F. On the Natural and Mathematical Laws Cncerning Ppulatin, Vitality and Mrtality, Lndn, 1833. 161 Duleep, H. «The Examinatin f Mrtality Differentials by Sciecnmic Status Using Scial Security Administrative Recrds Files.» Paper presented at the Ppulatin Assciatin f American, 1982. Dnabedian, A. et. al., «Infant Mrtality and Sciecnmic Status in a Metrplitan Cmmunity.» Public Health Reprts, 80 (December, 1965): 1083-1094. Fx, A.J. «Prspects fr Measuring Changes in Differential Mrtality.» Presented at the meetings f the Wrld Health Organizatin, Mexic City 1979. Fuchs, V.R. «Sme Ecnmic Aspects f Mrtality in the United States». Mime, Natinal Bureau f Ecnmic Research, 1965., «Sme Ecnmic Aspects f Mrtality in Develped Cuntries.» In The Ecnmics f Health and Medical Care, ed. Mark Perlman. New Yrk: Jhn Wiley & Sns, 1974. Gillum, R.F., H. Blackurn, and M. Feinleib. «Current Strategies fr Explaining the Decline in Ischémie Heart Disease Mrtality.» Jurnal f Chrnic Disease, 35 (1982): 467-474. Grtmarker, S.L. «Pverty and Infant Mrtality in the United States.» American Scilgical Review, 44 (1979): 280-297. Grssman. M. The Demand fr Health: A Theretical and Empirical Investigatin. New Yrk: Clumbia University Press, 1972. Gute. D.M. «The Assciatin f Occupatin and Industry with Mrtality in Rhde Island, 1968-72, Technical Reprt N. 23, Rhde Island Department f Health, July 1981. Hadley, J. «Cntributin f Medical Care t Gegraphic Variatins in Adult Mrtalty Rates.» Paper presented at the American Ecnmic Assciatin and Health Ecnmics Research Organizatin, 1979. Havlik, R.J., and M. Feinleib. Editrs Prceedings f the Cnference n the Decline in Crnary Heart Disease Mrtality. U.S. Department f Health, Educatin, and Welfare, Natinal Institute f Health, May 1979. Hunt, E.P. «Infant Mrtality and Prverty Areas.» Welfare in Review, 5 (August-September, 1967): 1-12. lives, A. «Sciecnmic tratificatin Applied t the Analysis f Health Prblems». State f New Yrk Department f Health Quarterly Vital Statistics Review, July-September, 1977 11-21.

162 Kitagawa, E.M. and M. Häuser: «Educatin Differentials in Mrtality by Cause f Death, United States, 1960. Demgraphy, 1968: 333-353, 1968. Kitagawa, E.M. «Sciecnmic Differences in Mrtality in the United States and Sme Implicatins fr Ppulatin Plicy.» In Cmmissin n Ppulatin Grwth and the American Future, Researh Reprts, Vlume I, Demgraphic and Scial Aspects f Ppulatin Grwth. Edited by C.F. Westff, and R. Parks, Jr. Washingtn, D.C. U.S. Gvernment Printing Office: 87-110, 1973. Kitagawa, E.M. and P.M. Häuser. Differential Mrtality in the United States: A Study in Sciecnmic Epidemilgy. Harvard University Press, 1973. Kleinmann, J.C., J.J. Feldman, and R.H. Mugge. «Gegraphic Variatins in Infant Mrtality. Public Health Reprts, 91: (1976) 423-432. Kvar, M.G. and J.A. Weed. «Cnsideratins in Using Individual Sciecnmic Characteristics in the Analysis f Mrtality.» Paper presented at the 1977 Annual Meeting f the American Statistical Assciatin. Office f Ppulatin Censuses and Surveys: Occupatinal Mrtality. Series DS, N. 1. Lndn: Her Majesty's Statinery Ofice. 1977. Luft, H.S. Pverty and Health: Ecnmic Causes and Cnsequences f Health Prblems. Cambridge: Ballinger Publishing C., 1978. MacMahn, B., M.G. Kvar, and J.J. Feldamn, «Infant Mrtality Rates: Sciecnmic Factrs. DHEW Publicatin N. (HSM) 72-1015, Vital and Health Statistics, Series 22, N. 14. U.S. Gvernment Printing Office, Washingtn, D.C, March 1972. Mare, R.D. «Sciecnmic Effects n Child Mrtality in the U.S.» Prpsal t Public Health Service. 1980. Mare R.D. «Sciecnmic Effects n Child Mrtality in the United States.» American Jurnal f Public Health, Vl. 72, N. 6 (1982): 539-547. Markides, K.S., and D. Barnes. «A Methdlgical Nte n the Relatinship between Infant Mrtality and Sciecnmic Status with Evidence frm San Antni. Texas.» Scial Bilgy, 21 (1977): 38-44. Mathis, E.S. «Sciecnmic Characteristics f Deceased Persns.» PHS Publicatin N. 1000, Vital and Health Statistics, Series 22, N. 9 U.S. Gvernment Printing Office, Washingtn, D.C, February 1969. Mayer, A.J. and R.V. Marks. «Differentials in Infant Mrtality by Race, Ecnmic Level and Cause f Death fr Detrit: 1940 and 1950.» Human Bilgy, 26 (1954): 143-155. Meyers, G.C «Scial and Ecnmic Differentials in Mrtality.» Prepared fr the Wrd Health Organizatin 1978.

Nagi, H., and E.G. Stckwell. «Sciecnmic Differentials in Mrtality by Cause f Death.» Health Service Reprt, 88 (1973): 449-456. 163 Nam, C.B. «Sciecnmic Status and Mrtality: Needed Research.» Presented at the Annual Meeting f the Ppulatin Assciatin f America; Seattle, Washingtn; April 17, 1975. Natinal Center fr Health Statistics. «Cmparability f Age n the Death Certificate and Matching Census Recrd, United States, May-August, 1960.» Vital and Health Statistics, Series 2, N. 29, June 1968., «Infant Mrtality Rates: Sciecnmic Factrs, United States.» Vital and Heath Statistics, Series 22, N. 14, March 1972., «Sciecnmic Characteristics f Deceased Pesns.» Vital Health Statistics, Series 22, N. 9, 1969., «Statistics Needed r Determining the Effects f the Envirnment n Health.» Vital and Health Statistics. Series 4, N. 20, July 1977., «Annual Summary f Births, Deaths, Marriages, and Divrces: United States, 1981.» Mnthly Vital Statistics Reprt, Vl. 30, N. 13, December 20, 1982. NCHS, Vital Statistics f the United States, 1950, Vlume 1., Users' Manual, The Natinal Death Index. September 1981. Patrick, C.H., Y.Y. Palesch, M. Feinleib, and J.A. Brdy. «Differences in Declining Chrt Death Rates frm Heart Disease.» American Jurnal f Public Health, Vl. 72 N. 2 (February 1982): 161-166. Puffer, R.R. and C.V. Serran. «Patterns f Mrtality in Childhd.» Scientific Pub. N. 262. Washingtn, D.C. Pan Americal Health Organizatin. 1973. Quincy, R. «Mrtality Differentials in a Metrplitan Area.» Scial Frces 43 (1965): 222-230. Rsen S. and P. Taubman. «Changes in the Impact f Educatin and Incme n Mrtality in the U.S.» in Statistical Uses f Administrative Recrds with Emphasis n Mrtality and Disability Research ed. Linda Delbene and Fritz Scheuren. Washingtn: Office f Researh and Statistics, U.S. Scial Security Administratin, 1979. Rsemberg, H.M., D. Burnham, R. Spirtas, and V. Valdisera, «Occupatin and Industry Infrmatin frm the Death Certificate: Assessment f the Cmpleteness f Reprting,» in Delbene and Scheuren, Editrs (p. cit.), pp. 83-89. Schwirian, K.P., and A. J. Lagreca. «An Eclgical Analysis f urban mrtality rates.» Scial Science Quarterly, 52: (1971): 574-587.

164 Shapir, S., E.R. Schlesinger, and R.E.L. Nesbitt. Infant, perinatal, maternal, and childhd mrtality in the United States. Harvard University Press, Cambridge, Mass., 1968. Shah, F.K. and H. Abbey. «Effects f Sme Factrs n Nenatal and Pstnenatal Mrtality.» Milbank Memrial Fund Quarterly, 49 (January, 1971): 33-57. Shin, E.H. «Black-white Differentials in Infant Mrtality in the Suth, 1940-1970.» Demgraphy 12 (1975): 1-19. Mrris S. «An Ecnmetric Analysis f Spatial Variatins in Mrtality Rates by Race and Sex.» In Essays in the Ecnmic f Health and Medical Care, ed. Victr R. Fuchs. New Yrk: Clumbia University Press, 1972. Smith, J.C., R.E. Fry and M.E. Pace, «A Sciecnmic Classificatin Technique fr Standard Metrplitan Statistical Areas.» Atlanta, GA, Centers fr Disease Cntrl, 1973. Stckwell, E.G. «Sciecnmic Status and Mrtality in the United States.» Public Health Reprts, 76 (December, 1961): 1081-1086. Stckwell, E.G. «Infant Mrtality and Sciecnmic Status: A Changing Relatinship.» Milbank Memrial Fund Quarterly, 40 (January, 1962); 101-111. Stckwell, E.G.: «Use f Sciecnmic Status as a Demgraphic Variable.» Public Health Reprts, 81 (Nvember, 1966): 961-966. Stckwell, E.G. Ppulatin and Peple. Quadrangle Bks. 1968. Stckwell, E.G., and B. Hutchinsn. «Mrtality Crrelates f Ecnmic Status.» Ppulatin Review, 19 (1975): 45-50. Stckwell, E.G., and K.A. Laidlaw. «Infant Mrtality and Sciecnmic Status Amng Ohi Cunties». Ohi Jurnal f Science, 11 (March, 1977): 72-75. Stckwell, E.G., and D.J. Adamchak. «Changing Patterns f Infant Mrtality Amng Scial Areas in Tled, Ohi: 1950-1970.» East Lakes Gegrapher, 13 (June, 1978): 62-68. Stckwell, E.G., J.W. Wicks, and D.J. Adamckak. Resarch Needed n Sciecnmic Differentials in U.S. Mrtality.» Public Health Reprts, 93 (Nvember-December, 1978): 666-672. Taubman, P., and S. Rsen. «Healthiness, Educatin, and Marital Status,» Wrking Paper N. 611, Natinal Bureau f Ecnmic Research, December 1980. Therriault, G.D., and V.M. Lgrill. «Sciecnmic Status and Mrtality: An

165 Applicatin Using Death Certificates.» Paper presented at the 1982 Annual Meeting f the Ppulatin Assciatin f America. Willie, C.V. and W.B. Rthney. «A Research Nte n the Changing Assciatin Between Infant Mrtality and Sciecnmic Status.» Scial Frces, 37 (March, 1959): 221-227. Willie, C.V., and W.B. Rthney. «Racial, Ethnic, and Incme Factrs in the Epidemilgy f Nenatal Mrtality.» American Scilgical Review. (August, 1962): 522-526. Wdbury, R.H. Causal Factrs in Infant Mrtality. Children's Bureau Publicatin N. 142. Washingtn, 1925. Yanhauer, A. «The Relatinship f Fetal and Infant Mrtality t Residential Segregatin: An Inguiry int Scial Epidemilgy.» American Scilgical Review, 15 (Octber, 1950): 644-648. Yeracaris, C.A. «Differential Mrtality, General and Cause-Specific in Buffal, 1939-1941.» Jurnal f the American Statistical Assciatin, 50 (December, 1955): 1235-1247.

167 DEVELOPMENTS IN RESEARCH ON SOCIO-ECONOMIC DETERMINANTS OF MORTALITY SINCE 1981 IN THE NETHERLANDS Jeren K.S. van GINNEKEN Dept. f Health Statistics, Netherlands Central Bureau f Statistics. Intrductin Research in cnnectin with sci-ecnmic differential mrtality in the Netherlands up until 1980 has been summarized by van Pppel, 1981; van Reek, 1981 and van der Maas et al., 1981 while prblems and prspects in cnnectin with future research n this tpic up until 1981 have been described by van Pppel, 1982; Habbema and van der Maas, 1982 and van Reek, 1982. The bjective f this paper is t describe develpments since 1981. The emphasis here will be n a discussin f the methdlgical and ther prblems cncerning research n sci-ecnmic differential mrtality since results f research prjects have nt been reprted in scientific jurnals and ther publicatins in the past three years. Summary f C.B.S. reprt Several times during the past years questins have been raised in Dutch parliament n the existence f differences in mrtality in varius sci-ecnmic grups and requests have been made t carry ut mre research n this tpic. In respnse t this request the Secretary f State fr Public Health asked the Central Cmmissin f Statistics (CCS.) which is the supervising bdy f the Central Bureau f Statistics (C.B.S.) in the Netherlands t examine the pssibility f cllecting statistical data n differential mrtality. Accrdingly a reprt by the Central Bureau f Statistics was recently submitted t the CCS. with the title: «An investigatin int the pssibilities f mrtality statistics by cause accrding t sci-ecnmic characteristics» by D. Hgendrn.

168 The pint f departure f the reprt is that ccupatin has been and will als cntinue t be used as the mst prmising indicatr f sci-ecnmic characteristics. After identificatin f a number f research designs which are mst suitable fr the study f sci-ecnmic mrtality differences, special attentin is paid t the prblems inherent t crss-sectinal study designs. On the basis f experiences in several cuntries it is cncluded that it is preferable wherever pssible t use prspective designs with matching f recrds and t avid as much as pssible crss-sectinel designs. This, hwever, cannt always be dne and fr the ppulatin f less than 65 years ld a recmmendatin is, therefre, made fr a study with a crss-sectinel design based n «emplyer» r «place f wrk». «Emplyer» r «place f wrk» is bradly defined here and includes all thse rganizatins r persns wh emply persns (including self-emplyed persns). It is argued that fr the belw 65 years ld ppulatin this is a mre prmising apprach than a system f registratin based n ccupatin. The numeratr fr statistical data f such a prject wuld cnsist f deseased persns accrding t their «place f wrk» and this culd be derived frm infrmatin t be prvided by the civil registratin fficers r undertakers. Detailed infrmatin n demgraphic characteristics and cause f death wuld be prvided by C.B.S. The denminatr wuld cnsist f the ppulatin gainfully emplyed in the Netherlands accrding t different categries f «emplyers» r «places f wrk». Infrmatin n this tpic is als available frm C.B.S.. The reprt stresses the limitatins f this apprach, but cncludes that fr the under 65 years ppulatin it may be the mst feasible way fr btaining statistics in the Netherlands. The prspects are smewhat better fr the 65 years and lder ppulatin because a prpsal is develped, making use f a prspective design with matching f recrds. Advantage can be taken f the fact that infrmatin n ccupatin can be btained when 65 years ld persns apply fr a state pensin. All residents f the Netherlands wh have been in the labur frce and have been insured in this natinal insurance schem are entitled t such a pensin accrding t the General Old-Age act (A.O.W.). The prpsal is t add t the applicatin frm a few questins n the main ccupatin f the applicant. This infrmatin wuld give data n the denminatr f statistical data n this subject while the numeratr wuld cnsist f persns wh die while receiving the A.O. W. pensin. The infrmatin n the main ccupatin f thse wh die needs t be linked t infrmatin n cause f death and ther demgraphic data which is cllected by C.B.S.. The reprt while acknwledging the limitatins f these tw appraches, cncludes with the recmmendatin t carry ut pilt studies in bth the belw and abve 65 years ppulatin t test the feasibility f setting up data cllectin systems with respect t differential mrtality. The Advisry Cmmittee fr Health Statistics f the Central Cmmissin f Statistics endrsed this recmmendatin, but expressed sme reservatins

169 cncerning the apprach adpted fr the belw 65 years lds. It ntes that it wuld be preferable if infrmatin n ccupatin and mutatins in ccupatin wuld be cllected by (gvernment) agencies engaged in implementatin f scial security legislatin and this can nly be dne successfully if these agencies based their administratin n a persnal registratin system. Cmments The tw prpsals develped in the C.B.S. reprt are expected t increase ur knwledge n differential mrtality in the Netherlands. Rutinely cllected statistical data n this tpic wuld prvide valuable descriptive data n the extent f differential mrtality; it wuld als generate hyptheses cncerning its causes; and it wuld indicate n which ccupatinal grups and n which tpics further research needs t be carried ut. One has t realize hwever, that such statistical data will nt give fully satisfactry answers t several questins raised n this tpic. Studies with mre prmising and mre scientifically rigrus designs can easily be frmulated fr the Netherlands and ne can think here mainly f lngitudinal studies and fllw-back surveys. Such studies are unlikely t be carried ut sn and it is nt at all certain whether this can be dne in the frm f rutine cllectin f statistical data referring t a sufficiently large enugh ppulatin. An additinal difficulty here is that several f these studies wuld have t rely n exchange f infrmatin and recrd linkage f gvernment and nn-gvernment agences in health and scial security and C.B.S.. A number f these agencies wuld in the current circumstances be reluctant t cmmit themselves t such linkage f recrds in view f the fact that legislatin cncerning prtectin f privacy and persnal registratin is currently under discussin and has nt yet been passed. Reference The article by van Pppel, 1981, van Reek, 1981 and van der Maas et al., 1981 are fund in U.N. Ppulatin Divisin/ W.H.O./ C.I.C.R.E.D., Sciecnmic differential mrtality in industrialized scieties, Vlume 1, 1981. The articles by van Pppel, 1982, Habbema and van der Maas, 1982 and van Reek, 1982 are fund in U.N. Ppulatin Divisin /W.H.O./C.I.C.R.E.D., Sci-ecnmic differential mrtality in industrialized scieties, Vlume 2, 1982.

171 RECENT MORTALITY CHANGE AMONG WORKING VIS-A-VIS NON- WORKING POPULATION AT AGE OF ECONOMIC ACTIVITY AND AGRICULTURAL VIS-A-VIS NON-AGRICULTURAL WORKERS IN POLAND Marek OKÓLSKI The University f Warsaw Pland 1. General mrtality trend in the 1960s and 1970s In 1967 the lng-lasting trend f declining crude death rate has finally disrupted. In the perid 1967-1980 the rate increased by 36 per cent. It had already reached the highest level in Eurpe in 1976, in terms f standardized death rate(o. Standardized male death rate started t rise frm between 1968 and 1970 / depending n the standard age cmpsitin / while the decline in female rate stpped in 1975. Cnsequently, with a certain time-lag, the life expectancy at birth, bth amng males and females, stabilized fr a while and began t fall afterwards. Between 1974 and 1980 it decreased by 1.8 amng males and 0.3 amng females. The increase in mrtality has nt affected all grups f ppulatin equally. In fact, until the end f the 1970s in sme grups there has cntinued a decline in death rate and in sme thers death rate has been cnstant. The decline was bserved amng infants and female children whereas the stability-amng mst f ther age grups f females and male children. The nly part f female ppulatin which s far experienced the increase in mrtality were the wmen aged 35-59 years; the death rates fr subsequent 5-year age grups started t rise in the 1970s althugh the ttal increase up t 1980 was very mderate / 5-10 per cent /. It was the ppulatin f adult / 20 years r mre / Plish men which underewent a steady and distinct increase in death intensity. The rise in mrtality was the strngest in the grup f men at the age f ecnmic activity. In this

172 grup it generally began between 1965 and 1967. The age-specific male death rates in 1979 / average fr 1978-1980 / were higher by 35-50 per cent in the interval 35-54 years relative t the lwest level / usually reached between 1965 and 1967 /; the sharpest increase being that in the grup 45-49 years / 50 per cent /. The mst substantial rise in terms f prbability f dying was nted between age 40 and age 60. It started in 1966 and in 1980 it reached 187 per cent f the 1966 level. In turn, the prprtin f males dying between age 20 and 40 stpped falling in 1970: it has been increasing in the 1970s and the 1980 level was by 48 per cent higher than the 1970 level. As in 1980 sme prprtins f males dying were higher than ever in the pst-war peridp), these were really astnishing and unprecedented phenmena. The differentials in mrtality rise are quite diversified. Apart frm differentiatin accrding t sex and age, serius dissimilarities exist as regards place f residence. 2. Differences in male mrtality increase by place f residence A relative backwardness f rural areas in respect f level f living, persnal hygiene, health care, etc. was cnsidered in the past as a temprary and in a sense natural phenmenn. This backwardness was i.a. reflected in differences in the respective death rates. It was believed, hwever, that impsing after the war the natinal prgramme f health care, aimed in particular at eradicatin f sme cmmn diseases, wuld cntribute t reducing the differences. Instead f narrwing, thugh, in the 1960s and 1970s the mrtality gap between cuntryside and cities has widened. This particularly refers t adult male ppulatin. Grwing excess f rural ver urban male mrtality ccured due t a faster increase in age-specific death rates, especially in yunger intervals f the age f ecnmic activity, in cuntryside than in cities. The 1980 male death rates expressed as a percentage f the 1968 rates are as fllws: 25-29 30-34 35-39 40-44 45-49 50-54 cities 110 113 116 130 144 134 cuntryside 126 137 157 152 150 138 On the basis f the abve evidence, ne may expect t find the greatest increase in mrtality f men f wrking age wh are the residents f agricultural territries. The rural r agricultural territries in Pland are thse with the predminance f traditinal and rather small family-type farms, little industry and lw level f urbanizatin. They cver central, eastern and suth-eastern

173 parts f the cuntry. The remaining territries, which in mst part can hardly be called typically agricultural, are abundant with big urban and industrial centres, and n mst f them agriculture is dminated by large, suppsedly mdern State-wned farms. Since it is nt pssible t set tgether a lng series f reginby-regin data because f the new subdivisin f the administrative units f the cuntry, in the verifying the abve hypthesis, I shall limit myself t a previsinal analysis f death rates cvering a perid frm 1976 t 1980. By means f the death rates f men in the 5-year grups f wrking age, all vivdeships / 49 principal administrative units / have been divided int three grups: with high mrtality, lw mrtality, and mrtality that des nt deviate frm the natinal average^). In 1976 as many ad 19 vivdeships deviated frm the nrm while in 1980-20; in 197612 vivdeships had lw mrtality and 7 high mrtality, whereas in 1980 the crrespnding rati was: 7 and 13. Thus a basic change ccured in the prprtin t the disadvantage f areas which had a lw mrtality. In 1976 the lw mrtality extended in a belt acrss the eastern and sutheastern vivdeships / with sme centrally lcated nes brdering n them /, whereas in 1980 the lw mrtality belt vanished cmpletely. High mrtality als extended ver a chesive area. At first it included the suth-western vivdeships and thse lying n the Baltic west cast as well as city f Ldz, and in the end f this perid it als included sme nrth-eastern and central vivdeships. The mrtality f middle-aged men is nt nly higher in the nrthern and suthwestern part f Pland than in the remaining part f the cuntry, but it is als grwing mre rapidly. What shuld be nted abut vivdeships with and fast rising mrtality is that they / with a few exceptins which prve the general rule / are lcated in the territries frmerly under Prussian administratin r annexed t Pland after the war. Since in the territry frmerly under the Prussian administratin artificial fertilizers, pesticides and ther agricultural chemicals began t be used earlier than in ther Plish territries and since the State-wned farms which nw cver mst f the area there are knwn fr their thughtless and excessive use f these agents, ne may assciate the particularly high level and unusual increase in the death rates f middle-age men in this territry with what may be the negative effects f the develpment f a specific type f agriculture / ften hand-in-hand with raising prductin f the extractive and heavy industries^). Therefre, a faster increase in adult male age-specific death rates in cuntryside than in cities must nt be cnsidered as an all-natin phenmenn but rather as a reactin t and side-affect f a miscnceived mdernizatin f agriculture, typical t sme regins f the cuntry, nt necessarily f traditinally rural character at that.

174 3. Differentiatin f mrtality change between 1970/1971 and 1978/1979 frm the view-pint f selected ecnmic characteristics An analysis f mrtality trend and differentials based n yearly data /e.g. accrding t age, sex, urban/rural residence r residence by regin/ suggests that sme ecnmic factrs like emplyment status, surce f incme r ccupatin might have played an imprtant rle in diversifying mrtality pattern in Pland. S far n studies n sci-ecnmic differential mrtality have been undertaken in Pland* 5 ). The main reasn fr this seems undervaluatin f the imprtance f sci-ecnmic factrs in shaping mrtality trends and patterns. The ther cause might be the shrtage f adequate statistical data, what hwever, des nt justify the ttal lack f such studies. The basic data required fr studying sciecnmic determinants f mrtality can be btained frm current registry based n death certificates and ppulatin censuses* 6 ). There seems t be n serius prblem with calculating f age - and sex-specific death rates fr the years brdering n the dates f ppulatin census, i.e. fr 1970/1971 and 1978/1979 accrding t emplyment status /3 main categries: ecnmically active, having independent means but nn-wrking and ther, i.e. supprted by thse belnging t the tw frmer grups, r 2 main categries: wrking and nn-wrking/ and surce f incme /2 main categries: agricultural incme and incme frm utside f agriculture/. Other characteristics which can be extracted frm death certificates /e.g. subdivisin f wrking ppulatin int: manuals, nn-manuals, wrking n wn accunt and thers/ d nt match census characteristics, meaningful death rates cannt be cmputed which wuld be based n them. A deeper disaggregatin f death rates within the wrking ppulatin accrding t surce f incme /e.g. subdivisin f ppulatin wrking utside f agriculture by industries and branches/ wuld be pssible nly fr 1970 but the quality f data des nt guarantee reliable results* 7 ); thus wrk n data testing and imprving wuld be necessary in case the existing statistics are t be used. In the presentatin t fllw I shall restrict myself t a brad analysis f differentiatin f mrtality by emplyment status and ecnmic sectr /in case f wrking ppulatin. This is nly a preliminary study whse majr gal is t pint t the usefulness f inquiring int the sci-ecnmic determinants f mrtality. An analysis will be based n the death rates given in Table 1 a Table 2 which have been cmputed as tw-year unweighted averages. As can be seen in Table 1, the changes in death rates between 1970/1971 and 1978/1979 display a remarkable cnsistency. Bth amng wrking and nwrking ppulatins the rates went up in the age grups: 35-44 and 45-54 while decreased in the age grups: 25-34 and 55-64. The increase was the strngest amng wrking men: by 20 per cent in the grup 35-44 and by 13 per cent in the grup 45-54 /as cmpared with 9 and 7 per cent increase amng nn-wrking men, 1 and 0 per cent amng wrking wmen and 7 and 2 per cent amng nn-

175 wrking wmen, respectively/. The deepest decline ccured amng nn-wrking males and females in the grup 55-64, by 33 and 25 per cent respectively. It might be presumed that such a cnsiderable decrease in mrtality f nn-wrking ppulatin in lder ages f ecnmic activity was due t premature retirement f many peple. In fact, in the 1970s, mstly because f deterirating health f many wrking peple, the share f nn-wrking in all ppulatin in lder intervals f age f ecnmic activity increased substantially. Between 1970/1971 and 1978/1979 it increased frm 9 t 18 per cent amng men and frm 32 t 42 per cent amng wmen in the grup 55-59, and frm 17 t 38 per cent amng men and frm 49 t 63 per cent amng wmen in the grup 60-64. Due t tw facts: 1/ a large difference in mrtality levels between wrking and nn-wrking ppulatins /in 1978/1979 4-8 times higher amng nn-wrking men and 3-4 times higher amng nn-wrking wmen/ and 2/ lwer mrtality f thse retiring than the average in nn-wrking ppulatin and higher than the average in wrking ppulatin, the intensified premature retirement inthe 1970s resulted in a seemingly paradxical effect f decreasing death rate in the grup 55-64, bth amng males and females, in the situatin where the respective verall rates were almst cnstant in the perid 1970/1971-1978/1979. Table 1. Selected age- and sex-specifici death rates /per thusand/ in Pland in 1970/1971 and 1978/1979 by emplyment status. Age 25-34 35-44 45-54 55-64 Age 25-34 35-44 45-54 55-64 Wrking Males 1970/1971 1978/1979 1.83 1.76 2.98 3.59 5.81 6.55 14.09 11.06 Nn-wrking Males 1970/1971 1978/1979 11.22 10.70 27.22 29.69 42.64 39.57 66.71 42.25 Females 1970/1971 1978/1979 0.55 0.46 1.03 1.04 2.27 2.28 5.59 4.45 Females 1970/1971 1978/1979 1.69 1.37 4.65 4.96 10.00 10.16 17.49 13.17 surce: Own cmputatins based n the Central Statistical ' Office data.

176 As far as wrking ppulatin is cncerned /see Table 2/, the changes in death rates fr 5-year age grups in the interval 25-64 years differed between males and females. Amng males they rse between 1970/1971 and 1978/1979 in all grups, except fr the last tw grups, while amng females they generally decreased. Therefre, it can be argued that the aggregate death rates fr wrking ppulatin presented in Table 1 cnceal sme imprtant regularities. It might be nticed in Table 2, fr istance, that cntrary t what the data in Table 1 suggest n increase in mrtality f wrking females aged 35-44 tk place in the perid under study; the death rates remained cnstant fr emplyed in agriculture in the Table 2. Selected age- and sex-specific death rates /per thusand/ fr wrking ppulatin in Pland in 1970/1971 and 1978/1979 by surce f incme /ecnmic sectr/. Age 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Age 25-29 30-34 35-39 40-44. 45-49 50-54 55-59 60-64 Nn-agricultural 1970/1971 1978/1979 1.7 1.9 2.5 3.4 5.0 7.1 10.5 15.8 1.7 2.1 2.8 3.9 5.6 7.6 10.3 13.4 Nn-agricultural 1970/1971 0.5 0.6 0.8 1.3 2.0 2.9 4.3 7.3 1978/1979 0.4 0.5 0.8 1.2 1.8 2.7 3.4 7.0 MALES FEMALES Agricultural 1970/1971 1978/1979 1.9 2.1 2.7 3.7 5.3 8.0 13.8 22.7 1970/1971 0.4 0.6 0.8 1.2 1.9 2.9 4.8 8.1 Agricultural Surce: Own cmputatins based n the Central Statistical Office data. 2.1 2.6 3.3 4.6 6.5 9.1 13.0 21.6 1978/1979 0.4 0.5 0.8 1.2 1.8 2.9 4.5 7.8

177 age grups 35-39 and 40-44, and fr emplyed utside f agriculture in the grup 35-39 while the death rate fr emplyed utside f agriculture aged 40-44 declined. Furthermre, n decrease in mrtality f wrking men aged 25-34 happened; just the ppsite, the relevant death rates, bth fr agricultural and nn-agricultural /except fr the age grup 25-29 where the rate did nt change/ men, increased quite substantially. Hance the changes, in certain aggregate agespecific death rates fr wrking ppulatin /see Table 1/ resulted t a large extent frm the differences between mrtality f agricultural and nnagricultural ppulatins in the situatin f an intensive utflw frm agriculture f yung wrkers. The mst imprtant finding based n the data given in Table 2 seems the much strnger increase in mrtality f males emplyed in agriculture than emplyed utside f agriculture. In the frmer ppulatin it was 22-24 per cent, as cmpared with 10-15 per cent in the latter ppulatin, in the grups f age frm 30 t 49 years and it was at least tw times strnger in the remaining grups in the frmer ppulatin /except fr the grups: 55-59 and 60-64 where the situatin was specific, due t the early retirement wave described abve/. It might be added that the decrease in mrtality f agricultural females was as a rule weaker than f nn-agricultural females /utside f agriculture in half f the grups n change was bserved/. Therefre, all ecnmically active agricultural ppulatin was particularly affected by unfavurable changes in mrtality which tk place in the 1970s. The changes which have just been described led t an acute despening f the difference between mrtality f agricultural and nn-agricultural wrking ppulatins. Amng females, hwever, it was nt such distinct ccurence as amng males; in few age grups the difference even remained cnstant. The characteristic feature f agriculture/nn-agriculture differential amng females in 1978/1979 was that in n age grup was mrtality f agricultural wrkers lwer than f nn-agricultural wrkers thugh still in 1970/1971 in three age grups the death rates were lwer amng agricultural wrkers. Amng males in 1970/1971 there was already a distinct excess f death rates fr agricultural wrkers ver the rates fr nn-agricultural wrkers /6-13 per cent in the grups frm 25 t 54 years and higher than these in the lder grups/. Nevertheless, in 1978/1979 agricultural rates were higher by 16-26 per cent in the grups frm 25 t 59 years and by 61 per cent in the grup 60-64. The differences, in relative terms, had at least dubled between 1970/1971 and 1978/1979 with tw exceptins: the 55-59 and 60-64 age grups where already in 1970/1971 they were the largest. The abve cnsideratins leave n dubt as t the drastic sci-ecnmic differential mrtality in Pland. They als call fr a mre in-depth analysis which wuld use the appraches free f numeratr-denminatr bias in

178 calculating death rates which is present in crss-sectinal, unlinked apprach demnstrated in this paper. Als, a mre detailed disaggregatin f death rates accrding t sci-ecnmic categries wuld seem needful, in particular by ccupatin and industry in nn-agricultural sectr, as well as by type f emplyer /large State-wned enterprise, small State-wned enterprise, cperative enterprise, private enterprise, etc./. Ftntes 1. See M. Okólski, Demgraphic Transitin in Pland: Current Phase, Oecnmica Plna, N. 2, 1983 /in print/. 2. This is in the perid 1950-1980. 3. Fr details, see M. Okólski, Dynamizm ludnsciwy Plski w latach 1971-1990 i jeg uwarunkwania, A reprt t the Plish Ecnmic Sciety presented in June 1981. 4.J. Aleksandrwicz was amng the first t call attentin t the fact that the relatively early appearance f leukemia amng cattle in the Western and Nrthern territries culd have been relaied t the widespread and cntinual use f chemicals in agriculture. See e.g. J. Aleksandrwicz, Sumienie eklgiczne, Warsaw 1979. 5. My 1981 study cited in ftnte 3 might be the nly exceptin. 6. In setting data fr the present study it was nt pssible, due t technical reasns (e.g. insufficient resurces), t link mrtality recrds back t census recrds. Thus the analysis t fllw will be based n unliked data. 7. Sme results, hwever, have been included in my wrk cited in ftnte 3.

179 PROBLEMS AND POSSIBILITIES OF RESEARCH IN COUNTRIES WITH LIMITED DATA Wilfried LINKE and Jan van REEK Federal Institute fr Ppulatin Research, Wiesbaden, Federal Republic f Germany Dept. f Medical Scilgy University f Limburg, Netherlands I. Necessity f research int sci-ecnmic differential mrtality In sme cuntries the evaluatin f death and the analysis f mrtality in cnnectin with sci-ecnmic variables have fr many decades been part f the tls f scial statistics. These cuntries in many cases are using evaluatin prcedures based n the linking f different data recrds. These prcedures have in cuntries like the United Kingdm and France in part already a lnger traditin. In sme cuntries, the applicatin f linking prcedures is hwever limited, if nt impssible, due t the intrductin f data prtectin prvisins. The necessity f research int differential mrtality, especially in cnnectin with sci-ecnmic variables, is f increasing imprtance in the industrialized cuntries. The stagnatin f mrtality in specific age grups, but als the existing differences f mrtality levels in the industrialized cuntries give rise t questins cncerning the pssible causes f differential mrtality. It shuld hwever nt be left alne t the initiative f the research institutins r prfessinal assciatins t decide what shuld be measured and investigated and hw this shuld be dne. Research int the sci-ecnmic differences f mrtality shuld als mre strngly be supprted and cnsidered by the ministries, the plitical grups and trade unins in cnnectin with sci-medical planning. With a view t the ensuing demands, it might be cnceivable that fr meeting scientific bjectives prcedures s far either nt yet used at all r nly n a restrictive basic culd als be drawn upn. The examples f the lngitudinal study in the United Kingdm and investigatins made in Sweden are shwing the pssibilities f hw linking prcedures can be applied even cnsidering existing data prtectin prvisins.

180 II. Feasibility f research int sci-ecnmic differential mrtality in industrialized scieties with privacy limitatins During an infrmal meeting in Wiesbaden n 15-16 June 1982 it was agreed, that Mr. Jan van Reek shuld write a shrt paper n the feasibility f research int sci-ecnmic differential mrtality in industrialized scieties with privacy limitatins. A classificatin f methds, drafted during a UN/WHO/CICREDmeeting(i), elabrated by Elsebeth Lyngea) and summarized by Linke fr the infrmal meeting in Wiesbaden was the basis fr this reprt. II shuld be nted, that this classificatin is nly useful as a practical descriptin f the present state f art. The verlapping categries are smewhat embarrassing frm the theretical pint f view. In the cuntries with privacy limitatins it is nt pssible t use methds which implicate a linkage f mrtality data t census data n an individual level. This results in the infeasibility f the matched recrd studies, prspective studies based n census data and lngitudinal studies based n census data< 3 ), The fllwing seven methds may be applied: 1. Crss-sectinal studies (mrtality by scial class using census data fr the denminatr and mrtality data fr the numeratr). 2. Eclgical studies (reginal mrtality related t ther reginal characteristis). 3. Prprtinal mrtality studies (prprtin f deaths due t a certain cause f death is cmpared between ccupatinal grups). 4. Case-cntrl studies (relative risks are studied). 5. Retrspective studies (fllw-up surveys in which relatives and physicians are questined abut the deceased). 6. Prspective studies based n chrt data (individuals are fllwed frm the data f entry ver a lnger perid f time). 7. Lngitudinal studies (a ppulatin sample is fllwed n an individual basis). These methds frm the present state f affairs (see Annex 1). New methds might be develped. The gvernments in cuntries with privacy limitatins tend t cnsider research int sci-ecnmic differential mrtality t be imprtant, but their cncrete supprt is rather hesitant. Fr that reasn researchers tend t chse cheap and quick methds. These are in rder f ppularity: eclgical studies, crss-sectinal studies and prprtinal mrtality studies. Occasinally ther methds are applied. Criteria fr the feasibility f a methd are rarely discussed. Instead researchers tend t cmplain abut privacy prblems, which even are t be fund in eclgical studies (4,5). In this paper the fllwing criteria will be discussed: csts, time, availability f data, privacy sensitivity, scientific relevance and scial relevance. Unfrtunately, scientific and scial relevance seem rarely t have a great

181 influence n the feasibility f a methd, despite the fact that the gvernment recgnizes the relevance f research int sci-ecnmic differential mrtality. Privacy-sensitivity is a very imprtant criterin als by the emtins which have been evked by previus abuse f persnal data. Csts, time and availability f data ara als wrth mentining. Therefre crss-sectinal studies, eclgical studies, prprtinal mrtality studies and case-cntrl studies are the best feasible methds (see Annex 2). The retrspective study is a favurable methd in terms f time and scial relevance. Unfrtunately the strng privacysensitivity f the data cllectin frm relatives and physicians renders the feasibility f this methd rather dubtful. Prspective studies based n chrt data and lngitudinal studies f ppulatin samples are unfavurable in terms f csts, time, availability f data and privacy sensitivity. The bject f study can als influence the feasibility f a mther. It is hardly pssible t study rare diseases by means f prspective studies fr instance. This exceptin cannt be included in the general evaluatin f the feasibility. The favurable scientific and scial relevance cause that by way f exceptin a few studies are planned and executed. Sme examples will be given. In the Federal Republic f Germany, a fllw-up survey, called micrcensus, has beed executed in the year 1979< 6 ) and a cancer register has been estabilished in Heidelberg. In the Neherlands, there has been sme experience with prspective and lngitudinal studies«17 ), at the mment an experimental cancer register is being established in Rtterdam and a prspective study is seriusly being prepared. Many useful methds can be applied in cuntries with privacy limitatins. During ptimistic discussins we are happy that we need repeat the large-scale surveys f Scandinavia, the Unite Kingdm, France and the United States, because these surveys lack many imprtant explanatry variables. Actually we will cme acrss many serius difficulties in ur future surveys. III. Investigatin f the phase preceding death The majrity f the investigatins is cnsidering the sci-ecnmic data at the time f death r fr a perid nly shrtly befre. It wuld be desirable t cnsider, as a further step f the investigatin f differential mrtality, the bigraphical prcess, especially the ccupatinal changes and the life style f the persns invlved. The WHO has emphasized the necessity f investigatins including the phase f life and ccupatin immediately preceding death. In principle, the bibligraphical apprach cnstitutes a differentiated lngitudinal evaluatin which wuld have t cnsider in additin t the persnal data and data f emplyment statistics ver time als the spheres f: line f behaviur, way f life, envirnment, mrbidity, cause f death. Investigatins f this kind are at present being made in the United Kingdm and the Netherlands. The evaluatin techniques and the analytical results f these studies will be f great interest t the institutins in the ther cuntries.

182 Annex 1

183 15 + + + + O + + O + Imr ë 8 c 5 i O O O «s I! s-s 1 ime! O O O > i + + + + 3 5 tí 8 + + x> cd si 2 3 > II I!

184 References 1. Reprt f the first meeting, Sci-ecnmic differential mrtality in industrialized scieties 1, UN/WHO/CICRED, Paris, 1981, 1-4. 2. Elsebeth Lynge, Sci-ecnmic differences in mrtality in Eurpe, cuncil f Eurpe, Strasburg, 1980, 10-14. 3. Jan van Reek, Future pssibilities f research n sci-ecnmic differential mrtality in the Netherlands, Sci-ecnmic differential mrtality in industrialized scieties 2, UN/WHO/CICRED, Paris, 1982, 61-63. 4. R.B. Hayes et al., Gegraphic distributin f cancer mrtality in the Netherlands, Rtterdam, 1980. 5. P.J. van der Maas, Habbema et al., Sci-ecnmic mrtality differences between districts in the city f Amsterdam, Sci-ecnmic differential mrtality in industrialized scieties 1, UN/WHO/CICRED, Paris, 1981, 79-82. 6. W. Linke, Deaths f ecnmically active persns: results f the fllw-up inquiring t the 1979 micrcensus, Sci-ecnmic differential mrtality in industrialized scieties 2, UN/WHO/CICRED, Paris, 1982, 33-39. 7. F. van Pppel, A review f research int the sci-ecnmic determinants f mrtality in the Netherlands since the secnd wrld war, Sci-ecnmic differential mrtality in industrialized scieties 1, UN/WHO/CICRED, Paris, 1981, 67-76.

185 SECTION IV GEOGRAPHICAL AND ECOLOGICAL APPROACH Reginal variatins in mrtality in Nrway (Gerd S. LETTENSTR0M and Jens- Kristian BORGAN) Cnsidératins préliminaires pur une étude sur la mrtalité par causes en Tscane (Silvana SALVINI et Silvana SCHIFINI d'andrea) Infant mrtality and mther educatin degree at the birth in Italy (Marzia VAL- LI TODARO)

187 REGIONAL VARIATIONS IN MORTALITY IN NORWAY Gerard S. LETTENSTR0M and Jens-Kristian BORGAN Central Bureau f Statistics f Nrway 1. Statistical basis The present study f reginal variatins in general mrtality and mrtality frm selected causes are based n all registered deaths in 1976-1980 assigned t the area f usual residence f the deceased. Based n infrmatin abut the residence f the deceased, the deaths have been gruped by cunty and by type f municipality. Fr calculatin f crude death rates, the registered ppulatin by sex and age in the varius regins 31 December 1978 has been used as denminatr. Sex and age specific death rates are calculated fr 12 age grups. Hwever, fr ages having lw mrtality, the basic number f deaths is very small. In rder t facilitate reginal cmparisns f the characteristic features in the mrtality, death rates have been calculated fr the ttals ppulatin and fr 4 main grups. Crude ttal death rates fr brader age grups will be influenced by sex and age distributin f the ppulatin in the different regins. Fr cmparative purpses standardized rates have therefre been calculated. The direct methd has been applied, and adjustments have been made fr bth sex and age. In the tables fr the specific perid 1976-1980, standardizatin fr cunties and types f municipalities has been based n the ttal ppulatin by age per 31 December 1978. In tables where the results fr cunties have been cmpared with data fr previus perids, the standard ppulatin is the census ppulatin by age 1 Nvember 1960. Causes f death are classified in accrdance with the 8th revisin f the ICD f 1965. The number f deaths frm selected causes in each cunty, when brken dwn by sex and age, will be small fr certain causes even fr a 5-year perid. Differences in the calculated rates may therefre reflect randm fluctuatins. Due cnsideratins must als be given t the differences in medical supervisin and diagnstic facilities thrughut the cuntry. Fr deaths in 1976, the average

188 tí 3 0 T3 3 D, a» Si 2 c I ent."2 O "03 <u c3 es - N r- n > rû - r^ fn fi i 00 Os 00 r*^ v r c c U L D. I X u Si 15 fij c C 8 O 2 I ü,o M T3 g-'s (r> OIOca>h<>ß!S «'S c 00 J2 C rt (ü O V. "O T3 -a E 5 S a c c e c S 8. (U a j. Il

189 per cent autpsies perfrmed was 14, with a reginal variatin frm 32 in Osl tgether with Akershus (the cunty surrunding Osl) t 7 in average fr the three Nrthern cunties. By calculatin f expectatin f life in cunties and types f municipalities, ne-year specific death rates have been based n the mean ppulatin in the perid 1976-1980. 2. Mrtality trends Standardized rates fr 1976-1980 cmparable with previus perids back t 1960 shw that the mrtality pattern fr cunties has changed very little. Cmpared t 1971-1975 the mrtality fr all ages had decreased in all cunties. Fr males the decrease varied frm 1 t 10 per cent, fr females frm 1 t 16, while the average decrease was 4 per cent fr males and 8 per cent fr females. Althugh the average mrtality rate fr age grup 40-69 years decreased with 2 per cent fr males and 4 per cent fr females cmpared t 1971-1975, half f the cunties had n decrease in mrtality fr males, and abut ne third had n decrease fr females. Cmparing standardized rates fr the bth sexes, male excess mrtality is fund in all cunties. Fr the perid 1976-1980 the male excess mrtality was abve 60 per cent in average, and with a variatin frm 77 in Finnmark and 76 in Osl t less than 50 fr inland cunties in the Eastern part f the cuntry. Excluding vilent deaths (shwing the greatest reginal variatins), and lking at ttal diseases, Osl shwed the highest male excess mrtality with 75 per cent, and with Finnmark secnd (72). Due t the mre favurable trend in female mrtality rates, the male excess mrtality has increased ver time. This tendency refers t almst all cunties fr perids back t 1960. Frm 1971-1975 t 1976-1980 the rate f increase has hwever been lwer than befre in mst f the cunties. 3. Expectatin f life in cunties The results f calculatin based n data fr 1976-1980 (table 5) shw that expectatin f life at birth varies fr males frm abut 69 years in Finnmark t 74,5 years in Sgn g Fjrdane. Cmpared t an average f 72,2 years, males in Finnmark lie 3,3 years belw, while males in Sgn g Fjrdane lie 2,3 years abve average. Fr females the variatins are much smaller. Cmpared t an average f 78,7 years, females in Finnmark have 1,6 years lwer expectatin, while females in Sgn g Fjrdane lie 1,4 years abve the average. The secnd lwest expectatin f life refers t Osl. The effect f the cnsiderable reginal differences in male mrtality is a variatin in the survival rate at age 65 frm 69 per cent in Finnmark t 80 in Sgn g Fjrdane. Due t the smaller differences fund in female mrtality the

190 gw "28 S " S rln r»i -"«!7 fi V i bd 2 g O c O " 8 «i -- v c S E~ a nepl 0-209 c «2 d c S ttvon g OOOí-OiOiOOOvOvOO»lNOnNNn OMlOSOOOiOO D. Sex- 1 aveirage ci 3 03 H G O "2 mz c - c «8 O "5 11 5S

191 S» "O O 8 rr^inr~ cs <j\onwin»^<irai»r--^-ct>r-r~onv>í3 -«VO O u. c S -^n r- \ 0> 0\ OVOOOSOOOO 3 8 info s IS! CO ON C Ô a a

192 S Q«i»»3iNaN OOOO\OOCT\CT\OCTNO\.c»n O s "c3 S 'S N <* Si O^Oa^OnO O\ CO u 8 c -<!? 8,5 8 r<i>^ir» 13 OO-H 00 c u S <* * 8 8 cnr- i 0\ 00 0 O ON N ^3 ^3 N /> u C D O < ^ c O T3 rt IS g -g Vi ~7> <u <u"o-< Ö A O I ;C f, 0 -^^ es r T}- i^) i H O O O O O ' O OTT) c ni O 8 <N U -^

193 g OOOOOONO>OÍN "r 8 MO\0-"0\OOMOr-M M < 1O 5» 9 00 O\ Oft-0»010lOO\0\0» OOOOOOSOOO Si *Si 8-9>N»s OOn g g OOOV i t~ VO >O -^ Q O r r>»o»oh<t ON S *S «8 d Z Cu OT O< s m 8 52tu O. u "S M fe -a u 'S P-8 a HE Ú eï le 1 I 2 fe

194 Table 4. Sex-specific mrtality 1971-1975 and 1976-1980. Cunty. Standardized rates') v-uniy Deaths per 100 000ppulatin 1971-1975 1976-1980 Males Females Males Females Mrtalily 1976-1980 cmpared t mrtality 1971-197«(= 100) Males Females ALL AGES The whle cuntry 0'stfld Akershus Osl Hedmark Oppland Buskerud Vestfld Telemark Aust-Agder Vest-Agder Rgaland Hrdaland Sgn g Fjrdane MdYe g Rnisdal Sr-1 rpndelag Nrd-Trpndelag Nrdland Trms Finnmark 088 175 058 201 012 990 081 141 085 058 093 I 074 039 946 981 100 996 139 151 347 684 756 704 678 710 685 683 683 688 645 672 673 653 628 617 699 689 716 742 792 044 088 997 182 985 948 051 114 030 034 081 052 985 852 929 1 076 953 063 080 317 626 656 629 661 656 620 676 650 604 615 640 620 568 553 549 645 617 609 624 716 96 93 94 98 97 96 97 98 95 98 99 98 95 90 95 98 96 93 94 98 92 88 89 97 92 91 99 95 88 95 95 92 89 88 89 92 90 85 84 90

195 Cunty Deaths per 100 000 ppulatin 1971-1975 1976-1980 Males Females Males Females Mrtality 1976-1980 cmpared 1 mrtality 1971-1975 (= 100) Males Females AGE GROUP 40-69 YEARS The whle cuntry ^stfld Akershus Osl Hedmark Oppland Buskerud Vestfld Telemark Aust-Agder Vest-Agder Rgaland Hrdaland Sgn g Fjrdane Mre g Rmsdal S0r-Tr0ndeIag Nrd-Trpndelag Nrdland Trms Finnmark 1 111 1 175 1 021 1 330 972 949 1078 200 103 061 097 076 1061 905 959 1 145 972 1 183 1 193 1499. 540 583 536 594 546 482 528 531 542 525 495 548 504 437 463 562 533 563 583 591 1093 1 143 028 318 021 904 049 185 1077 1061 129 I 091 I 009 839 938 1 153 916 1 095 1219 1 528 516 528 475 635 523 489 526 535 478 486 474 511 462 440 436 553 480 472 536 622 98 97 101 99 105 95 97 99 98 100 103 101 95 93 98 101 94 93 102 102 96 91 89 107 96 101 100 101 88 93 96 93 92 101 94 98 90 84 92 105 1) Standard ppulatin 1960.

196 t~ 58 m ON Q r- S! Oí 3 r^ t^ r- 00 s00 Tj- r r~ r~- 58 S S v ON u 60 «I m Tf «N m PI r- Tt Kl * <.71 1.17 1,61 1,88 OO l/~> m ar-,03 ] r- r~ svo SN S Tt 00 O Tt S,01 1,36 1,04,07,63 1,26 I ON OO VO rs r» TT ON ON ON OO ON ON ON ON O Ç? ON ON O ~* *-^ ON O O ON 00 *O *O *O O *O *O *O **O ^5 < * ** "^ *^3 *^i ^D ^5 * *ro i 1 «2 3 1!3 8. lcd ä h ' O t «vo""fn«n^-. n. ^.. N."î î. ".. 'f. "...... 1..... b"b"ó"*b"*" r CN""ON""C*Có"*r--* t ^ r r ^ r t - r t ^ t ~ r ^ i i ~ t r i ^ r r r r r c 2 5 ê 8 Sa i!i!jliliî!îilffi!fi

197 survival rate varies nly frm 86 t 90 per cent. In average fr the whle cuntry the survival rate at age 65 was 76 per cent fr males and 88 per cent fr females. 4. Mrtality differences fr types f municipalities Fr the perid 1976-1980, calculatins crrespnding t thse fr cunties were made n sex-specific mrtality in municipalities gruped by type n the basis f industrial structure, ppulatin density, and prximity f service centres. The classificatin by type refers t data frm the ppulatin census 1970, and it has nt been pssible t take int cnsideratin changes in distributin by industry, etc. after 1970. Frm the crude death rates (table 6) it is seen that agricultural municipalities have the highest rate fr males and fr females, while nncentral, manufacturing municipalities have the lwest rates. After the standardizatin, agricultural municipalities changed t be in the mst favurable psitin. The highest standardized rates fr males refer t the especially central, mixed service and manufacturing municipalities. This grup includes all the largest twns. Next t these municipalities fishing municipalities had highest rates. Fr females, the highest rate was fund in central mixed agricultural and manufacturing municipalities. Standardized rates fr selected causes (table 7) shw that the grup f especially central municipalities had the highest death rates fr males, regarding malignant neplasms, diseases in respiratry rgans and in digestive rgans, while fishing municipalities had the highest rates fr diseases in the circulatry rgans and fr vilent deaths. Agricultural municipalities had the lwest rates fr malignant neplasms and diseases in the circulatry rgans. Almst the same pattern was fund fr females, except that females in especially central municipalities have medium mrtality frm diseases in respiratry rgans but high rates fr vilent deaths, and females in fishing municipalities have mre mderate rates frm diseases in the respiratry rgans and frm vilent deaths. As far as sci-ecnmic and eclgical factrs have been included in the classificatin f municipalities, mrtality differences fr municipal types may, accrding t their distributin gegraphically, cntribute t the explanatin f differences fund fr the cunties.

198 Table 6. Sex-specific mrtality. Type f municipality. 1976-1980 Type f municipality Deaths per 100 000 ppulatin Crude death rates Males Females Standardized rates') Males Females THE WHOLE COUNTRY 1 101 904 1 275 783 1. Agricultural municipalities 2. Nn-central, mixed agricultural and manufacturing municipalities 3. Central, mixed agricultural and manufacturing municipalities 4. Fishing municipalities 5. Nn-central, manufacturing municipalities 6. Central manufacturing municipalities 7. Expecially central, mixed service and manufacturing municipalities 8. Remaining mixed service and manufacturing municipalities 9. Other municipalities 1 318 1 230 1 099 1 208 990 1 065 1 068 1 075 1 090 1 062 966 885 900 780 852 923 878 877 1 117 1 176 1 207 1 334 1 182 1 289 1 354 1 325 1 181 724 754 828 774 731 812 794 792 751 1) Standard ppulatin 1978. Table 7. Sex-specific mrtality frm selected causes by type f municipality as percentage f natinal average. 1976-1980 Tvnp nf municipality All causes 140-209 390-458 N. ICD8. rev. 460-519 520-577 Res.N 000-779 780-796 E800- E999 ALL AGES Males The whle cuntry 1. Agricultural municipalities 2. Nn-central, mixed agricultural and manufacturing municipalities 3. Central, mixed agricultural and manufacturing municipalities 100 88 92 95 100 82 87 83 100 86 94 95 100 86 86 104 100 72 81 88 100 101 90 106 100 97 99 104 100 107 106 100

199 Type f municipality All causes 140-209 390-458 N. ICD8. rev. 460-519 520-577 Res.N 000-779 780-796 E800- E999 4. Fishing municipalities 5. Nn-central, manufacturing municipalities 6. Central manufacturing municipalities 7. Expecially central, mixed service and manufacturing municipalities 8. Remaining mixed service and manufacturing municipalities 9. Other municipalities Death rate per 100 000 ppulatin 105 93 " 101 106 104 093 1 275 94 91 102 115 104 81 258 112 94 102 104 104 95 632 93 89 97 116 101 83 114 69 66 97 122 103 94 32 94 91 100 103 99 98 88 112 109 107 82 121 107 68 117 96 94 100 99 105 83 Females The whle cuntry 1 2 3 4 5 6 7.... 8 9 Death rate per 100 000 ppulatin 100 92 96 106 99 93 104 101 101 96 783 100 84 95 95 94 92 101 108 99 88 170 100 90 96 107 102 94 108 99 102 98 381 100 101 93 107 91 95 99 103 97 105 74 100 109 86 109 100 82 100 114 91 91 22 100 103 102 129 97 95 95 95 103 97 66 100 115 106 100 130 100 100 82 115 106 33 100 95 95 100 76 82 100 108 100 87 38

CONSIDÉRATIONS PRÉLIMINAIRES POUR UNE ÉTUDE SUR LA MORTALITÉ PAR CAUSES EN TOSCANE. 201 Silvana SALVINI et Silvana SCHIFINI D'ANDREA Department de Statistique, Université de Flrence, Italie En affrntant une étude sur les caractéristiques territriales de la mrtalité en Tscane à partir de 1970, dans le but de cerner des znes hmgènes de mrtalité, cntiguës u nn gégraphiquement, et vérifier s'il existe des facteurs du milieu en mesure d'expliquer d'éventuelles différences de mrtalité par causes, nus avns remarqué que la série des dnnées dispnibles ne cnvenait pas à ce but. Nus smmes en effet cnvaincus que le phénmène mrtalité par causes est prfndément cnditinné par les caractéristiques du milieu' et que pur cette raisn, aussi bien du pint de vue de la cnnaissance que du pint de vue pératinnel, une étude éclgique de la mrtalité dit se référer au lieu de résidence des décédés. D'autre part, n ne peut pas ignrer le fait que tute élabratin accmplie sur la base du lieu du décès prte la marqué' de la répartitin sur la territire des structures hspitalières. Puisque l'agrandissement de la dimensin territriale cmprte inévitablement une perte d'infrmatin, l'unité territriale à la base de l'étude dit être la «cmmune» de résidence. La surce des dnnées à la base de la recherche est cnstituée par les enregistrements furnis par l'istat pur la péride 1970-1981, mais actuellement nus dispsns des dnnées seulement jusqu'en 1979. Cmme n le sait, les enregistrements cntiennent les décès individuels avec les mêmes caractéristiques prévues par les fiches de décès et ne prtent pas, jusqu'en 1979 inclus, la cdificatin des décès par cmmune de résidence. Les infrmatins dnt nus dispsns se réfèrent dnc à la cmmune de décès et à la prvince de résidence. Elles spécifient si l'individu était résident dans la cmmune dans laquelle est arrivé le décès. Seulement pur ce dernier agrégat, nus dispsns cmplètement des infrmatins nécessaires à ntre étude; en cnséquence, bien que nus nus rendins cmpte des difficultés et du caractère aléatire inhérents à la

202 recnstitutin de l'infrmatin des décès seln la cmmune de résidence, l'entité des décès «hrs de la cmmune» et la différenciatin cnstatée au niveau de la prvince pur le triennat 1970/1972 (tableau 1), nus nt cnduits à frmuler quelques hypthèses de travail dans le but de rejindre ntre bjectif. Si la distributin des décès par sexe, âge et cause de décès était la même pur les deux agrégats cernés seln le lieu de décès, il n'y aurait pas nécessité de frmuler des hypthèses pur cerner la cmmune de résidence pur les décès survenus «hrs de la cmmune». La cnstatatin que ces distributins snt frtement différenciées n'a pas permis de suivre la slutin la plus simple, c'està-dire de travailler exclusivement sur le premier agrégat. A titre d'exemple nus rapprtns la distributin des décès de la ppulatin masculine par causes et par âge en Tscane et pur les prvinces de Massa Carrara et de Siena. Pur le triennat 1970/1972 (tableaux 2 et 3), n bserve des différences remarquables dans les distributins par causes des décès et par âge des deux agrégats, différences que l'n retruve pur le triennat 1975/1977 (tableaux 4 et 5). La cnditin ptimale, mais pérativement difficile à suivre, est de récupérer l'infrmatin, en demandant aux cmmunes de décès les dnnées individuelles des nn-résidents. A travers les paramètres cntenus aussi bien dans les registres municipaux que dans les enregistrements 1ST AT (sexe, date de naissance, date de décès, état civil etc..) il serait pssible de relier les infrmatins sur la cause de décès (surce enregistrement 1ST AT) et celles des cmmunes de résidence (surce anagraphique). En alternative, sur la base d'une analyse cmparative de l'entité des décès présents et des décès résidents au niveau cmmunale) (respectivement surce enregistrements ISTAT et surce «Ppulatin et muvement anagraphiques des cmmunes») nus avns estimé puvir repérer les cmmunes dans lesquelles u bien le nmbre des décès présents (Dp) dépasse celui des décès résidents (D r ), u bien les décès d'une autre cmmune nt été truvés particulièrement nmbreux, après une vérificatin empirique. En même temps, ayant relevé dans ces cmmunes l'existence d'au mins une unité hspitalière, nus les avns appelés «pôles d'attractin hspitalière». En excluant, pur le mment, aussi bien les décès survenus dans une autre prvince tscane que les décès hrs régin, nus évaluns l'ensemble des décès hrs de la cmmune mais au sein de la prvince même. Par exemple, pur 1970, dans les pôles d'attractin hspitalière des prvinces de Massa Carrara et de Siena, snt cncentrés envirn 85% des décès résidents dans une autre cmmune de la même prvince. Ntre hypthèse de travail a été de chercher à évaluer la frce d'attractin des pôles hspitaliers individuellement (D p /D r ) et de cmparer à cette infrmatin (1) Même si, sur ces dnnées, nt une incidence les transcriptins manquees de variatins de résidences.

203 quelques paramètres de nature variée, de façn à attribuer au pôle même un pids glbal qui lui sit prpre, paramètres d'ailleurs nn cmplètement cernés à cause de la difficulté de repérage des infrmatins et pur la variété des cmpsantes qui peuvent définir l'attractin du pôle en des termes qui vnt audelà de la simple structure hspitalière (par exemple, les structures de réceptin de type turistique, saisnnier, etc.). A titre d'exemple, utilisns deux indicateurs de type crissant, qui peuvent être cnsidérés cmme étant les plus immédiats, aussi bien du pint de vue de la cmpréhensin que du repérage des dnnées, le nmbre des spécialités de l'rganisatin hspitalière et le nmbre des lits par habitant. Le rapprt D p /D r, pndéré par ces indicateurs, amène à la cnstructin de cefficients synthétiques d'attractin des différents pôles (tableaux 6 et 7). En intrduisant ensuite cmme variable la distance kilmétrique* 2 ' entre chaque pôle et tutes les cmmunes de la même prvince, pur chaque pôle, n btient une série de cefficients de «réattributin», fnctin des indicateurs chisis et des distances entre chaque cmmune et tus les pôles d'attractin hspitalière de la prvince examinée (Schéma A). Puisque les décès qui viennent d'autres cmmunes de la même prvince pèsent sur un pôle déterminé et peuvent être analysés par cause, âge et sexe, ce sera sur ces distributins que s'appliquernt les cefficients ainsi calculés pur redistribuer/ 3 ) entre tutes les cmmunes de la prvince, les décès des nnrésidents survenus dans la cmmune-pôle, décès qui, d'ailleurs, présentent une distributin par causes différenciée par rapprt à ceux qui snt en même temps présents et résidents dans le même pôle (tableau 8). Les pôles individualisés pur 1970, tut spécialement pur les prvinces de Massa Carrara et Siena se retruvent pur les deux triennats cnsidérés et, cmme n peut vir (tableaux 9 et 10) les différences entre les distributins par causes de décès de l'agrégat des résidents dans la même cmmune de décès et celui des résidents dans une autre cmmune de la même prvince, snt frt remarquables. On arrive ainsi à recnfirmer l'évaluatin imprécise des risques de décès au cas u l'analyse a été établie seulement sur le lieu de décès u bien sur le seul grupe sélectinné des résidents dans la même cmmune de décès. Nus nus prpsns, de tute façn, de vérifier la validité des hypthèses visant à réattribuer les décès aux différentes cmmunes seln la distributin par cause bservée dans les pôles hspitaliers. Cette vérificatin (indispensable pur évaluer la marge d'erreur due à l'hypthèse) purra être faite en repérant, pur quelques znes, la cmmune de résidence des mrts et en cmparant les résultats btenus avec ceux de ntre mdèle. (2) Dans l'éventuelle impssibilité de dispser d'une telle dnnée pur tutes les cmmunes de la Tscane, cette infrmatin sera déduite sur la base d'une cartgraphie apprpriée. (3) Pur telle redistributin n tiendra évidemment cmpte de la cnditin dérivée de la quantité (surce anagraphique) de l'ensemble des décès seln la cmmune de résidence.

204 Tableau 1. Distributin en purcentage des décès seln la prvince de résidence et le lieu de décès (myenne du triennat 70-72) Lieu de décès Prvince Même Prvince de Résidence même cmmune autre cmmune Autre Prvince Hrs de la Tscane Ttal Massa Carrara Lucca Pistia Firenze Livrn Pisa Arezz Siena Grsset 88.8 81.2 82.1 83.4 86.4 84.0 84.3 88.7 82.0 4.6 13.9 10.4 12.8 7.0 10.0 10.8 6.5 11.6 2.3 3.4 5.9 2.2 4.6 4.5 2.7 2.7 3.3 4.3 1.5 1.6 1.6 2.0 1.5 2.2 2.1 3.1 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 TOSCANA 84.1 10.7 3.3 1.9 100.0

205 O OS OO CO «"> "H < c «-i fs I I 00 00 O VO 00 - I I v «S rr O\ q v es > d d -*" ~ 1-2 (A Cd 2 O T.S Ñ g 6. S g s ^ ON ^f r- # q -«' ON - s ^ I I S w ^r fs O >r\ O i n N t I I O> Ov >ñ I v -. c rr O rr in h O W O M v5 «rr r- <n ON O c O> " ' <-"i O d d d es' rf p u S E M S. a l 'S - ë I i " 1 s u, -a SÄ Jlls-a t: S 1.. E «C 1> u a ;a g»-a S-s M a E c <U O c ü.2 3 «L) S Q fs "O 3 «" a n 'U 3 U vp c c S vq ÍS có <' rs) 00 -H CO 00 S I I VOCM 00 O 00 00 ON r- -MI VO fs in c (S rs rr O m in v -N in vq q N N r-' 00 i i T3 28 ON VO ON O \ fs ON ^D r^- ^ c^rq i vq r-; «s c c rr<nr-;q «rr-^ I d O - 6 " -" d -ri m'd cs rr «ONvcrrrrrrrrc «nrsvc vqrr^-"'-"qcrrqn «VD s t^ -vi«dd-'«(»v5- I d d «' ri» g vv<nr~r~ct~«cfsrrqfscrrrr cóó-^ddd'nóv-^ i i CO in m rr cs r~ «O m 00 O O O «S rr 28 rs m c O c <s O ON -H «O >n «S CO ON -r -... i ri; fs rr v ON O X VO «fs 00 «CN c m v d d d ri rr d 2 Ñd«-"fScórr'invr~ [ C II y» v il <! ^ il«iii II s 13 sí: n a ~ a 4. s a -c fa. 5 u -s Ä -:S 8 II ' 3 M -g ; 3 a M ÏËl S '«ta; - 2x> 13 II«2.* S n 3 II 2 a có (3 t If5 SU w J "O 3 u _ - 1» ii II «- -3 3 5 ä

206 t^ ci N «> < r-;rvq I d ^ vi 1; «ri O O O r4 vi 2 p u IT *cj cd c r** r** ^r j ^ v es r-; r-; ON d vi d ^' ' d w 1975- E E ta u c >. en; «3 une E S t^ O c K K e U «>r> r-j í «s lg*«- I O ««d «! «S III in q N I t*5 fi es -< v «in c4 «t «* h (O NO Ö Ó < rñ v Q 2 8 aaies iden B rts E (A *-» V3 l-l S" 4> O es r; - f; d!q - I I d 9 2 ^ es _, Tt v es O O "N fn Tt i; es v d d - ri «d -s u IE 3 c E «5 <i> E es t > i v t «/ > r~ Ö es es g -H «m f- < O ~ 3 «ta 3 a 1 3*

207 >ri O O O v «Tt -H vi d - t»! O\ <S m (S > 75-1 ince; Os <-^ 2 > C3 C Sie r- ON n t- CI PI PI PI r^* v * v -<t r~ ««! es c "O I i u CO U SS «1-, T3 & l si 11 I» e 8 s s T3 ^ S-8 c> rt ^ -«t M ri «v \ ci -4 u-î i N vi pj h n h ^f ri vô vi «ô î " <S (S <S «d «! n ri «p m p) in q n <c «M tc O\ (S M >C <s c> n \q \ «-<t ci rî ô ö ci S M<L> O il 51 s a 3 60 S <««O Cl TT 00 CI -4 -^ vi CTÑ fs ri ô <N ci rs Os ON O\ <s <T /» v r- + J. ^ ó 6 «S >r> v r-

208 5 to>» «m t v m "< Os 00 O\ «vô O\ fi O * «s m (S r-.5 ON > es es es «ON es O en 22 O 100 es g e 47 ^ es O /"> ON VI 00 es r- 00 ^* en 00 8 C "O 55 «S> 8 i: «2 O 03 <L> cd c "" J 3 O. 2 E -g e/i S f. O "O "O g^ Ri c S l 3 «u S J2-11 s 3 60 O «8 00 00 es 00 es es ON es WÎ en en r~- - ^3 en ON -> v <n O 00 en -> t- - ON O ON OO es en ON rî es en es ON ès en es es O 00 es >/i es ON es 00 00 es en es cjofñoó -< «N N «es O v en es VO ON en \ en es ON es O en 8 100 8 100 8 100 8 8 S ÎS 8. Os Os Os Os <s TT «v r- + 1 J. ó ó ó fi N m«h t h

209. tn u O 52 O fs u 3 < Q., Q 82 O O\ G O 2 G O S Q «-> r~ n m v «VO «-* r- t~- C O îsai î3 *_iids u (J 1» Q leau H S s; U U C )rvi S da: 0l u <O CU ^^ VO (S OO ON ri m ~* "* "* 3 2 2 O g g cn I» «M «N VO «S s H «S «.> H U c S «4> ás"5 a s S Illls 5 - <= 5 g c u a C n *O Cl«38 Si û "b g U 3.^ 2 < I I I I I I

210 < OvOtSíS. (S S " CÍ. SS T3 Q ^ (S O N O \ O O O O N C \ 0 -^* O a g a c a P r O t T «««<s«o VO VO 00 t <S v f- rr> - - JZ T} 8 <3 a les i«s dan '8 S SÑ ^, CO CJ C/3 u S vin 0 I ON ^^ r** O " ON r- ««h in H O s 00 t^ r» <*î v (^ ON O VO VO eau. vi c - cd A - S g û t^3 <UUU2S iflins l whh ^-^^

211 8 8 8 S 8 8 8 8 8 8 S S 8 8 8 8 8 8888 I <s O «in CO I V*i OO ^í rl N m c*j r TÍ" l»n ^H i * I VO r^^ (S N M < i rn ^t î c u i I u <<t f.»* -^ f; O «1 00 O\ t-; ^ I I 2 " S O i <u 3 O r-' I I «O "^ VO VO VO t-í ve ci «s -4 ci»t a -S s* ils! HÜ! fill ii'. c.1

212 s <O O. < 8 8 8 8 8 8 S 8 8 8 S S 8 8 8 8 8 8 8 8 8 vq v q >* ô l> O g a - ri í 73 a 8 "3 C u J -: M «s v ^ œ m' m' T3 8 " c " r~ m vd r~ I - ««u c 8 a S3 X> es ai j ai»i d! í t t't'ín í N * m q q «r*5 fñ ri I -«d 8 «fn m v.9 ~ 11 3 q ; -' ri h ai m' á d M r<nn «"> 00 VO r~ OÑ á «' g S

213 (2 00000000000000000 0000 8888888888 88888 8888 t-_ p 1; O >* ô 00 r- ri m ri 00 Tf f. ; ô- (S v vô 8 "a 8 S î ON C T3 <u c 3 E 00 rn ** O CS v r~ 1- rs r-; v 00»ifn ri Id ft I es m m in 00 ~ T3 tu e*i r*" r^ 5 ô ô v «X ru vs u m h «<í 5 es i«q O r^\ v+ v+ ^ «^ w+ «^\ v v es r) «fi r»i es rj h ;»t m es d r»i v "t m r; es d es fi vi g; 1 i 'S g 0000 j m\m es N r i i! i - NN-HN - -" - M Ñ es -1 U

it 214 "O U 2 ; z 3 lú; 55 II I «m es "O U en Q S I JP '5 Q -?»slu pôles V 73 t/1 a Ü u 5 c c u- c u sd'att c «1 ç < u C < r ^j «Ö c D nt : 3 ca -2 "ft! O _<j '03 u ^ c su a «r a Ü _, ^c " 5. a "à Q la" Q OQ. a OD, C ^r M lû: < Q. U ft. -3 O

215 INFANT MORTALITY AND MOTHER EDUCATION DEGREE AT THE BIRTH IN ITALY Marzia VALLI TODARO University f Palerm, Italy 1. Where mrtality analysis is t be carried ut with the purpse f making ratinal actins f sci-sanitary plicy, the way in which ppulatin cnditins f life affect mrtality is quite imprtant. In this paper, a particular aspect f differential mrtality is cnsidered, i.e., infant mrtality accrding t the mther educatin level, which, in many respects, can be assumed as indicating family scial r envirnment cnditins f children* 1 ). Availability f statistical data n the number f deads accrding t the mther degree f educatin is recent in Italy, while there are n published data n deads in the 1st year f life classified accrding t the father prfessin^. S, it seemed interesting t carry n a reginal analysis f infant mrtality, as well as, f natimrtality in relatin t the mther degree f educatin^). Statistical data als allwed an estimate f endgenus and exgenus cmpnents f deads in the 1st year f life in relatin t such a degree f educatin* 4 ). (1) MARZIA VALLI TODARO, Talune caratteristiche demgrafiche differenziali in relazine al grad di istruzine, Rivista Italiana di Ecnmía, Demgrafía e Statistica, n. 3-4, 1976. (2) On these data are based studies by: M. LI VI BACCI, La mrtalità infantile secand la prfessine del padre, Atti dellaxxiv Riunine Scientifica délia Scietà Italiana di Statistica. G. CHIASSINO, Mrtalità infantile e stratißcazine sciale, Girnale degli Ecnmisti e Annali di Ecnmía, n. 3-4, 1965. (3) Recently IST AT published a vlume n infant mrtality in Italy. 1ST AT, Tendenze evlutive delta mrtalità infantile in Italia, in «Annali», Serie VIII, Vl. XXIX, 1975. (4) MARZIA VALLI TODARO, Talune caratteristiche demgrafiche differenziali in relazine al grad di istruzine, Rivista Italiana di Ecnmía, Demgrafía e Statistica, n. 3-4, 1976.

216 2. Table 1 presents infant mrtality rates fr regin and mther degree f educatin derived frm aggregate data fr the perid 1976-79. All the Italian regins shw decreasing rates fr hirer degree f educatin. Strng differences are shwn by mrtality rates calculated n the basis f dead children brn frm mthers with the same level f educatin within the different regins. It is, hwever difficult t trace ut a particular gegraphical behaviur. By X test, the null hypthesis that N samples cme frm a ppulatin fr which is p the prbability that a certain event ccurs, can be tested. As it is well knwn, such an hypthesis crrespnds t data hmgeneity implying a relatin with Lexis' Q ratiw. Results are shwn belw: Test n certificate Primary schl Level f educatin Secndary schl High schl University degree Ttal Q 5,15119 530,69440 7,74028 11198,2399 5,31981 566,01062 3,60629 262,30630 1,84146 67,8192 9,65879 1865,84600 It,is easily seen that fr nne birth grup the hypthesis f territrial hmgeneity f death prbability in the 1st year can be accepted. In fact, Q values are higher than unity, while fr y =20 1 = 19 d.f. # 2 (0,05) = 30,144, and X z (0,01) = 36,191. The same hlds when, instead f natimrtality rate, ratis between still-brn children and the ttal f legitimate births fr regin and educatin degree are cnsidered. As matter f the fact values shwn belw lead t reject the hypthesis f hmgeneity f natimrtality risk in the regins als fr the same educatin degree f the mther. Test n certificate Primary schl Level f educatin Secndary schl High schl University degree Ttal 1,50504 45,30275 5,20872 542,42874 6,291791 784,195560 1,76955 62,62626 1,40546 39,50621 9,71655 1888,22620 (5) Fr frmulas see: S. VIANELLI, Metdlgía Statistica delle Scienze Agrarie, Vl. II, pag. 116 e segg., Ed. Agricle, Blgna, 1956.

217 3. In rder t prceed t the bimetrical analysis suggested by Bugeis- PichaK 6 ), an aggregatin f death distributins accrding t the age in mnths at the death in the 1st year f life in the perid 1976-79, was The functin D n = a + ß Ig3 (n+l) = a + ß <p (n) [l] where D n are cumulative deads accrding the time in days and Ig3 (n +1) is a trasfrmefn, i.e. n = 6, 30,60, 365 was fitted t the distributin f deads in the first year f life fr different degrees f'educatin accrding the distance in mnths frm the birth date. As shwn by R.2 values fitting is gd enugh and this result enabled us t divide the number f bserved deads int endgenus and exgenus cmpnents. Since a classificatin f births accrding t the educatin degree f the mther is nt available, it is nt pssible t derive exgenus and endgenus infant mrtality rates. Hwever, frm table 4 it is easily seen that can be estimated at 65,29% the endgenus cmpnent f deads accrding t the educatin degree f the mther; such an incidence exceeds 79% fr children brn frm wmen university graduate r with high schl degree f educatin and is 28% in the case f children whse mther had nt a degree. 4. Results f the analysis shwed: a) infant mrtality and natimrtality accrding mther degrees f educatin are quite different; and b) there is nt a territrial hmgeneity f phenmena within selected grups births accrding t the same educatin level f the mther. Anther interesting result is that exgenus cmpnent f infant mrtality reduces t 20% fr high schl r university graduate wmen, while it is mre than 70% fr children bm frm wmen withut educatin degree and is 30% fr children whse mther attended nly primary schl. (6) J. BOUGEOIS-PICHAT, Le mesure de la mrtalité infantile, I Principes et méthdes, Ppulatin n. 2, 1931 II Les causes de décès, Ppulatin n. 3, 1951. M.L. NADOT, Mesure de la mrtalité infantile. Etudes statistique de la méthde bimétrique de M.J. Bugeis-Pichat, Ppulatin n. 5, 1971. (7) A critical analysis can be fund in: E. LOMBARDO, Sulla misura délia mrtalité infantile, Genus, n. 1-2, 1973.

218 Table 1. Infant Mrtality Rates f Legitimate Births by Regins and Mther's Educatin Level f educatin Regins N certificate Primary schl Secndary schl High schl University degree ltai Piemnte Valle d'asta Lmbardia Trentin A.A. Vénet Friuli V. Giulia Liguria Emilia Rmagna Tscana Umbría Marche Lazi Abruzzi Mlise Campania Puglia Basilicata Calabria Sicilia Sardegna 23,02 25,44 100,27 56,23 102,93 128,70 22,73 63,15 27,16 20,16 23,46 72,19 25,99 62,69 43,18 37,04 33,45 27,55 39,04 20,25 26,11 17,75 10,15 15,88 12,64 19,59 17,02 19,54 14,18 14,31 16,85 19,71 12,99 27,11 22,83 19,21 21,11 24,33 17,19 17,46 12,97 14,62 11,54 14,10 12,87 16,15 14,48 12,68 10,95 14,16 23,30 14,05 10,93 16,88 15,08 10,77 15,86 14,84 21,55 10,78 19,16 10,96 7,99 10,73 9,82 12,83 11,09 7,17 6,52 12,18 4,44 10,70 8,14 10,91 10,67 9,01 10,72 9,91 6,38 8,44 10,74 8,67 8,29 8,35 8,42 8,54 9,54 4,45 9,85 7,33 3,83 12,18 11,71 9,39 10,41 17,81 7,75 9,97 6,03 17,42 16,35 15,26 10,75 14,67 12,26 16,95 14,57 14,34 11,09 13,60 16,05 16,58 12,12 23,28 20,80 16,87 19,02 20,39 17,51 ITALIA 37,30 20,99 15,56 9,69 8,30 17,61

219 Table 2. Infant Mrtality Rates by Regins and Mther's Educatin fr legitimate births Index Numbers Level f educatin Regins N certificate Primary schl Secndary schl High schl University degree Ttal Piemnte Valle d'asta Lmbardia Trentin A.A. Vénet Friuli V. Giulia Liguria Emilia Rmagna Tscana Umbría Marche Lazi Abruzzi Mlise Campania Puglia Basilicata Calabria Sicilia Sardegna 132,15 166,71 932,74 383,30 839,56 759,30 156,01 440,38 244,91 148,24 146,17 435,40 214,44 269,29 207,60 219,56 175,87 135,12 222,96 116,25 159,69 116,32 94,42 108,25 103,10 115,58 116,82 136,26 127,86 105,22 104,98 118,88 107,18 116,45 109,36 113,87 110,99 119,32 98,17 100,23 79,33 95,81 107,35 96,11 104,98 95,28 99,38 88,42 98,74 104,12 145,17 84,74 90,18 72,51 72,50 63,84 83,39 72,78 123,07 61,88 117,19 71,82 74,33 73,14 80,10 75,69 76,12 50,00 58,79 89,56 27,66 64,54 67,16 46,86 51,30 53,41 56,36 48,60 36,44 48,45 65,69 56,82 77,12 56,92 68,68 50,38 65,48 31,03 88,82 53,90 23,86 73,46 96,62 40,34 50,05 106,57 40,75 48,90 34,44 100,00. 100,00 100,00 100,00 100,00 100,00 100,00 100,00 100,00 ' 100,00 100,00 100,00 100,00 100,00 100,00 100,00 100,00 100,00 100,00 100,00 ITALIA 211,81 119,19 88,36 55,03 47,13 100,00

220 Table 3. Adjustment f the functin D n = a + ß <jp (n) t the varius distributins f deaths in the first year f life by Mther's educatin (1976-1979) Level f educatin N certificate Primary schl Secndary schl High schl University degree TOTAL D n D n D n D n D n D n D n = a- *-ß<p (n) = 919,68 +- 83,81 = 19.054,76 + 611,24 = 10.521,19 +- 256,97 = 3.331,90 4-. 57,90 = 642,67 +-.9,32 9>(n) f (n) 9>(n) gp(n) g>(n) = 35.472,22 + 1018,50 çp(n) 0,98 0,96 0,93 0,88 0,83 0,85 Table 4. Endgenus and Exgenus Deaths in the first year f life by Mther's Educatin (1976-1979) Level i eaucaiin N certificate Primary schl Secndary schl High schl University degree TOTAL Endgenus 919,68 19.054,76 10.521,19 3.331,90 642,67 35.472,22 Deaths in the first year Exgenus 2.330,32 9.528,24 3.933,81 870,10 135,33 15.95,78 Ttal 3.250 28.583 14.455 4.202 778 51.268 u / cnagenu: deaths 28,30 66,66 72,39 79,29 82,61 65,29

221 SECTION V INFANT MORTALITY AND SOCIO-ECONOMIC STATUS Mrtalité infantile en Italic La qualité des dnnées et les pssibilités d'améliratin (Marcell NATALE) Facteurs différentiels de la mrtalité fet-infantile en Italie (Antnella PINNELLI) Facteurs sci-démgraphiques des disparités réginales de la mrtalité infantile en France (DINH Quang Chi) Infant mrtality in seven Eurpean scialist cuntries: 1955-1980 (Andras KLINGER) Trends f perinatal and infant mrtality in Sweden and in ther Nrdic cuntries and their assciatin with demgraphic and sci-ecnmic variables (Anne Marie BOLANDER)

223 MORTALITÉ INFANTILE EN ITALIE. LA QUALITÉ DES DONNÉES ET LES POSSIBILITÉS D'AMÉLIORATION Marcell NATALE Département de Sciences Démgraphiques Université de Rme, Italie I. Avant de me cnsacrer exclusivement à l'activité universitaire, j'ai dirigé pendant plusieurs années le Bureau d'etudes sur la Ppulatin de l'istat. J'ai fini par me cnvaincre de la nécessité de cnsacrer une grande partie de la recherche à l'analyse de l'infrmatin statistique de base pur en amélirer la qualité. En effet, il y a d'rdinaire, un certain cntraste entre la demande de cnnaissances de plus en plus apprfndies et la fiabilité des myens qui devraient les garantir. Pendant plusieurs années l'istat a prcédé dans cette ptique, surtut dans le dmaine de la mrtalité infantile. Dans le cadre d'un séminaire cnsacré justement à l'améliratin de la qualité des dnnées sur le phénmène, j'ai dne estimé pprtun d'illustrer par cette cmmunicatin ce que l'istat a fait au curs des dernières années dans le dmaine de la mrtalité infantile. A cet égard j'ai eu la cllabratin du Dcteur Pal Pasquali, le fnctinnaire de PISTAT qui s'est le plus ccupé du prblème. II. Au curs de ces dernières années, l'istat a plusieurs fis et avec des finalités diverses abrdé le prblème de la mrtalité infantile en Italie. 1) Avant tut, en 1974 année mndiale de la ppulatin l'istat a préparé un mdèle ad hc, qui a été utilisé jusqu'en 1979 en même temps que le traditinnel bulletin de décès («scheda di mrte»), qui pur la première année de vie ne prévyait que peu de questins. En 1980, n est parvenu à un mdèle unique cntenant des questins supplémentaires par rapprt à celui de 1974 (par exemple, n a inclu des questins sur la mrtalité infantile précédente et sur le résultats des grssesses précédentes). Tujurs à partir de 1980 n a prévu un plan très analytique pur l'élabratin des dnnées; entre 1974 et 1979, par

224 cntre, les elabratins nt suivi le schéma traditinnel, auquel n avait ajuté quelques études particulières dnt nus parlerns par la suite; 2) en 1975, n publiait un grs vlume sur le tendances de phénmène depuis l'unité de l'italie jusqu'aux premières années de la décennie passéeo; n en analysait tutes les principales caractéristiques cmpatibles avec les infrmatins dispnibles. Dans ce vlume n mettait en lumière tutes les pssibilités qu'avait ffert l'intrductin du nuveau bulletin de 1974 et aussi les prblèmes qui restaient uverts; 3) Les résultats d'une première utilisatin smmaire exécutée manuellement du nuveau matériel de base furent publiés en 1976< 2 ). Les principales finalités de ce travail étaient de reprter, par la première fis, à un niveau désagrégé ce phénmène au lieu de résidence des parents de l'enfant mrt et nn à celle de décès et, sur la base de ces dnnées, de vérifier l'existence u nn d'une relatin entre mrtalité infantile et taille démgraphique, ce qui était déjà examiné par d'autre pays* 3 ). Ces résultats mis à part, le travail a permis de cnstater que beaucup de mdèles ne parviennent pas u parviennent incmplets: il faut dnc truver une slutin qui garantisse une infrmatin cmplète; 4) A cet égard, n a essayé tujurs manuellement, de criser évidemment pur un nmbre restreint de cas-bulletin de décès et bulletin de naissance crrespndant. Au départ, le but était de cmpléter les bulletins de décès en se servant ds infrmatins cntenues dans le bulletins de naissance. On y a renncé car n s'est aperçu que les deux bulletins prtaint des répnses différentes à la même demande. On a alrs décidé de partir de l'hypthèse de la fiabilité des bulletins de naissances et par cnséquent de prendre cmme base de l'infrmatin, crrespndant aux deux bulletins, celle cntenue dans le bulletin de naissance; 5) Le matériel ainsi btenu a servi de base à élabratin de certains crisements qui paraissaient intéressants et qui tuchaient à la fis des caractères bidémgraphiques et sci-écnmiques. Ces résultats, qui se référaient à une année qui n'était pas récente et à un grupe de régins italiennes, chisies par ailleurs avec des niveaux de mrtalité infantile différenciés, cnstituent néanmins une nuveauté pur l'italie, et ils sernt présentés dans un vlume de prchaine publicatin^). (1) Cit. ISTAT, Tenderize evlutive délia mrtalità infantile in Italia, Annali di Statistica, Serie VIII vl 29, Rma 1975. (2) CU. ISTAT, Indagine sulla mrtalità infantile nell'ann 1974, Supplement al Bllettin mensile di Statistica, n. 15, 1976 (3) Autriche, Canada, France. (4) ISTAT, Recenli livelli e caralteristiche délia mrtalité infantile in Italia. Analisi deu'infrmazine e prpste di miglirament, Cllana d'infrmazine.

225 Ce vlume cntiendra, utre ces résultats, une analyse des tendances de la mrtalité infantile en Italie de 1974 à 1981 et une cmparaisn entre 1974-75 et 1979 au sujet de la relatin mrtalité infantile-taille démgraphique. Une autre caractéristique très imprtante de cet uvrage dans une ptique perative est d'abrder le prblème de l'acquisitin de l'infrmatin de base, en prpsant des slutins dnt la mise en euvre devrait furnir de bnnes garanties de fiabilité. En particulier, n prpse de faire régulièrement un crisement par rdinateur des bulletins de décès et de ceux de naissance et d'en tirer les infrmatins cmplémentaires d'une part pur les décès et d'autre part pur les naissances, après avir vérifié sur un échantilln la fiabilité du mdèle. Dans ce même vlume n a apprfndi la relatin entre mrtalité infantile et taille démgraphique en mettant en relief la situatin des grandes villes et des aires les envirnnant u de tute façn gravitant autur de celles-ci. On attire l'attentin sur la nécessité de dispser et cela puvrait être réalisé en des temps assez brefs de dnnés relatives à tute la phénménlgie démgraphique au niveau sub-cmmunal et à travers une divisin en tris parties (centre, aire envirnnante, périphérie) qui semble avir un certain intérêt. Finalement, ce vlume cntient des dnnées, nn publiées jusqu'à ce jur, relatives à l'année 1979 sur la fréquence des naissances au dessus du pids (immaturité) avec une durée de gestatin inférieure à la nrmale (enfant prématuré); r ces facteurs snt habituellement cnsidérés cmme cmprtant un risque aussi bien pur la survivance intrautérine que pur celle dans la première année de vie. Ces dnnées mettent en lumière, nn seulement une crrélatin négative avec la mrtalité infantile, mais aussi une variabilité territriale diverse de l'immaturité et des naissance prématurées. Cela nus amène à retenir que, pur l'analyse de la «survivance à risque», il est nécessaire de tenir cmpte des deux séries et nn d'une seule, ainsi qu'n le fait suvent. III. La descriptin faite ci-dessus met en lumière les effrts effectués par l'institut Natinal de Statistique de l'italie dans le dmaine de l'analyse critique de l'infrmatin. Cela est d'autant plus nécessaire dans une péride ù l'n peut réduire ultérieurement le bas niveau que la mrtalité infantile a atteint en Italie seulement en basant la plitique sanitaire sur des dnnée analytiques qui sient entièrement dignes de fi. Naturellement, u purra atteindre plus aisément ce but si les chercheurs universitaires, qui snt d'rdinaire plus experts en recherche thérique, travaillent en étrite cllabratin avec les prépsés à l'acquisitin et à l'élabratin de l'infrmatin.

FACTEURS DIFFÉRENTIELS DE LA MORTALITÉ FETO-INFANTILE EN ITALIE 227 Antnella PINNELLI Département de Sciences Démgraphiques Université de Rme, Italie 1. Dnnées et variables La pssibilité d'étudier la mrtalité différentielle depuis la naissance jusqu'au premier anniversaire a rencntré, en Italie cmme dans la plupart des autres pays dévelppés, des bstacles dus au manque d'infrmatins adéquates dans les statistiques curantes. Pur faire face à cela n a réalisé à l'istat un recrd linkage desfichesde naissances et de décès dans la première année de vie pur la génératin des naissances de 1975, en se limitant à tris grupes de régins de naissance: 1) Piémnt et Vallée d'aste; 2) Tscane, Marches et Ombrie; 3) Campanie et Mused). Le chix de ces grupes de régins avait pur but de permettre une analyse apprfndie pur tris types de situatins qu'une étude précédente avait indiquées cmme celles qui différencient le plus frtement les cnditins de suvie infantile en Italie* 2 ): la première représentée par le Piémnt et la Vallée d'aste, régins du Nrd, d'industrialisatin ancienne, à niveau de vie élevé, à frt dévelppement écnmique et sanitaire, caractérisée par un taux élevé de naissances prématurées (10%) ce qui a pur cnséquence des taux de mrtalité fét-infantile assez élevés surtut pur ce qui est de la cmpsante relative à la (1) v. ISTAT, Recenti livelli e caratteristiche délia mrtalità infantile in Italia. Analisi critica dell'infrmazine e prpste di miglirament, par M. Natale, M. Gramegna Caprale e P. Pasquali, en curs de publicatin dans la Cllana di Infrmazine. Cela ne se rend pas nécessaire pur le mrt-nés, car l'italie relève sur un même type de fiche les mrt-nés et les naissance vivantes. (2) v. A. Pinnell, e F. Zannella, Mrtalità e qualità délia sprawivenza infantile, Genus v. XXXV n. 3-4, 1979

228 mrtalité nénatale précce: ce genre de situatin peut être cnsidéré cmme l'extrême négatif des régins de l'italie septentrinale. La secnde situatin est actuellement la plus favrable à la survivance infantile en Italie: elle est représentée par la Tscane les Marches et l'ombrie régins du Centre présentant un niveau plus bas de dévelppement industriel, écnmique et sanitaire, des taux de naissance prématurées inférieurs à ceux du grupe des régins précédent (7%) et des taux minima de mrtalité fét-infantile dans le cadre natinal. La trisième situatin est la plus mauvaise au niveau natinal en ce qui cncerne la mrtalité fét-infantile, dans tutes ses cmpsantes, atténuée tutefis par la présence de taux minima de naissances prématurées (4%): elle est représentée par la Campanie et le Mlise, régins du Sud ayant un niveau plus bas de dévelppement industriel et sci-écnmique-sanitaire par rapprt à celles du Centre-Nrd. La recherche déjà citée furnit une plus ample illustratin des caractéristiques territriales de la survivance infantile en Italie et des cnditins de dévelppement sci-écnmique et hygiénique-sanitaire auxquelles ces caractéristiques snt justement liées('). Les résultats du recrd linkage snt utilisés dans cette étude aux fins de l'analyse différentielle de la mrtalité fét-infantile( 2 ): ces tris grupes de régins qui, ainsi que nus l'avns dit, représentent des situatins très différenciées à la fis du pint de vue de la survivance infantile et des cnditins de dévelppement, cnstituent une première variable, qu'n purrait dire «cllective» et dnt il faut tenir cmpte; à côté de celle -ci, n a cnsidéré les variables suivantes, de nature individuelle, telles: la durée de la grssesse, le rang de naissance, l'âge de la mère, l'instructin de la mèretf). Ces variables snt retenues cmme faisant partie des plus imprtantes en tant que facteurs de différenciatin de la mrtalité fét-infantile. Chaque variable a été classée en srte d'identifier avec un nmbre minimum de mdalités, les grupes que la littérature indique cmme ceux ayant le plus haut risque. L'utilisatin du plus petit nmbre pssible de variables et de mdalités vient de la nécessité de ne pas trp fractinner les dnnées, si l'n veut tenir cmpte des interactins existant entre les variables. On a déjà remarqué, en effet, qu'entre les tris grupes de régins, il existe des différences dans les taux des naissances prématurées; n peut aussi mettre en évidence les différences de structures démgraphique et sciale: un plus grand (1) v. A. Pinnelli et F. Zannetla, cit. (2) Pur l'élabratin des dnnées manquantes relatives aux naissances et aux décès, v. A. Pinnelli: Changements sci-sanitaires et récent déclin de la mrtalité fét-infantile en Italie, cmmunicatin présentée au «Séminaire sur l'influence des plitiques sciales et de santé sur l'évlutin future de la mrtalité», UIESP-INED, Paris 28-2/4-3-1983. (3) L'instructin de la mère est ici cnsidérée sit cmme meilleur indicateur de la cnditin sciécnmique de la famille sit cmme indicateur culturel référé à la femme.

229 nmbre de nuveaux-nés de rang élevé et de mères âgées de plus de 34 ans, de femmes ayant une instructin élémentaire (au maximum 5 années de sclarité) en Campanie-Mlise. Les relatins entre l'âge de la mère et le rang de naissance snt évidentes; en utre, il est clair que les naissances de mère de plus de 34 ans et de rang supérieur au 3ème snt plus fréquentes parmi les mères ayant un niveau d'instructin bas etc. (Table 1). Naturellement le crisement entre variables dubles dnne une visin limitée des assciatins existant entre elles; celles-ci snt significatives jusqu'à celles du trisième rdre (Tab. 2), et dans un cas jusqu'à celles du quatrième rdre (assciatin entre instructin de la mère, âge de la mère, rang de naissance et régin de résidence)* 1 ). La mrtalité fét-infantile a été séparée en ces tris cmpsantes: mrtinatalité, mrtalité dans la première semaine, mrtalité au-delà de la première semaine et avant le premier anniversaire; les taux snt tus calculés en se référant à l'ensemble des naissances: c'est nécessaire si l'n veut cmparer crrectement les taux spécifiques des diverses cmpsantes de la mrtalité fétinfantile, à égalité de structure des naissances. On dnnera quelques éclaircissements sur le chix des cmpsantes: la mrtinatalité et la mrtalité dans la première semaine de vie nt presque la même entité et représentent 70-80% de la mrtalité fét-infantile: généralement calculées en un taux unique de mrtalité périnatale, elles snt ici distinctes pur mettre en évidence les diversités éventuelles de l'influence des variables explicatives sur celles-ci; la mrtalité au-delà de la première semaine de vie est une cmpsante de plus faible entité, en Italie cependant encre élevée dans le Sud et particulièrement en Campanie; elle est généralement cnsidérée cmme liée, plus que les précédentes, à la fis aux cnditins de l'envirnnement et aux cnditins sci-écnmiques individuelles. 2. Méthde Pur étudier les différences de mrtalité fét-infantile, pur chacune des tris cmpsantes indiquées, suivant les diverses mdalités des variables explicatives, n a utilisé une méthde de standardisatin multiple indirecte; cela permet de décmpser la différence entre le qutient crrespndant à chaque mdalité de (1) Pur le test d'assciatin marginale v. M. Brwn, Screening effects in multidimensinal cntingenty tables, Appl. Statist. 25, 1976.

230 ja z Nç ON 8 8 ON S 8 r» 00 192 'S 8 8 8 ON S IS 107 105 8 8 IS Ñ IS 8 r-»n»n O r* r- m 222 8 8 «n S 109166 8 8 238 8 en"»n VO w* IN IS *r" c*ï en" **! m rn ri ON IN 00 " NO IN «S. NO ** * " r t ON" IS NO r-t O* V~l í rj ^t nr *n^ ON (N!!!»n «t 00 ON <N -S g M H r, m _ s" NO S M ri 00 s" Ôj en" is" ON rn * IS ON NO_ IN NÇ_ r^ râ ON ON VO m " m a I t! NO ON"! IS* ON! >n 24. \ ri í" u CS ë I 00 < a ci u.2 a «: : : : : ~ ci ct n ^ - " í' î" ONOOO m in»n in >n r> c s a 3 t/3 ni u 3.2 I S S I E Ä 4Í '5 3 O. 8.ä S = ís < I" O O g E ON ON VAX < O S -3 S g -ÎJ -g =5 *>!_.!-. X 0Í M ñ Í

231 Tableau 2. Assciatins marginales significatives entre les variables explicatives (P = 0,00) Assciatins IOD IDR EOD ODR IEOR degrés de liberté 4 4 4 4 16 14,25 21,38 27,75 28,50 35,00 légende: I = instructin de la mère E = âge de la mère O = rang de la naissance D = durée de gestatin R= régin de naissance N.B.: tutes les assciatins d'rdre mins élevé cmprises dans les assciatins du tableau snt évidemment significatives. chaque variable explicative et le taux myen général, en deux parties, l'une due à l'effet des taux spécifiques (spécifiques par rapprt à la cmbinaisn des variables restantes) et l'autre due à la structure des naissances (de manière analgue, relative à la cmbinaisn des variables restantes). La méthde, qui se rattache à la méthde classique de standardisatin directe et indirecte habituellement utilisée en démgraphie et au dévelppement prpsée en 1955 par Kitagawa, en cnsent un élargissement ultérieur: à savir, elle permet de décmpser chaque partie de la différence entre taux (effets qutients et effet structure), dans l'effet glbal, simple et itératif de chaque variable* 2 ). Ensuite, nus n'expserns, et cela par brièveté, que les résultats relatifs à la décmpsitin dans les deux effets principaux (taux et structure) en laissant de côté ceux qui nt trait aux effets de chaque variable explicative. (1) E.M. Kitagawa, Cmpnents f a difference between tw rates, American Statistical Assciatin Jurnal, Dec. 1955. (2) Pur de plus amples détails sur la méthdlgie, mise au pint par F. Zannella pur une recherche précédente, v.a. Pinnelli, 1983, cit.

232 3. Résultats Les dnnées relatives aux taux bruts de mrtinatalité, de mrtalité dans la première semaine et au-delà de la première semaine de vie, seln les cinq variables explicatives, mntrent d'abrd la relatin que nus avns déjà illustrée avec la régin de naissance. Mais elle fait ressrtir aussi une relatin inverse avec l'instructin de la mère pur chaque type de taux; une relatin directe avec l'âge de la mère pur la mrtinatalité et en frme de U pur la mrtalité qui précède et qui suit la première-semaine de vie; une relatin en U avec le rang de naissance pur la mrtinatalité et la mrtalité dans la première semaine, directe au cntraire pur la mrtalité au delà de la première semaine; des taux plus élevés pur les naissances prématurées surtut pur la mrtalité dans la première semaine, en mindre mesure pur la mrtinalité, et encre mins pur la mrtalité au delà de la première semaine (Tab. 3). Il est évident que ces relatins peuvent être cmplément u en partie «crées» par les différences de structure des naissances entre les diverses mdalités de chaque variable explicative. En appliquant la méthde de décmpsitin indiquée plus haut, n btient, ainsi que nus l'avns dit, la partie de la différence entre le taux relatif à chaque mdalité d'une variable et le taux général, due aux seuls taux spécifiques: la cmparaisn entre les diverses mdalités de chaque variable se fait dnc «à égalité de structure». Afin d'évaluer les résultats, n a reprté, sur la Tab. 4, les différences, par rapprt au taux général, du taux brut et du taux standardisé u net (à savir, épuré de l'effet de structure) de chaque mdalité de variable. La standardisatin a peu d'effet sur la mrtalité seln la durée de gestatin; elle a, par cntre, un effet de réductin du champ de variatin des différences, pur chaque type de taux, par rapprt à tutes les autres variables, exceptin faite pur la régin de naissance: dans ce cas, en effet, les différences s'amplifient eu égard à la mrtinalité et à la mrtalité dans la première semaine, puisque les taux du Piémnt-Vallée d'aste deviennent inférieurs à la myenne tandis que ceux de la Campanie-Mlise augmentent davantage. Les taux de mrtalité tardive, même pur cette variable, deviennent plus hmgènes. Certaines caractéristiques semblent cmprter un risque élevé (au mins + 20% par rapprt au taux général) et ce snt en définitive: la durée de gestatin inférieurs à 9 mis, l'âge de la mère ^ 35 ans, la naissance en Campanie-Mlise, cela pur les tris cmpsantes de la mrtalité cnsidérée; en utre le rang de naissance > 4ème pur la mrtinatalité et pur la mrtalité après la première semaine de vie; l'âge de la mère inférieur à 20 ans seulement pur la mrtalité après la première semaine. Un risque de décès bas (au mins -20% par rapprt au taux général), semble être lié à la naissance dans les deux grupes de régins du Centre-Nrd pur la mrtinatalité et pur la mrtalité pstérieure à la première semaine; à la naissance à terme pur la mrtinatalité et pur la mrtalité dans la première semaine; à l'âge de la mère inférieur à 20 ans pur la mrtinatalité; à

233 Tableau 3. Cmpsantes de la mrtalité fét-infantile (taux pur 1.000 naissances) Variables Mrtinatalité dans la l ère semaine Mrtalité après la l ère semaine Instructin de la mère primaire cllège lycée, université 14,18 9,32 8,53 15,41 12,43 10,03 10,29 6,02 4,79 Age de la mère <20 20-34 >35 8,99 10,33 24,96 17,63 12,17 22,94 12,11 7,24 14,35 Rang de naissance 1 2-3 >4 11,77 9,75 23,94 14,03 12,48 19,43 6,99 8,08 16,21 Durée de gestatin < 9 mis ^ 9 mis 84,03 7,18 112,39 6,97 25,89 7,25 Régin de naissance Piémnt-Vallée d'aste Tscane-Marches-Ombrie Campanie-Mlise TOTAL Nmbre de cas 10,73 8,83 15,24 12,19 2.908 15,17 11,01 15,18 13,94 3.323 6,15 4,07 12,59 8,48 2.022 l'instructin de la mère plus élevée, pur la mrtalité au-delà de la première semaine (Tab. 5)(D. Il faut remarquer que les cmpsantes de la mrtalité les plus différenciées par (1) Une imprtante étude sur les facterus différentiels de la mrtalité périnatale, a été crdnnée par l'oms pur huit pays. Les deux vlumes jusqu'ici publiés se basent sur l'analyse des variables dubles et triples et ne permettent pas de cnclusins définitives sur le facteurs de risque; celles-ci ne sernt pssibles qu'après l'analyse multidimensinnelle actuellement en curs (v. WHO, A WHO reprt n scial and bilgical effects n perinatal mrtality, v.l et 2, 1978).

234 Tableau 4. Différences abslues entre les taux bruts (DB) et nets (DN) de chaque mdalité des variables explicatives et le taux général Variables Mrtinatalité DB DN Mrtalité Dans la 1ère après la l ère semaine semaine DB DN DB DN Instructin de la mère primaire cllège lycée, université Age de la mère <20 20-34 >35 Rang de naissance 1 2-3 >4 Durée de gestatin < 9 mis > 9 mis Régin de naissance Piémnt-Vallée d'aste Tscane-Marches- Ombrie Campanie-Mlise 1,99 1,07 1,47 0,85 1,81 0,89 2,87 -- 1,46-3,66 -- 2,08-1,51-0,77 2,46-1,19 3,91-2,47 3,69-1,86 3,20 -- 4,24 3,69 1,57 3,63 3,55 1,86 -- 1,11-1,77-1,14 1,24-0,82 12,77 8,71 9,00 6,10 5,87 3,40 0,42 1,46 0,09 1,01 1,49 -- 0,31 2,44 -- 2,28 1,46-1,20 0,40-0,27 11,75 3,38 5,49 0,69 7,73 2,36 71,84 72,16 98,45 97,99 17,41 18,30 5,01 -- 5,03 6,97-6,94 1,23-1,29 1,46 -- 3,54 1,23-2,30 2,33-2,32 3,36 -- 2,91 2,93-3,04 4,41-3,53 3,05 3,87 1,24 3,20 4,11 3,53

235 Tableau 5. Différences en purcentage entre les taux bruts (DB) et nets (DN) de chaque mdalité des variables explicatives et le taux général Variables Mrtinatalité DB DN Mrtalité Dans lai 1*«Après la l ère semaine semaine DB DN DB DN Instructin de la mère primaire cllège lycée, université Age de la mère <20 20-34 >35 Rang de naissance 1 2-3 5*4 Durée de gestatin < 9 mis ^ 9 mis Régin de naissance Piémnt-Vallée d'aste Tscane-Marches- Ombrie Campanie-Mlise 16,3-23,5-30,0-26,3-15,3 104,8-3,4 20,0 96,4 589,3-41,1-12,0 29,0-27,6 25,0 8,8 12,0-17,1-34,8-9,1 71,5 12,0-18,7 27,7 592,0-41,3-23,9 31,7 10,5 6,1-10,8-5,5-28,0-17,7 26,5 11,3-12,7-8,2 64,6 43,8 706,2 50,0 8,8-21,1 8,9 702,9-49,8 16,5 21,8 23,0 21,3 10,5 29,0 -- 14,0 43,5 -- 21,9 42,8 41,9 14,6 -- 9,7 69,2 40,1 0,3 7,2-17,7-3,7 10,5-8,7-4,7-3,2 39,4 4,9 9,1 27,8 205,3 215,8-14,5-15,2 27,5 52,0 48,5-27,4 41,6 41,6 rapprt à chaque variable cnsidérée, snt celles des extrémités la mrtinalité et la mrtalité tardive alrs que la mrtalité dans la première semaine présente des différenciatins mindres si ce n'est par rapprt à la durée de gestatin (Graph. 1). Cela pruve un manque d'hmgénéité substantiel des deux parties qui frment la mrtalité périnatale: l'une la mrtinatalité est nettement plus sensible à l'influence des caractéristiques démgraphiques et de l'envirnnement, résultat qui ne paraît pas illgique car il s'agit d'un phénmène beaucup plus lié aux cnditins de santé de la mère, à la surveillance de la

236 GRAFIQUE 1. Différences en purcentage entre les taux bruts (DB) et nets (DN) et le taux général 20-34»35,<?0 20-34 -»35,,*20 *< 1» RANG DE NAISSANCE RECION DE NAISSANCE

237 710 (suite graph.1) 700 590 580 210 200 *-, 40 30 20 10 0 10 20 30 40 50»9m»9«HN H<ls H > Is DUREE DE GESTATION

238 grssesse et à l'hspitalisatin pur l'accuchement; l'autre la mrtalité nénatale précce est liée, nn seulement aux facteurs précédents, mais aussi à l'efficacité des structures sanitaires qui nt pur tâche l'assistance à l'accuchement et au nuveau-né, puisque c'est sus le cntrôle de celles-ci qu'elle se prduit nrmalemenid). On peut penser que dans certains cas il y a un glissement de la mrtinatalité à la mrtalité nénatale précce, ainsi que semblent le suggérer, par exemple, les résultats qui intéressent la durée de gestatin inférieure à 9 mis, qui présente un risque de mrtinatalité inférieur au risque de mrtalité nénatale précce; il semble prbable que cette cnditin de risque évident puisse amener une plus grande surveillance sanitaire qui, dans beaucup de cas, ne prlnge que de peu la vie de l'enfant: n arrive à éliminer la mrt intrautérine u pendant l'accuchement, mais les difficultés se présentent de nuveau après la naissance et le risque de décès précce est très élevé. Une réflexin mérite d'être faite au sujet du cmprtement des tris types de taux en crrespndance avec une autre cnditin cnsidérée nrmalement «à risque», un âge de la mère inférieur à 20 ans: dans ce cas la mrtinatalité est nettement inférieure à la myenne, mais la mrtalité dans la première semaine est, elle, un peu supérieure, et celle après la première semaine bien supérieure à la myenne: il est pssible que cette cnditin sit cnsidérée «à risque» surtut pur la réussite de l'accuchement mais pas pur la survivance de l'enfant, ce qui prterait à une plus grande surveilance de la grssesse mais pas nécessairement à une plus grande surveillance de l'enfant: la cnditin effective de risque serait ainsi passée de la phase ntrautérine à celle nénatale et, surtut, à celle pstnénatale qui, plus que tute autre, se dérule lin de la surveillance sanitaire, et par cnséquent, peut être davantage cnditinnée par le manque d'expérience de la mère très jeune. L'influence des deux facteurs sciaux, celui individuel, l'instructin de la mère, et celui cllectif, la régin de naissance, est un peu plus marquée sur la mrtalité au-delà de la première semaine que sur les autres types de taux. Pur ce qui est de l'instructin qui, cmme n l'a vu, n'est de tute façn pas un facteur de frte différenciatin de la mrtalité si elle est calculée au net de l'influence de la structure des naissances, le champ de variatin est, pur la mrtalité après la première semaine, de 32,4 (de 21,9% à + 10,5%), pur la mrtinatalité de 25,9, pur la mrtalité dans la première semaine de 23,8. La (1) L'pprtunité de cnsidérer séparément la mrlinaialité et la mrtalité nénatale précce est mise également en évidence par Karleberg et Ericsn sur la base de l'analyse des dnnées de l'étude de l'oms déjà citée (vir P. Karleberg et A. Ericsn: Perinatal mrtality in Sweden, analysis with internatinal aspects; Acta Paediatrica Scandinavica Suppl. 275).

239 cnditin sciale individuelle a dnc une influence à peine plus frte sur la mrtalité tardive que sur les autres cmpsantes. Ce résultat d'un côte blige à recnsidérer la distinctin assez nette qui est traditinnellement faite entre facteurs de la mrtalité périnatale (endgènes) et de la mrtalité tardive (exgènes), au mins pur ce qui cncerne la situatin italienne. D'autre part, il ne dit pas prter à susévaluer le rôle de l'instructin. Car, cmme nus le verrns plus tard, même si ce facteur n'est pas parmi les plus imprtants du pint de vue statique, il ne garde pas mins éventuellement une imprtance du pint de vue de la dynamique de la mrtalité, nn seulement de la mrtalité tardive, mais aussi de la mrtalité nénatale précce et de la mrtinatalité. Si l'n cnsidère la régin de naissance, le champ de variatin est de 69,8,60,7, 39,5 respectivement pur la mrtalité tardive, la mrtinatalité, la mrtalité dans la première semaine: la cnditin sci-écnmique cllective semble dnc elle aussi n'influencer qu'à peine plus la mrtalité tardive que la mrtinatalité, mais tutes les deux, et cela paraît intéressant, beaucup plus que la mrtalité dans la première semaine. Vilà ce qui cnfirme à la fis le manque d'hmgénéité qui existe entre mrtinatalité et mrtalité nénatale précce, ce que nus avns déjà relevé, et la ressemblance entre mrtinatalité et mrtalité tardive, tutes deux nettement plus variables tant du pint de vue des caractéristiques démgraphiques que de celui des caractéristiques sci-écnmiques individuelles et, surtut, cllectives. Ces résultats cnfirment, à travers l'utilisatin des dnnées individuelles, ce qui était apparu au curs de la recherche sur les caractéristiques territriales de la survivance infantile en ItalieO à travers l'utilisatin de dnnées regrupées au niveau prvincial et avec une autre méthdlgie (analyse factrielle) pur 1974-75. 4. Facteurs différentiels et dynamique de la mrtalité fét-infantile II est bn de mettre en évidence que la situatin que nus venns d'illustrer est liée, n le suppse, à la phase de transitin de la mrtalité fét-infantile que l'italie traversait dans la péride examinée: une phase de déclin glbal, mais surtut de ces cmpsantes extrêmes la mrtinatalité et la mrtalité tardive accmpagnée par un accrissement de la variabilité territriale de ces cmpsantes, par rapprt à la mrtalité nénatale précce. Cette dernière n'a présenté qu'après 1973 une frte diminutin. Dans les années les plus récentes, (1) A. Pinnelli, F. Zannella, 1979, cit.

240 par cnséquent, la mrtalité nénatale précce a elle aussi cmmencé à se différencier territrialement et, peut-être, du pint de vue démgraphique et scial également (Tab. 6). On peut dnc penser qu'un nuveau recrd linkage, effectué maintenant, dnnerait lieu à des résultats relatifs à la mrtalité différentielle légèrement différents. En cnclusin, n peut frmuler l'hypthèse seln laquelle, l'améliratin prgressive des cnditins écnmiques-sciales et sanitaires qui s'est prduite en Italie, aurait prvqué en premier lieu la diminutin de cette part de mrtalité Tableau 6. Cmpsantes de la mrtalité fét-infantile, Italie Mrtinatalité Mrtalité Années dans la1* après la 1*«fét-infantile semaine semaine 1965 1973 1981 (1973-1965)/1%5 (198I-1973)/1973 taux pur 1.000 naissances 19.79 16,75 13,17 15,16 7,77 9,22 18,56 10,71 4,76 variatns relatives des taux (%) -33,5 41,0-9,5 39,2 42,3-55,6 55,10 39,04 21,75 29,1 44,3 Cefficients de variatin (ô x / x 100) des taux réginaux 1951 27,29 13,36 40,43 25,34 1961 32,48 7,01 43,36 26,60 1971 28,48 9,79 46,92 25,01 1981 18,77 16,86 24,13 16,31 fét-infantile la plus liée à l'état général de santé de la femme et de l'enfant (améliratin de l'alimentatin, des cnditins d'hygiène, de la surveillance sanitaire de base, hspitalisatin plus fréquente pur l'accuchement); cela permet à la femme de ne pas arriver à l'accuchement dans des cnditins déjà gravement cmprmises, et, dnc, par exemple, avec un fétus nn viable, et d'éviter que l'enfant, la phase nénatale dépassée, tmbe malade et meure à cause d'une alimentatin u de sins inadéquats. Dans cette phase, la mrtalité tardive et la mrtinatalité diminuent plus rapidement que la mrtalité dans la première semaine: cela est aussi dû au fait que la diminutin même de la mrtinatalité peut

241 Tableau 7. Décmpsitin de la différence entre 1973 et 1979 des taux de mrtalité fét-infantile et de ses cmpsantes Italie Surce de la variatin Mrtinatalité dans la l è «semaine Mrtalité après la l ère semaine fét-infantile taux spécifiques structure des naissances TOTAL 2,30 2,57-4,87 1,90 3,07 4,97 4,24 1,26-5,50 8,43 6,91 15,34 Tableau 8. Décmpsitin de la partie de variatin due à la structure des naissances entre 1973 et 1979, dans les effets de chaque variable Italie Variables Mrtinatalité dans la 1*«semaine Mrtalité après la l ère semaine fét-infantile Instructin de la mère Age de la mère Rang de naissance Durée de gestatin Répartitin gégrafique TOTAL 0,95 0,28 0,34-1,51 0,51-2,57 0,63 0,19 0,13 2,46 0,34 3,07 0,88 0,17 0,25 0,55 0,59 1,26-2,47 0,64 0,72 4,52 1,44 6,91

242 entraîner la naissance d'enfants vivants qui ne réussissent tutefis pas à survivre à la première péride de la phase nénatale ce qui gnfle, prbablement, les taux de mrtalité dans la première semaine de vie, et en réduit le rythme de diminutin et la variabilité territriale et sci-démgraphique('). Ainsi que nus l'avns dit, la situatin a changé depuis lrs: le déclin de la mrtalité fét-infantile s'est accéléré et une frte diminutin de la mrtalité nénatale précce a également cmmencé. Une analyse apprfndie des causes du déclin accéléré de ces dernières années mntre que celui-ci est dû à une frte diminutin des taux spécifiques seulement pur la mrtalité tardive, alrs qu'il est dû en grande partie aux mdificatins'de la structure des naissances pur les deux autres cmpsantes (Tab. 7). Les mdificatins structurales snt en partie liées à la diminutin de la natalité (et par cnséquent à la diminutin du nmbre des naissances de rang élevé et de mère de plus de 34 ans), et en partie aux transfrmatins sciales qui nt intéressé en particulier les génératins de femmes qui snt entrées plus récemment dans le plein de leur activité reprductive: ce snt des femmes qui n'nt pas suffert des difficultés de la guerre, étant nées, pur la plupart, dans les années '50, qui nt été élevées dans une péride de bien-être crissant, qui nt jui d'une plus grande péride d'instructin car elles nt tutes pu bénéficier du prlngement de l'éducatin sclaire bligatire (de 5 à 8 ans), entré en vigueur en 1962O. Il est prbable que l'améliratin de l'état de santé des femmes sit le cause principale de la mdificatin structurelle la plus imprtante aux fins de la diminutin de la mrtalité: à savir de la réductin du taux de naissances prématurées, passé de 7,9% en 1973 à 5,2% en 1979. D'autre part l'augmentatin du niveau d'instructin peut avir favrisé chez les femmes une plus grande attentin au prpre état de santé, à la surveillance de la grssesse, à l'usage des structures sanitaires, aux critères d'alimentatin et de sin au nuveau-né. Par cnséquent, si une grand partie de la diminutin de la mrtinatalité et, surtut, de la mrtalité nénatale précce, s'explique par la diminutin des (1) Lrs de sn interventin au Cngrès internatinal de Pédiatrie de 1971 (Vienne 29-8/4-9), H, Hansluwka faisait remarquer que l'améliratin des sins médicaux dans le dmaine de l'bstétrique peut prvquer un glissement du décès, en évitant Pavrtement tardif, et augmenter la mrtalité périnatale u en cacher la diminutin. Il semble raisnable de retenir que la même chse peut se prduire pur la mrtinatalité et la mrtalité dans la première semaine de vie. (2) Nus avns emplyé la même méthde que celle que nus avns précédemment utilisée pur l'analyse de la mrtalité différentielle; nus l'avns appliquée ici à l'analyse des différences de mrtalité entre 1973, année après laquelle a cmmencé l'accélératin du déclin de la mrtalité fétinfantile et 1979, dernière année pur laquelle en peut dispser de dnnées sur tutes les caractéristiques des naissances. On renvie au travail déjà cité: A. Pinnelli, 1983, pur les critères suivis dans l'adaptatin des taux spécifiques de mrtalité, rendus dispnibles par le recrd linkage, à la situatin de 1973.

243 naissances prématurées, une autre partie, qui est lin d'être négligeable, s'explique par l'augmentatin du niveau d'instructin: et c'est à ce dernier que l'n dit la plus grande partie de cette mince part de la diminutin de la mrtalité tardive due à des variatins de structure des naissances (Tab. 8). On peut ainsi bserver qu'un facteur qui n'était pas très imprtant du pint de vue de la mrtalité différentielle, cmme par exemple le niveau d'instructin de la mère, a également eu une grande influence sur la diminutin de la mrtalité grâce à sa frte dynamique dans le temps (les naissances issues de femmes avec un degré d'instructin supérieur au niveau élémentaire snt passés de 43,9% en 1973 à 63,8% en 1979); au cntraire, des facteurs de plus frte différenciatin de la mrtalité, cmme l'âge élevé, qui se snt eux aussi réduits au curs de ces mêmes années (les naissances issues de mère de plus de 34 ans snt passées de 14,4% à 10,8%, celles avec un rang de naissance supérieur au trisième de 12,2% à 7,3%), mais avec une mins grande intensité, nt eu un pids mindre dans la diminutin récente, particulièrement rapide, de la mrtalité fét-infantile.

245 FACTEURS SOCIO DEMOGRAPHIQUES DES DISPARITÉS RÉGIONALES DE LA MORTALITÉ INFANTILE EN FRANCE DINH Quang Chi Chargé de missin de l'i.n.s.e.e., Paris, France Lrs de la 2ème réunin du grupe à WIESBADEN, j'ai présenté les principes et les principaux résultats au niveau natinal d'une étude spéciale sur la mrtalité infantile en France faite à l'i.n.s.e.e. grâce à la pssibilité d'apparier les avis nminatifs de décès des enfants de mins d'un an aux bulletins de naissance. Cette nte est une suite de la cmmunicatin précédente et a pur bjet de présenter un essai de mise en évidence du rôle des structures scidémgraphiques dans les disparités réginales de la mrtalité infantile des génératins 1970-1972. Les tableaux indiqués dans la première cmmunicatin, mis à jur avec les derniers résultats dispnibles, snt reprduits en Annexe.

246 1. Divers indicateurs de mrtalité infantile 1.1. Mrtalité infantile ttale Le taux de mrtalité infantile pur les génératins 1970 à 1972 varie par régin de 13,8 décès d'enfants de mins d'un an pur 1.000 nés vivants (régin parisienne) à 26,l% (Crse), alrs que le taux France entière s'établit à 16,6. Le graphique 1 mntre que les plus frts écarts psitifs à la mrtalité myenne France entière se truvent en Crse, dans le Nrd-Pas-de-Calais, puis en Picardie, Lrraine, Franche-Cmté et Auvergne. Les taux les plus faibles snt bservés dans la régin parisienne et dans les Pays de la Lire. C'est le Nrd-Est qui s'ppse, par sa mrtalité infantile élevée, au Sud-Ouest alrs que pur la 14.9 16,6 18,3 Decet pur 1 000 nil vivants. Indice baie 100 France entière. GRAFIQUE 1. Taux de mrtalité infantile par régins Génératins 1970-1972

247 Cr» Nrd Aquitaine Languedc Prvence Picardie # Auvergne I Midi Ptu \ \ \B Nrmandie Burggne Champagne Bretagne \ \ Alsace P. Lire \ L R. Parisienne Mrtalité pst-natale GRAPHIQUE 2. Taux de mrtalité né-natale et pstné-natale par régin (pur 1 000 nés vivants) régin, qui présente la plus grande dispersin (taux variant de 9 / à 21 /). La mrtalité pst-nénatale, reflet du milieu scial, varie avec une amplitude plus étrite (4% à 7%). D'un pids sensiblement équivalent à la mrtalité pstnénatale en 1950, la mrtalité nénatale tend à devenir prépndérante dans la mrtalité infantile et en cnstitue actuellement les deux tiers. Le graphique 3 mntre qu'il existe également un certain regrupement gégraphique des régins figurant dans un même quadrant du graphique 2. Les régins du premier quadrant (mrtalité nénatale et pst-nénatale supérieures aux myennes natinales) se lcalisent dans le Nrd et l'est de la France; celles du quatrième quadrant (mrtalité nénatale supérieure, mrtalité pst-nénatale inférieure aux myennes natinales) se retruvent dans le Sud et Sud-Ouest. La

248 lf)iqhht-nh 1 1 l t*o>liîfo'fn0ot*r v O O CO CO CO ^H O) 'O f-t CD W5 "1* 00 lo ^H»~t O fo Cl ÍO Oi to CQ t 1 - t~ io "^ (O io OS 00 CD 00 ^* to tdt"** to CO ^i* t"* CO CD *f ^^H ^^H ^^H ^^ r> ^^^ ^^i ^^" ^^" ^^^ ^^" ^^* ^^^ ^^^ ^^^ t*^ ^^ ^^ ^^ ^^^ ^^ r*j S. S CJiOïO *f OOHOhHO CI CDOlOOCOt^'t'^nO^CO'-^OO^ u x u + t- Cl to lo»o_ CJ 00^ O 00^ CI C0_ cd j 3 T3 -*» uiv l/î u > su C O ^* 3 a sc 3 T3 C c 'S "Si e 1 a E C 11 c-5 5 S 52 g.2 > i I s c *f c t~ Oi PO r^»-h c * CD ^I O ^H ^ CJ ~f lo io lo "4*»i 1 TCCD 1* iß ira "f *t *t *t n *t "I 1 lo *f ^t id H*tC9HMi0tfH0OOtD(DH0>'1'Wt*OOHNû0 > ci e'»-i" i-î ci ci c' "t ci" e' ci ci c ci ^-T ^-î" c* c' c' ' C7> 00^ f-i t* i-i CJitfï f-^ Cl^ *J^ 00^ t-^ O OO^OOOOCO^OO^t^CJOO u. Taux (Décès 3 H d'en MU _E iff Ctí 1 1«S3 a.s e 0) -) <V T3 là ll 1 fi ' > X.H I s

249 mrtalité générale résumée par l'espérance de vie à la naissance, c'est plutôt dans la France du Nrd qu'n bserve la plus frte mrtalité!']. Remarquns que le cntraste Est-Ouest caractérise les disparités sci-écnmiques de la France. En revanche, le cntraste Nrd-Sud semble plus cnfirmé pur les caractères démgraphiques (tableau 1). Sur 20 ans, la mrtalité infantile réginale est marquée par une duble évlutin: d'une part, sn intensité myenne a diminué de deux tiers (49,5% de décès nés vivants pur les génératins 1950-1951,16,6 pur les génératins 1970-1972), d'autre part, la dispersin des taux réginaux s'est réduite (cefficient de variatin = 0,14 cntre 0,18 en 1950-1951). Cependant, en valeur relative, les écarts se maintiennent (rapprt de 1 à 2 entre les taux le plus faible et le plus frt). La hiérarchie des régins a peu varié si l'n excepte d'une part, la Bretagne et la Haute-Nrmandie dnt la situatin relative s'est amélirée et d'autre part, l'aquitaine, le Pitu-Charentes et le Limusin dnt le classement s'est légèrement dégradé. 1.2. Décmpsitin de la mrtalité infantile suivant la durée de vie. Typlgie des régins. Si 9(0,12) est le taux de mrtalité infantile, q(l,l2) celui de 1 à 12 mis, n peut écrire: l-q(0,12)=[l-q(0,l)j X l-q(l,12)j les taux étant petits, n peut remplacer le schéma multiplicatif ci-dessus par le schéma additif suivant: q(0,12) = q(0,l) + q(l,12) u, en clair: mrtalité infantile = mrtalité nénatale + mrtalité pstnénatale L'intérêt de cette décmpsitin vient du fait que, très prche de la décmpsitin de la mrtalité infantile en mrtalité endgène et exgène [2], dnc dnnant les mêmes indicatins, elle est cependant d'un calcul plus simple. Le graphique 2 illustre les résultats btenus. Dans l'ensemble, les pints représentatifs de la mrtalité infantile des régins snt assez prches de la drite lieu des pints dnt la smme des deux taux nénatal et pst-nénatal est égale au taux de mrtalité infantile de la France entière. Les Pays de la Lire et la régin parisienne d'une part, la Franche-Cmté, le Nrd-Pas-de-Calais, la Lrraine et la Crse d'autre part, s'en écartent en raisn, pur les premières de leur faible mrtalité, pur les secndes de leur frte mrtalité. En valeur abslue, c'est la mrtalité nénatale, plus liée aux caractères physiques u spécifiques de la

250 tr-=rí cf. p. 4 I Mrtalités infantile, né-natale et pst-nénatale supérieur«aux myenne* France, entier«crrespndantes., Mrtalités infantile, né-natale et pst-nénatale inférieure! aux myennes France entière crrespndante!. Mrtalités infantile et né-natale supérieures aux myenne» France entière, mrtalité pst-nénatale inférieure. GRAPHIQUE 3. Typlgie des régins suivant le taux de mrtalité infantile

251 Haute-Nrmandie est une régin à part: c'est la seule régin ù la mrtalité pstnénatale lui est inférieure (deuxième quadrant). Exceptins faites pur la Haute-Nrmandie, la Bretagne et les Pays de la Lire, les régins des façades maritimes de la France snt des régins ù la frte mrtalité infantile est le fait d'une frte mrtalité nénatale, la mrtalité pstnénatale de ces régins étant dans l'ensemble inférieure à la myenne France entière (tableau 1). 1.3. Mrtalité infantile suivant le sexe Cmme n puvait s'y attendre, les disparités réginales de la mrtalité infantile se différencient peu par sexe. Dans l'ensemble le niveau relatif de mrtalité, par rapprt aux myennes France entière est sensiblement équivalent pur l'un et pur l'autre sexe sauf pur l'auvergne et les régins du littral méditerranéen ù celui des filles est plus élevé et pur le Limusin et la Basse- Nrmandie ù, au cntraire c'est la mrtalité des garçns qui est relativement plus élevée. La surmrtalité masculine, mesurée par le rapprt du taux de mrtalité des garçns sur celui des filles, est par cnséquent plus faible que la myenne (1,26 cntre 1,36) pur les premières régins, plus élevée (1,47) pur les secndes (tableau 1). 1.4. Mrtalité infantile suivant le statut juridique de l'enfant. La surmrtalité de l'enfant né illégitime par rapprt à l'enfant né légitime est un fait bien établi. Pur les génératins 1970-1972, le rapprt du taux de mrtalité des enfants nés illégitimes à celui des enfants nés légitimes est de 1,65 pur la mrtalité infantile, 1,56 pur la mrtalité nénatale et 1,83 pur la mrtalité pst-nénatale alrs que pur les génératins 1956-1960, ces rapprts étaient respectivement de 1,57,1,41 et 1,82. Du fait d'une réductin plus lente de la mrtalité nénatale chez les enfants illégitimes, l'écart relatif entre les mrtalités infantiles légitime et illégitime s'est accentué. Il serait intéressant de puvir analyser plus en détail les facteurs de cette surmrtalité. La faiblesse du nmbre de décès bservés chez les enfants nés illégitimes (1 600 au ttal par génératin) ne nus l'a pas permis dans le cadre du présent travail. Nus relèverns simplement que la surmrtalité des enfants illégitimes et particulièrement élevée dans le Centre, la Crse et l'auvergne (tableau 1).

252 1.5. Mrtalité infantile suivant le mis de la naissance La frte mrtalité du premier mis nus a cnduit à nus intéresser à la mrtalité par mis de naissance. Malgré les prgrès accmplis de ns jurs dans l'équipement climatisant des maternités et des lgements, le mis de naissance ne semble pas être indifférent aux chances de survie de la première année. En effet, les enfants nés en autmne et en hiver cnnaissent une mrtalité supérieure à celle des enfants nés au printemps et en été (16,8 à 17,3 décès pur 1 000 enfants nés entre ctbre et mars, 15,9 à 16,5 décès pur 1 000 enfants nés entre avril et septembre). Les infrmatins dispnibles au niveau réginal ne snt pas encre suffisamment nmbreuses pur nus permettre de déterminer s'il existe u nn des prfils saisnniers particuliers à certaines régins. 1.6. Mrtalité infantile suivant la catégrie urbaine/rurale Pur l'ensemble de la France, n peut bserver tris niveaux de mrtalité infantile. Le niveau le plus bas est celui que cnnaît l'agglmératin parisienne avec 13,6% décès, le plus élevé est celui bservé pur l'ensemble des cmmunes rurales avec 17,5 /<x>; les cmmunes faisant partie d'une unité urbaine autre que l'agglmératin parisienne enregistrent un taux prche du rural avec 17,l%. Dans l'ensemble des unités urbaines (agglmératin parisienne exclue), la catégrie de l'unité urbaine semble n'exercer qu'une faible influence sur la mrtalité infantile: le taux s'établit à 17,24 pur les unités urbaines de mins de 20 000 hab. à 16,92 pur les unités de 20 000 à 100 000 hab. et à 17,18 pur celles de plus de 100 000 hab. (tableau 2). Au niveau des régins, il est mins aisé d'établir l'incidence de la tranche d'unité urbaine sur la mrtalité infantile en raisn de l'inégale distributin des bservatin dans chaque catégrie et de la diversité des structures urbaines de chaque régin. On peut nter néanmins que dans l'ensemble la mrtalité infantile est plus faible dans les unités urbaines que dans les cmmunes rurales. Cinq régins fnt exceptin à cette bservatin: ce snt le Nrd-Pas-de-Calais, la Lrraine, l'alsace, la Franche-Cmté et les Pays de la Lire ù au cntraire, c'est dans les cmmunes rurales que l'n enregistre les plus faibles mrtalités infantiles. La carte de France des disparités réginales de la mrtalité infantile en milieu rural présente les mêmes mdulatins que celle de la mrtalité infantile ttale sauf pur quatre régins: la Lrraine, l'alsace, le Midi-Pyrénées ù la mrtalité infantile rurale est inférieure à la mrtlité infantile de l'ensemble des cmmunes rurales française et la Haute-Nrmandie ù au cntraire, elle est supérieure.

253 0) 0J CO W "t H h> c t* " ÎC in ifl f O *f *f t-#rt fl Ot--f M H n t^ " ai" r-" ci -t* t t- ó t t* uí c* t-" ' 3 X) B.S S5 O b i t-flíhiooolfltoto^olcoo' S ffï t^ (O h; ffl ««f» m cd HVD1«M IO «Nil ^NOO «O -t C5 O Oî IO 'O td <O_ O «* r~" ni uí t us r-" t» " ui #* is t " c i -i 1 * r~* t-* i O s«a 00 t l-l t t?s ers t m t- IO f-i ' O c t a> c CO -! t- r-td O CO 00 \D 00 t- IN M CO 1- O 00 C0 W M, ^ rjí" t-" T í t " «í t «r- W t-' í ÍO t-" e g $ s 3 ai û II & 8 a c.3.3 i Li A n a, a,» ai T3-O c a 2 2 41-0) e ss SS < < tu Cu CQ CL, <!

254 1.7. Mrtalité infantile suivant la catégrie sci-prfessinnelle du père. Dans ce paragraphe, il est questin seulement de la mrtalité des enfants légitimes. Les tableaux 3 et 4 mntrent que les catégries sci-prfessinnelles se répartissent, en fnctin de leur mrtalité infantile, en quatre grupes: Le premier grupe est cnstitué des prfessins libérales et des cadres (myens u supérieurs). Leur taux de mrtalité infantile s'établit à 11,6%» pur l'ensemble de la France et varie de 10,2 à 15,2%, sit dans un rapprt de 1 à 1,5 suivant les régins. Dans deux régins sur tris, c'est le grupe qui présente la plus faible mrtalité infantile. Pur un tiers des régins le taux est inférieur à ll%x>. C'est l'rdre de grandeur de la mrtalité infantile des Pays- Bas. Les patrns de l'industrie et du cmmerce, les agriculteurs, explitants, les emplyés, les cntremaîtres et les uvriers qualifiés frment le deuxième grupe avec un taux évluant de 14,7 à 16,2 / pur l'ensemble de la France, de 9,6 à 19,5%» suivant les régins. L'étendue relative est plus large que celle du premier grupe: de 1 à 2. Relevns que les taux extrêmes snt ceux de la régin Nrd-Pas-de-Calais: 9,6 pur les «agriculteurs explitants», 19,5 pur les «cntremaîtres et uvriers qualifiés». Le trisième grupe rapprche les «uvriers spécialisés» des «salariés agricles», avec respectivement 19.0 et 19,8%» décès. Par régin, le taux varie de 15,6 à 27,6%». Aucun taux de ce grupe n'est inférieur à un taux du premier grupe. Le quatrième et dernier grupe est celui des maneuvres (25,7%»). C'est pur cette catégrie que dans la plupart des régins le plus frt taux de mrtalité infantile est enregistré (18,3 à 33,4%»). L'ensemble des autres catégries nn prises en cmpte dans le classement cidessus cnnaît une mrtalité infantile visine de celle du grupe 2:16%«décès. La tableau 4 mntre l'évlutin de la mrtalité infantile par catégrie sciprfessinnelle depuis 1956. Sur 12 ans, la mrtalité infantile a diminué de près de mitié dans chaque catégrie si bien que dans l'ensemble, la hiérarchie des catégries est restée invariante. Remarquns que cette hiérarchie crrespnd pint par pint à celle établie pur la mrtalité des adultes [3]. Au terme de cette première partie, n peut dégager les cnclusins suivantes: Dans la péride récente (1956-1972) la mrtalité infantile a diminué dans tutes les catégries sciales, dans tutes les régins, suivant un rythme qui paraît être mdulé autant par le facteur «régin» que par le facteur «catégrie sciale». Par régin, la baisse varie entre 32 et 51%. Ce snt les régins du Nrd (Nrd- Pas-de-Calais: 51%) et de l'ouest (Bretagne: 51%, Pays de la Lire: 47%)

255 "53 c l/l CO & t/u c cd > 00 C 6 - sc tu égr 1972. S J2 ivant ratins! S d t u _C "3 t: S D -a X ns H f" 3 cl <u 15 C3 H OH 6 S i> MU u s ON 3 «-> M c 2 1) c Ü u S -Ö. -.tí 3 M HO S Sg II«O «It- I "I O «Ctg O 530 Ser- O e 00 t- 1-1 t 00 en r- ci 00 -r. c. in i t. «t-. c >n O * -* t- i-t" ci c "»" t-" *" " " t' c" 00" ci 1"» t" *" m" t-* eó t-' n" uí W CO N N W M Cl M CO IN «.-I «Cl «H CI (M M CI M M M Cl 1 e en c t en * e t-^cts^» c M -^ <û c_ c^ ^ c^ ç^ 00^ c 00 r iß a i-t a 01' t-^ c ci t-" *r' M ifi IO í ci r-' ' ^ CJ ^f "cco0t^'^ (t3 i ccoi'ci t ci'rr^ O 00 * rh CO 00f Iß O> r-_ t-_ "T O5_ O>^ «),CO_ * CO_ N_ -t_ CO «5^ O_ <3 r-" c" c-" in t-* 00" ci " ci i-î «" (-* 00* " 00 <" >" 00" 00* t-^ 00 01 W Í H C í C J M N l H H W t í l H t Í C Í H Ci lo O ÍO P5 r- N 01t-l O M Nfc 'f *ifl CO H Hifl 05^ r ^ r ' r ^ V í ' r i í í í ' ^ t - t ci rinhnnninin 00 >. ci ci ci c «_ t-_ te _ ci c" t-" t-" m" te" <û" 00" aï 00 in 00" f t < r-' in t V i> t-" 00 t _ c_ c-_ 1"_ t~_ * <N_ ^l_ -*_ 1"_ CO <H O _ ci e> i-t r-^ «i 00" <D í c" " t- 'iinini «5" t-" m" t 00* C» Cl CO CI Cl Cl CJ CO CO CO CO M CO M M Cl «ClC-l C4 N CO Cl ishs ci 1^ < ci_ t t ci r cn_ <D C» «t_ c> œiqijici» en i-t «" m* c* ci en" en en " ^ * t" i-î c" t» c' c CD ** ci < T" NMOCIMMMClNtMnMMIMMNCINIMHMO«" m" c " " ci c" c' ci c' ci fi *r* ci 10 ci ci r- in" t-^ rj t-" > 00* *" i-<" ci c" en i-f 00 00* t-^ 00" t-t c" 1-* 00 00" cji e^ c t- en -f. _ i-< en CD_ * t-_ c c c_ en «0>f ci rt IH -t " ri i " " * i " i i " " " i ^ i " " IH» u> ci t _ en t-; t^ «en <r c_ «> 10 -r e^có"tcd*3"í **i*cícícn'c *cicn*inc'r-t-»c»íc^e"f-*in m MCNCICIMC1C1COCOC1C1CIC1CIC1C1CIC1COC1CICOC1 en m" 00 i-î " ci * t~* t" ci en" < * ci.-t * en t-' ai ci m cctcc-tcoincci'ci-tcecccmcccj-rc «0 t c-_ Ot O ci «H in c_ "f»f in cq cj c-l r-_ -t M_ es i~, cl O f l 0 p, c «t, fj en in tn t_ in * IOIOHH O «O M t en t. en, c" t-" t-" in" f" t t en" e" t" 00" >]" m* t" t- t" t* t* t-" t' t* *r m nnohoca 00 cji^ t-; 00, ci tc_. t.c_ t_ IH O_ CI t. ''d " c- " i-î î in i-î î r- * c- " c * f * t~ " en t " r- " i-t T 00 c " en cci'j'ccecicciciciciciccici-*ci

256 qui nt prgressé le plus rapidement. Les régins côtières du Sud et du Sud- Ouest, ainsi que la Burggne et le Limusin, nt prgressé avec plus de lenteur (baisse inférieure à 38%). Cette différence dans le rythme de baisse a mdifié la physinmie réginale de la mrtalité infantile (ppsitin Nrd-Sud en 1950; Nrd-Est - Sud-Ouest en 1972). Par catégrie sciale, la baisse s'établit entre 37% (prfessins libérales et cadres) et 51% (agriculteurs explitants). L'évlutin rapide de cette dernière catégrie est à rapprcher du changement radical du milieu agricle lié à la crissance glbale de l'écnmie française et à l'urbanisatin de l'après-guerre. Les disparités actuelles entre régins d'une part et catégrie sciales d'autre part snt imprtantes, les taux de mrtalité variant dans le rapprt de 1 à 2. Ce rapprt était un peu plus frt (2,5) en 1956-1960 pur les catégries sciales, mais n'a pas varié pur les régins* 3 ). Avec le niveau atteint actuellement pur la mrtalité pst-nénatale (28% de la mrtalité infantile ttale cntre 38% pur les génératins 1956-1960 et 51% pur les génératins 1950-1951), la mrtalité nénatale apparaît de plus en plus cmme un indicateur susceptible d'attirer l'attentin sur des régins ù des prblèmes spécifiques se psent. Ainsi la haute mrtalité de la Crse est due à sa mrtalité nénatale anrmalement élevée. Ceci est d'autant plus précupant que des deux cmpsantes de la mrtalité infantile, c'est la mrtalité nénatale qui baisse le plus lentement. 2. Facteurs structurels et spécifiques des disparités réginales Nus avns vu dans la première partie que la mrtalité infantile est très variable suivant le statut juridique, la catégrie urbaine-rurale, la catégrie sciale, etc. Cette variabilité agit sur la mrtalité infantile de la régin sur deux plans: celui de la «structure», indirectement traduite par les différentes distributins de naissances et celui des «spécificités», exprimées par le niveau des taux partiels. Dans cette partie nus nus prpsns de préciser l'imprtance respective des deux facteurs. (3) L'évaluatin précise de l'imprtance relative de la régin u de la catégrie sciale ne peut être établie qu'après un traitement statistique apprfndi et suppse un mdèle de référence. Ce travail est en curs à l'i.n.s.e.e. Il n'est pas suffisamment avancé pur nus permettre de faire état, ici, des résultats.

257.5 «'5b '> Generatins 1970-1972 Ttale Nénat Pstne O OS CO 00 30 OO 00 Cl ' > '1 CO CO ^T CO 'O in 01 "** t- ci -T f ci i -r 00 OfHr-lt-l CO-1* ÍO th 'D r-omm O 00 l- 3) th *t m t IO CTÏCD in in Génératins 1956-1960 Pstne Nénat Ttale 4,6 8.2 8,0 10,4 10,4 13.3 14.3 21,7 11.2 -r r* -f i* r t-i -t Cl r -û t^- l~" O O5 th 00 35 th thththd H«C'1 th 17,0 24.9 25,4 28.1 31.2 32.9 35,3 44.8 29.6..5 <* 'H Prfessins libérales, cadres Emplyés Patrns industries, cmmerce Cntremaftres, uvriers qualifiés Agriculteurs explitants Ouvriers spécialisés Salariés agricles Manœuvres France (enfants légitimes)

258 2.1. Principes Appelns «disparité réginale» de la mrtalité le rapprt du taux de mrtalité de la régin sur celui de la France entière: Q(r.) d(r.) (1) q(f.) Sn interprétatin est évidente: si d{r) est plus petit que l'unité, la mrtalité infantile de la régin est plus faible que celle de l'ensemble de la France. Si d(f) est plus grand que 1, c'est le cntraire. Le classement des régins suivant d(r) est identique à celui suivant les taux eux mêmes. Sient n{r,î) et m(r,i) respectivement les naissances et les décès de la régin r répartis suivant les différentes mdalités / d'un critère /cnsidéré. Si q{f,î) snt les taux «France entière» relatifs à ces mdalités, n peut calculer les décès n(r,i)-q(f,i) qu'n aurait bservés dans la régin si la mrtalité de la régin était identique à celle de la France entière. Le rapprt des deux nmbres de décès réelement bservés et la décès «thériques» est un indicateur de la mrtalité ptentielle de la régin. Appelns-le i(r,i). Par définitin 2m(r,i) s(r,i) = (2) Si s(r,i) est plus grand que 1, la mrtalité ptentielle spécifique de la régin est plus frte que la mrtalité «France entière». Elle est plus faible si s(r,i)<\. Cnsidérns le rapprt II s'écrit aussi a(r,i) = (3) s(rj) 2m (r,i) 2n(f,i) 2n (r,i). q(f, a(r,i) = x x 2n(r,i) 2m (f,i) 2m (r,i) 2 n(r,i). qff.i) 2n(f,i) 2n(r,i) 2m(f,i) Le premier terme de la dernière égalité est un taux cmparatif calculé en appliquant aux naissance réparties suivant i de la régin les qutients crrespndants q(f,i) France entière. Appelns-le q'(r,i).

259 On a alrs: a(r,d = q'(r.i) a(r,i) peut dnc s'interpréter cmme un indice de disparité imputable au seul facteur «structurel». Plus grand que 1, il indique une structure défavrable. Plus petit que 1, il indique le cas cntraire. Des relatins (1), (2) et (3) n tire: Q(r) = q(f) x a(r,i) x s(r,i) (4) Le taux de mrtalité infantile réginale apparaît finalement cmme la résultante de tris facteurs à effets multiplicatifs: la myenne natinale ç(f) l'avantage u le handicap a(r,i) que lui vaut sa structure I, l'intensité spécifique s(r,i). Prenns à titre d'exemple l'effet des structures par catégrie sciale sur la mrtalité infantile légitime de la régin parisienne. Sn taux est de 12,96 / cntre 15,88 / pur la France entière, le rapprt des deux taux indique sa disparité, sit 12,96:15,88 = 0,816. Si la mrtalité par catégrie sciale de la régin était identique à celle de la France entière, sn taux s'élèverait à 15, 10%». L'effet des structures est alrs égal à 15,10 : 15,88 = 0,951 d'ù l'effet des «spécifités» s(r,i) = 0,SÏ6 : 0,951 =0,858. Dnc, sur une baisse relative ttale de 18%, l'effet favrable des i(r,7)=0,816 : 0,951=0,858. Dnc, sur une baisse relative ttale de 18%, l'effet favrable des structures sciales «explique» 4%, le reste, sit 14%, est imputable à l'ensemble des autres facteurs u aux «spécificités réginales». 2.2. Résultats Les calculs n été faits pur les principaux critères examinés dans la première partie: le sexe, le mis de naissance, le statut juridique, la catégrie urbaine, la catégrie sciale. Alrs que les diverses spécificités s(r) varient de 0,816 à 1,577, les cefficients a{r) ne varient que de 0,847 à 1,043. Dans l'ensemble, l'influence glbale des «structures» est faible devant celle des «spécificités» réginales sur le niveau ttal de mrtalité infantile de la régin. Par critère, n peut faire les distinctins suivantes: a) L'effet «structurel» est pratiquement inexistant pur les deux premiers critères, sexe et mis de naissance (a(r) = 1). Dans ce cas, le taux cmparatifs snt

260 très visins du taux myen «France entière» et les disparités d(r) snt ttalement expliquées par les spécificités s(r). Autrement dit, les différences de mrtalité par sexe u par mis de naissance n'interviennent pas en définitive sur le niveau de la mrtalité infantile ttale de la régin. b) Pur le «statut juridique», l'effet structurel existe mais il est relativement faible devant celui des spécificités. Il est défavrable à la régin parisienne, à la Champagne-Ardenne, à la Picardie et à la Haute-Nrmandie. c) Dans les effets par catégrie urbaine-rurale, la régin parisienne se situe à part en raisn du pids particulier de l'agglmératin de Paris. Hrs régin parisienne, l'effet glbal de la «structure urbaine» ne semble pas être plus prépndérant pur une régin que pur une autre (a(r) = 0,847 pur la régin parisienne et 1,035 à 1,043 pur les autres régins). d) C'est la «structure sci-prfessinnelle» qui apparaît cmme le meilleur facteur explicatif des disparités réginales parmi les critères examinés ((r) = 0,951 à 1,036). Sn rôle est psitif pur la régin parisienne, le Rhône- Alpes, la Bretagne, la Prvence-Côte d'azur et le Midi-Pyrénées. Dans les deux premières régins, la faible mrtalité réginale est le fait d'une faible mrtalité spécifique et d'une structure prfessinnelle favrable. En revanche, dans les deux dernières régins, l'effet résultant d'une frte mrtalité spécifique a été atténué par une structure sci-prfessinnelle favrable (tableau 6). Dans les autres, régins, la structure sci-prfessinnelle agit plutôt cmme un handicap; ntns, en particulier, le cas de la Basse-Nrmandie qui cnnaît, malgré un effet «des spécificités» favrable, un taux de mrtalité infantile supérieur au niveau myen natinal. e) Une typlgie des régins françaises suivant l'effet des catégries sciprfessinnelles (enfants légitimes seulement) est très prche de celle suivant l'effet des catégries urbaines-rurales de dmicile (ensemble des enfants); tutefis le classement n'est pas le même pur la Bretagne, le Limusin, le Rhône-Alpes, le Pitu-Charentes, le Midi-Pyrénées en raisn des différences de structures suivant le statut juridique. Ces deux effets apparaissent dnc cmme liés mais le mdèle utilisé ne permet pas de déterminer la nature de la liaisn. Cnclusin Les disparités de mrtalité infantile suivant la régin de dmicile de la mère snt particulièrement marquées puisque les taux de mrtalité infantile snt dans le rapprt de 1 à 2 entre régins extrêmes; ce rapprt ne s'est pas mdifié depuis 1950. L'intensité de la baisse de la mrtalité infantile a été différente suivant les régins: il en résulte qu'à la traditinnelle ppsitin Nrd-Sud s'est substituée une ppsitin Nrd-Est - Sud-Ouest.

261 mi 00 r^ O Oí O O>»"H»~* O) O Ot-lt-(r-f»Hr-ft-li-»rHO»-'»-fOfHi-)O»-IOrH»HO*-* <L> C 'S lloonplololluot-tmonnnlot-îirts«500<3>0>osor-*thoi-icooooooioïoo^lo a i < S a g-g, «ja «1 INfnHMOONWHOl-rtOll-OhOOM CO loiomhlímfflooolf^rlohllli OOO OOTOOOM.-lOrHCJlOOOOOOlOO Of-lf-lOO*HfHiHf-lTHrHOOi S* O 3 O 'G.9. S2.y 3 S s g 2 5

262 Les baisses les plus imprtantes nt été enregistrées dans la Haute-Nrmandie, la Bretagne et le Nrd-Pas-de-Calais, régins qui se classaient parmi les plus défavrisées en 1950-1951: les deux premières snt actuellement parmi les mieux placés mais le haut niveau du taux de la régin du Nrd, en dépit d'une spectaculaire prgressin, maintient cette régin à l'avant-dernier rang devant la Crse. Les régins ù la situatin s'est relativement dégradée snt le Pitu- Charentes, l'aquitaine et le Limusin. Depuis 1970, l'étude de la mrtalité infantile menée par l'i.n.s.e.e. s'est enrichie de nuvelles variables (sexe, mis de naissance, habitat rural-urbain,...) et de nmbreux crisements entre la régin et diverses autres caractéristiques nt été élabrées. Des travaux en curs tentent de chiffrer la part de ces caractéristiques dans les disparités bservées. Il semble d'res et déjà acquis que la catégrie sci-prfessinnelle du père est le facteur explicatif le plus imprtant. Il semble, par ailleurs, qu'n ne puisse mener une étude sur la mrtalité infantile, ntamment au nvieau réginal, sans étudier cnjintement la mrtinatalité. Bibligraphie 1. Labat J.C. et Viseur J. Dnnées de démgraphie réginale 1968. Cllectins de l'insee série D, n 23, 1973. 2. Burgeis-Pichat J. La mesure de la mrtalité infantile. Ppulatin, n, 1951. 3. Desplanques G. La mrtalité des adultes suivant le milieu scial 1951-1971. Les Cllectin de rinsee, série D, n 44, 1976.

263 Annexe 1 Régins de prgramme AUVERGNE \ ' -; '; ALPES '"

264 s; ON 00 b" O* NO ON" s I) <N 00 rñ <M NO ON" t NO" NO d u 2 - er "C p C3 a 3 ' s I *w N O VÓ Q ON NO O ON r- i C m" ON ON cr I 's E Ö 3 O ni S ' s O PS ON O> O NO NO ON ON Tí O 00 O* NO O" *, ON_ ON_ r- ««i <»T NO" X U cr "(3 & 31 3

265 Tableau 2. Taux de mrtalité infantile suivant l'âge de la mère et la durée de vie (enfants nés légitimes Génératins 1963 à 1970) Pur 1000 nés suivants Age de la mère Mrtalité du 1er mis Mrtalité du 2ème au 12ème mis Mrtalité delà 1ère année Génératins Génératins Génératins ' 1966-1970 1971-1974 1966-1970 1971-1974 1966-1970 1971-1974 Mins de 20 ans 20 à 24 ans 25 à 29 ans 30 à 34 ans 35 à 39 ans 40 ans u plus 17,8 12,8 11,9 13,0 16,0 21,2 14,7 10,0 9,1 10,2 12,7 16,1 7,5 5,4 4,9 5,1 5,8 8,7 6,0 4,4 3,9 3,8 4,5 6,7 25,2 18,1 16,8 18,1 21,8 29,8 20,7 14,4 13,0 14,0 17,2 22,8 Tus âges 13,4 10,4 5,5 4,3 18,9 14,7

266 10,3 11.3 14,0 16,2 14,9 20,2 23,8 15,4 14,7 I Cu S 3 ô en r^ r, 2 :, CÍ 20, Os r- r3 m t 30, VD Os Os OO M i m (N rn ^.22 "S c I E 12 q ^ q rí n m «*n" v* I S.H 1 s i E.a 5 " î. 1 "l»n" " m" tn m ^^ (S r^ * " i-í -^ ^a- ^ * * * c <2 _c.2 MU c ^-«** OUI u "> u 3 "4», a, a t 3 "2 Ç ^ 2 8 t E del' merci 'C «n i 3 t: a. - Û. ON 10, ins 1 iupéri rns :m fessi 3 ri M C >» s" VO* Os" -tu E in "H. CD E O tü r- rm C^ VO 19, VO 20, VO 3 'a. vt uvrieiz c O u O S O Os m a v so O cnt:atat) uvriei ineur m VO S O\ 00 U il ut 00 3 j

267 î 14,2 23,7 16,4 14,3 24,0 16,1 14.7 I a s 5 «18,2 30,9 r" IN 22.6 38,7 24,4 22,6 18,4 40,4 31,7 24,4 22,4 18.9 23.1 *> "O c EE q n ** C f'i >/. Tt i.; all IN 3 C/S a 00 >O* IN* r IN c c-t «i E O "5b H m 2i C/Î MU C Vi 3 Tablea (enf IN VO * T" " I*" 00_ t" IN O rn f* 00 00 C vd O rr VD V* 00 «n /*! Wi r-" vi r-^ Q O Tf O CTi * imes) E

269 INFANT MORTALITY IN SEVEN EUROPEAN SOCIALIST COUNTRIES (1955-1980) András KLINGER Hungarian Central Statistical Office, Budapest The purpse f this study is t describe the trends f infant mrtality in seven Eurpean scialist cuntries during the 25-year perid frm 1955 t 1979. The cuntries which participated in this study were Bulgaria, Czechslvakia, the German Demcratic Republic /GDR/, Hungary, Pland, Rmania and Yugslavia. In a cmparisn f infant mrtality between these cuntries, nt nly the similarities but als the differences in sci-ecnmic cnditins are cnsidered. In all f the cuntries a significant scial change ccurred in the years fllwing Wrld War II; capitalism was fllwed by the building f scialism, and the rapid pace f the changever t planned ecnmies resulted in the ecnmic transfrmatins f these cuntries frm being predminatly agricultural t becming industrial. The cncmitants f this were greater urbanizatin, higher cultural levels, a rise in the standard f living, and an imprvement in sanitary cnditins. Free scial insurance systems were develped fr the whle ppulatins, the netwrk f health institutins widened and the number f physicians and health persnnel increased. Prir t Wrld War II infant mrtality rates in the seven Eurpean scialist cuntries were amng the highest in Eurpe. In 1930, f 28 develped cuntries inside and utside Eurpe, six f the Eurpean scialist cuntries in this study had the highest infant mrtality rates. In the seven cuntries, 135 t 176 f every thusand live-brn children did nt survive t their first birthday. The mrtality rate was lwest in Czechslvakia and highest in Rmania /the rate in Prtugal was similar t the latter/. Since Wrld War II this situatin has hardly changed. Amngst the same 28 develped cuntries, five f the seven Eurpean scialist cuntries /Yugslavia, Rmania, Hungary, Pland and Bulgaria/ have had the highest infant mrtality

270 rates almst cntinuusly since 1955, tgether with Prtugal, where since 1970 infant mrtality has been the highest in Eurpe. Only the GDR imprved its psitin in the rank rder during the study perid. In 1955 it was in 20th place, but since 1975 it has mved up t the 10th place. The ranking f Czechslvakia has fallen. In 1955 it was in 12th place /its infant mrtality was 30 percent lwer than in the GDR/; but since 1975 it has been in the 21st place. Hwever, despite the higher infant mrtality rates f the seven cuntries, their rates relative t the ther develped cuntries have altered. Fr example, in 1955 Yugslavia had the highest infant mrtality rate which was almst seven limes higher than in Sweden where the situatin was best, whereas in 1978 it was nly fur times as high. Czechslvakia, which had the lwest mrtality rates amngst the seven cuntries, had an infant mrtality rate in 1955 which was five times higher than Sweden, but in 1979 the Czech infant mrtality rates was nly three times higher than that f Sweden. Thus, amngst the seven cuntries, nly slight changes ccurred in the levels f infant mrtality relative t ne anther during the study perid. Of these, the mst interesting was the «change f place» in the rder between the GDR and Czechslvakia, which have had the lwest rates cntinually during the study perid; frm 1955 t 1965 infant mrtality was higher in the GDR, in 1965 the rates in bth cuntries were almst the same, since then infant mrtality has been higher in Czechslvakia /by ver ne third in 1979/. During the study perid infant mrtality decreased significantly in fur f the seven cuntries /Bulgaria, the GDR, Pland and Yugslavia/; in each f these fur cuntries the infant mrtality rate in 1979 was abut 25 percent f the 1955 value. Imprvement was smallest in Czechslvakia where the rate fell by nly 50 percent; it was medium in Hungary and Rmania where in 1979 the infant mrtality rate was 40 percent f the 1955 value. Thus, it is apparent that the extent f the imprvement was nt cnnected with the levels f mrtality since amngst the cuntries where infant mrtality fell the mst were bth the GDR which had the lwest rates and Yugslavia which had the highest rates. In' Czechslvakia, hwever, the relatively small imprvement was due t the wrsening ecnmic situatin, especially after 1965. Hwever, the infant mrtality rate was calculated by a different methd befre 1965 and it is prbable that the earlier rates are lwer than actually was the case. Thus the real imprvement might be greater than that indicated by the data. During the last five years f the study perid frm 1975 t 1979 the nly significant imprvement in infant mrtality was in Hungary where it drpped by ver 25 percent f its ttal decrease during the study perid. This is significant because the fall in mrtality was nly 5-6 percent in Bulgaria, Pland and Rmania. Frm the data n infant deaths by age fr the study perid, the seven cuntries can be divided int several grups /nly deaths in the early nenatal and pstnenatal perids are cnsidered here/. In the first grup f three cuntries

271 /Czechslvakia, the GDR and Hungary/ the prprtin f infant deaths in the early nenatal perid was high /these increased during the study perid, especially relative t the pst-nenatal deaths/. In the secnd grup f three cuntries /Bulgaria, Rmania and Yugslavia/ the prprtin f early nenatal deaths was relatively lw and did nt increase much. In tw f these cuntries /Rmania and Yugslavia/ mst infant deaths were in the pst-nenatal perid /hwever, their prprtin declined ver time/. The seventh cuntry /Pland/ assumed a middle psitin between the tw grups. Its incidence f bth nenataland pst-nenatal deaths was relatively high. Data n the abve trends shw that fr the first grup f cuntries, in 1955 the prprtin f early nenatal deaths was high: 41 percent in the GDR and 37-38 percent in Czechslvakia and Hungary. After 1955 these prprtins increased gradually and by 1965 they represented mst f the infant deaths in all three cuntries. The percentages were maximum in 1975 when early nenatal deaths amunted t 71 percent in Hungary, 64 percent in Czechslvakia and 61 percent in the GDR. During the same 20-year perid, the prprtin f infant deaths in the pst-nenatal perid fell by abut ne-half in each f these three cuntries t 19 percent in Hungary and t 25-26 percent in the ther tw cuntries. After 1975 a slight shift ccurred. The prprtin f early nenatal deaths decreased and that f the pst-nenatal deaths increased. This can be ascribed t the different trends f infant mrtality. Fr the secnd grup f cuntries, in 1955 the incidence f early nenatal deaths was still very lw /18 percent in Rmania and Yugslavia and 21 percent in Bulgaria/; althugh it has increased since then, in 1978-1979 it was still much lwer than in the first grup f cuntries /22 percent in Rmania and 37-39 percent in Bulgaria and Yugslavia/. Tw factrs might have cntributed t these differences: registratin f deaths /namely in these cuntries the immature fetus which died early was less likely t be cnsidered as live brn/, and late mrtality which was very high. Althugh the prprtin f the pst-nenatal deaths decreased, its incidence was still much higher than fr the first grup f cuntries. Thus, in Rmania since the mid-1960s tw-thirds f infant deaths ccurred after the first mnth, while this prprtin was still ne-half in Bulgaria and Yugslavia, /in 1955 it was arund 60 percent/. The situatin in Pland was at an intermediate level between these tw grups. The prprtin f early nenatal deaths in Pland dubled during the study perid frm 25 t 50 percent, but in 1979 the prprtin f pst-nenatal deaths was still ver ne-third /thugh it had declined frm 59 percent in 1955/. The mst imprtant grup which cntributed t the decline f infant mrtality rates was the grup f deaths in the early nenatal perid /Table 2./ This grup is mst affected by the differences in registratin prcedures amngst the cuntries and therefre a cmparisn between the cuntries may be inaccurate, althugh their trends will still give an idea f the situatin. Fr the ttal study perid the early nenatal mrtality rate was highest in

272 Hungary. It 1955 it was 22 per 1 000 and during the fllwing 10 years it hardly changed. Frm 1975 t 1979 it fell by ver 30 percent t 16 per 1 000, which was higher than in any f the ther six cuntries. In 1979, cmpared t the GDR, the surplus mrtality in Hungary was 110 percent while in Czechslvakia it was 38 percent. The surplus mrtality in the ther fur cuntries was mre favurable than in Hungary, but this may have been because f the differences in definitins, exceept perhaps in Yugslavia. In the GDR in 1955 the rate was almst as high as in Hungary /20 per 1 000/. Thereafter it decreased gradually until the last five years f the study perid when it fell by ne-quarter. In 1979 the rate was 37 percet f the 1955 value /7 per 1 000/. In Czechslvakia in 1960 the rate was lw /10-11 per 1 000/. It increased t 15 per 1000 in 1965, a rise f almst 40 percent. Hwever, befre 1965 the definitins used were narrwer, and the rate in 1960 might actually have been higher, abut 15-17. Snce 1965 the imprvement has been smaller and in 1978 the rate was 12 per 1 000. In Pland the rate declined relatively gradually. In 1979 it was 55 percent f the 1955 value /19 per 1 000/. Its imprvement was mst significant between 1955 and 1965 as well as in the 1979s. In 1955 in Yugslavia the rate was 21 per 1 000. By 1978 it had fallen by nethird but even s it was the secnd highest amngst the seven cuntries. Bulgaria and Rmania have been cnsidered separately as their practices f recnding deaths differed frm the internatinal recmmendatins used by the ther cuntries. In Bulgaria thugh, the rate was 17 per 1 000 in 1955. It is difficult t believe that it culd have fallen t 10 by 1960 and decrease further t 7 by 1979 /the level in the GDR/, which is 45 percent f the rate in Hungary. Frm 1970 t 1979 the rate fell by 20 percent. It is prbable that in the 1970s the early nenatal mrtality was lw because f the recrding practices and that the rates were abut 5-10 per 1 000 lwer than they wuld have been if the internatinal recmmendatins had been used. In Rmania the situatin was similar t that in Bulgaria. In 1955 the early nenatal mrtality rate was 14 per 1 000 which fell t 6 per 1 000 by 1965, i.e. a decrease f 60 percent. It is accepted that between 1965 and 1970 the rate increased by ver three-quarters under the impact f the 1966 ppulatin plicy measures. Since then, the rate appears t have fallen again. In 1979 the rate was nly 7 per 1 000, which might cnfirm the decrease in the 1970s by nearly 40 percent. But, as in the case f Bulgaria, 5-10 deaths per 1 000 are «missing» because f the differences in recrding cmpared t the internatinal recmmendatins. The situatin fr late nental deaths was mre cnsistent and reliable amngst the cuntries than that fr early nenatal deaths as differences in definitins used by the cuntries did nt have as much effect. At the beginning f the study perid the late nenatal rate was highest in Rmania and Yugslavia; it was relatively high in Bulgaria, medium in Pland

273 and Hungary and lw in the GDR and Czechslvakia. In 1955 the late nenatal mrtality rate was highest in Rmania, 26 per 1 000 /ver five times higher than in Czechslvakia with the lwest rate/. The rate decreased by 22 per 1 000 during the study perid, mstly between 1955 and 1960 /by ver ne-half/, althugh the natinal definitin might have had sme effect. Between 1960 and 1965 the rate decreased by 40 percent, fllwed by a slight increase up t 1970. After time it declined by 40 percent until 1975. Since 1975 it has changed by nly 8 percent. Of the seven cuntries, the greatest imprvement in infant mrtality was due t late infant mrtlity. Since the exgenus diseases cause mst f the late infant deaths, the decline in late infant mrtality can be primarily ascribed t changes in the sci-ecnmic cnditins. In 1955 pst-nenatal mrtality rates varied greatly amngst the seven cuntries. During the ttal study perid there were similar dwnward trends in pst-nenatal mrtality in all the cuntries, althugh by 1979 the rates were still different and the rder f the cuntries had changed. In 1955 the pst-nenatal death rate was highest in Yugslavia /71 per 1 000/, fllwed by Bulgaria and Pland /45-48/ and then Rmania /38/. The rate was lwest /17/ in Czechslvakia, fllwed by the GDR /23/ and Hungary /29/. Thereafter, the mrtality rate fell in general t a great extent. In 1979, the rate was 16 percent f the 1955 value in Pland and the GDR, 18 percent in Hungary and 19 percent in Bulgaria. The decrease was smaller in the tw cuntries with the highest rates; in 1978 in Rmania it was ne-half f the 1955 value, and in Yugslavia ne-quarter. In Czechslvakia, where the rate was lwest in 1955, it had declined t 30 percent f the 1955 value by 1978. The rder f the cuntries as regards pst-nenatal mrtality rates changed under the impact f their different levels f develpment. In 1978 r 1979, Rmania had the highest pst-nenatal mrtality rates /19 per 1 000/ fllwed by Yugslavia /17/. The rates were lwest in the GDR /under 4/, and in Czechslvakia and Hungary /each arund 5/. Bulgaria /9 per 1 000/ and Pland /!/ were in the middle. The difference in pst-nenatal mrtality frm 1955 t 1978 r 1979 between the cuntries with the maximum rates /Yugslavia and Rmania/ and the cuntries with the minimum rates /Czechslvakia and the GDR/ increased frm 330 t 420 percent, which means that the dispersin f the rates grew. In sum, frm 1955 t 1979, f the three age grups, deaths in the pst-nenatal perid cntributed mst t the fall in infant mrtality in six f the seven cuntries. Pst-nenatal deaths accunted fr 77 percent f the ttal decrease in infant mrtality in Czechslvakia, 69 percent in Pland and Yugslavia, 67 percent in Hungary, 61 percent in Bulgaria, 55 percent in the GDR, and nly 38 percent in Rmania. The cntributin f bth the early nenatal and late nenatal deaths t the ttal decrease in infant mrtality was much smaller in general than that f the

274 pst-nenatal deaths, and their rates caused a greater dispersin in the imprvement f infant mrtality in the cuntries. Of the ttal decrease in infant deaths frm 1955 t 1979, the prprtin f the early nenatal deaths was high nly in the GDR /35 percent/; in Bulgaria, Rmania, Hungary and Pland it caused ne-sixth f the decline, and in Czechslvakia and Yugslavia its prprtin was small /7 percent and 9 percent, respectively/. The imprvement in late nenatal deaths had, in general, a smaller impact, except in Rmania where they accunted fr 46 percent f the ttal decrease in infant deaths. In Bulgaria late nenatal deaths were respnsible fr 22-23 percent f the ttal decline in infant deaths, while in Yugslavia and the GDR they accunted fr nly 10 percent, and in Czechslvakia, the GDR and Hungary, arund 17 percent. During the 1975 t 1979 perid there was a great shift in the mst imprtant age grups causing the decline in infant mrtality amngst each f the cuntries. In Czechslvakia, the GDR and Hungary the early nenatal deaths caused 80-90 percent f the fall in infant mrtality. In Rmania and Yugslavia, hwever, the pst-nenatal deaths accunted fr 60-70 percent f the fall in infant mrtality. Pland and Bulgaria were in a middle psitin between these tw grups; the decline f bth early nenatal and pst-nenatal deaths played a great rle in the imprvement f infant mrtality. In Bulgaria early nenatal deaths caused 52 percent f the decrease and pst-nenatal deaths 33 percent, while in Pland early nenatal deaths caused 40 percent and pst-nenatal deaths 46 percent f the decrease. Because f the differences in definitins, instead f cmparing the early nenatal deaths amngst the cuntries, it is mre reasnable t cmpare the perinatal deaths, i.e. early nenatal deaths and late fetal deaths /Table 3./. Althugh there might still be uncertainties using this indicatr /due t the cmplete exclusin f fetal wastage fr a gestatin perid under 28 weeks regardless f any sign f life/ there are less prblems relating t the definitin f live birth. This is als reflected in the perinatal mrtality data because the differences in the levels and trends amngst the cuntries were smaller and in a mre lgical directin than fr the early nenatal deaths. In 1955 in the seven cuntries the perinatal mrtality rate varied frm 39 per 1 000 in the GDR and Hungary t 25 per 1 000 in Czechslvakia, i.e. the difference was under 60 percent. In Czechslvakia this rate might be lwer than the true value and thus the range smaller because f the registratin practices in that cuntry. The rates were 32-33 per 1 000 in Rmania, Yugslavia and Pland, and 30 per 1 000 in Bulgaria. During the ttal perid the imprvement in the perinatal mrtality rate varied amngst the cuntries. The rate declined mst in the GDR; as a prprtin f the 1955 value, in 1979 the rate was 37 percent in the GDR, abut ne-half in

275 Bulgaria, Pland and Rmania, tw-thirds in Hungary and Yugslavia, and 73 percent in Czechslvakia. At the beginning f the study perid the imprvement was smaller, but it incrased in the 1970s. Frm 1965 t 1979 the perinatal mrtality rate decreased by ne-third in the GDR and Rmania, and by abut 30 percent in Hungary and Pland, by 17 percent in Yugslavia, and by 12 percent in Czechslvakia. As a result f the different trends, the perinatal mrtality rates in each f the seven cuntries relative t ne anther changed. In 1978-1979 the perinatal mrtality rate was lwest in the GDR /14 per 1 000/; ihe rates in Bulgaria and Rmania were nt much higher /arund 15/ althugh fr registratin reasns they might be lwer than the actual values. The highest rates were in Hungary /24/ and Yugslavia /21/. Czechslvakia and Pland ccupied a middle psitin amngst the cuntries with rates f 17 and 18, respectively. S, in 1979 the difference between the maximum rate /in Hungary/ and the minimum rate /in the GDR/ increased t 70 percent; but even s it was lwer than that f the early nenatal deaths rate. Prbably sme f the differences in perinatal mrtality were due t cnceptual reasns, but even if these are nt cnsidered, it is likely that there wuld still be great differences in perinatal mrtality amngst the cuntries. At present it is a general view that the develpment f the fetus has the greatest influence n infant mrtality. Unfrtunately, in the seven cuntries investigated in this study there are n cmparative data n infant mrtality and the age f develpment f the fetus /gestatin perid/, and nly a few data are available n birth weight in fur f the cuntries /Table 4/. These data shw that the prprtins f lw weight infants brn with a weight less tha 2,500 grams differed amngst the cuntries. In 1978 the prprtin was highest in Hungary /10.5 percent/ while in Pland it was 7.6 percent. It Czechslvakia and the GDR if was much lwer, 6.3 percent and 6.6 percent, respectively. Since 1970 this percentage distributin has hardly changed except fr slight increases in the GDR /frm 5.9 t 6.6 percent/ and in Czechslvakia, and a small decrease in Hungary. The large differences in the prprtin f lw weight infants cntributes greatly t the differences in infant mrtality amngst the cuntries which is reflected by the fact that the weight-specific infant mrtality rates d nt shw the same differences as the general crude rates. This was illustrated best in Czechslvakia and Hungary where in 1970 the general infant mrtality was twthirds higher in the frmer than the latter, but there was nly a small mrtality surplus fr weight-specific rates in Hungary. By 1978 the «crude» mrtality in Hungary, cmpared t Czechslvakia, fell t ne-quarter, and fr each birth weight grup there was surplus mrtality in Czechslvakia f 10 percent fr the under 1 000 grams grup, 6 percent fr the 1 000-1 500 grams grup, 26 percent

276 fr the 1 500-2 000 grams grup, and 43 percent fr the 2 000-2 500 grams grup. Fr the ther tw cuntries, the GDR and Pland, the ttal number f lw weight infants can be cmpared, but their trends were als different with respect t thse f the crude rates. The differences amngst the cuntries were smaller fr the infant mrtality f nrmal weight births /brn with a weight ver 2 500 grams/. In 1978 the GDR was in the mst favurable psitin, while in Hungary the mrtality surplus was 33 percent, in Czechslvakia 50 percent, and in Pland 85 percent. Again, the rder f the cuntries is different frm that f the crude rates reflecting als the differences in the distributin f mrtality by birth weight. The imprtant rle f lw weight babies in infant mrtality is als prved by the fact that in each f the cuntries mst infant deaths were f babies with a birth weight under 2 500 grams. The prprtin f lw weight infants was lwest in Pland /53 percent/ which is cnnected with the higher infant mrtality fr birth weights ver 2 5000 grams; it was similar in Czechslvakia and the GDR /58 percent/ and was greatest in Hungary /68 percent/ because f the high rati f premature births. Since 1970 these prprtins have nt changed much. The nly small increase was in the GDR where the prprtin f lw weight babies amngst the infant deaths increased frm 51 t 58 percent. It is difficult t draw unanimus cnclusins frm the data n infant mrtality by causes f death since apart frm the cnceptual differences mentined abve, the results are affected by the varius practices f diagnsing the causes f death in the individual cuntries. Table 5 shws the distributin f infant deaths fr the majr causes f death in the seven cuntries in 1970/1973 in the case f the GDR/ and in 1978. Frm this data the cuntries can als be divided int tw grups. In the first grup f cuntries /Hungary, the GDR, Czechslvakia and Pland/ the prprtin f early infant deaths was relatively high. Mst deaths were due t «cngenital» causes, i.e. cngenital anmalies and perinatal causes. In the secnd grup /Rmania, Bulgaria and Yugslavia/ the prprtin f late infant deaths was high. It shuld be nted that in Rmania and Bulgaria the numbers f early deaths were very lw fr cnceptual reasns. It was difficult t analyze the data f Yugslavia because the prprtin f undefined causes f death was high /42 percent in 1970 and 29 percent in 1978/. Hwever, based n the knwn causes f death, Yugslavia might be in a middle psitin amngst the seven cuntries as the ratis f bth the endgenus and exgenus causes f death were high. Of the endgenus causes f death, the grup f perinatal causes plays an imprtant rle. In 1978 perinatal causes accunted fr nearly 60 percent f infant deaths in Hungary, 53 percent in the GDR and Czechslvakia and 44 in Pland. In Yugslavia, where the data was mre uncertain, this incidence was 35 percent,

277 in Bulgaria 28 percent, and in Rmania nly 20 percent. Since 1970 the relative prprtins f the grup f perinatal cause did nt change much in Czechslvakia r Hungary; the prprtin decreased slightly in the GDR and it declined by ne-tenth in Rmania while it increased by ne-tenth in Bulgaria and Pland. The nly significant change was in Yugslavia frm 1970 t 1978 when the prprtin increased frm 23 t 35 percent, prbably due t the «unknwn» causes, but even s the relative increase was mre than 50 percent. There are similar trends in the incidence f cngenital anmalies amngst the seven cuntries. In 1978 they caused ver ne-fifth f infant deaths in the first grup f cuntries /Czechslvakia, the GDR, Hungary and Pland/, but less deaths in the secnd grup f cuntries /7 percent in Yugslavia and 12 percent in bth Bulgaria, and Rmania/. Between 1970 and 1978 the relative incidence f cngenital anmalies did nt change in Bulgaria and Czechslvakia, thugh it increased slightly in the GDR and Hungary /prbably due t the decrease in the incidence f perinatal causes/. It increased greatly in Pland and Yugslavia, by 50 percent, and in Rmania by three-quarters. Fr the exgenus causes f death the trends amngst the cuntries are in the ppsite directin cmpared t the endgenus causes. This was mst evident fr the diseases f the respiratry system. The prprtin f infant deaths frm this cause grup was highest in Rmania and Bulgaria /46 percent and 39 percent, respectively/; it was relatively high in Yugslavia /15 percent/, as well as in Pland and Czechslvakia /each 13 percent/, and it was lwest in Hungary and the GDR /7-8 percent/. Frm 1970 t 1978 the relative incidence f this cause f death did nt change in the GDR r in Rmania /the cuntries with the lwest and the highest incidences, respectively/. It decreased slightly in Yugslavia /by less than ne-tenth/, and in Bulgaria and Czechslvakia /by ne-sixth/, in Hungary /by ne-quarter/ and in Pland /by ne-third, frm 20 t 13 percent/. Fr the grup f infective diseases the trends are similar fr all the cuntries. Their incidence was highest in Yugslavia /12 percent/, in 1978, and relatively high in Pland, Rmania and Bulgaria /6-7 percent/. It was lwer in Czechslvakia /under 1 percent/, in Hungary /3 percent/ and in the GDR /4 percent/. Since 1970 the relative incidence f infective diseases incrased by nequarter inpland, remained cnstant in the GDR, and fell by ne-quarter in Bulgaria and Czechslvakia and by ver ne-third in Hungary and Rmania. Table 5/a. shws a smewhat different situatin if the infant mrtality rates per 100 000 live births are cmpared fr each f the cause-f-death grups in bth 1970 and 1978 amngst the seven cuntries. The trends f the rates by the cause-f-death grups are the same as fr the percentage distributin, but in mst cases the differences are much greater. T summarize, there are great differences in the levels and trends in infant

278 mrtality by causes f death between the seven cuntries which participated in this study. These differences are mainly due t their varius levels f mrtality. It was difficult t cmpare the actual differences between the cuntries because f the variatins in definitins. Hwever, the differences fr the exgenus causes f death seem t be real and they explain in many respects the discrepancies in infant mrtality amngst the cuntries. Further imprvement f infant mrtality culd be achieved by the decrease f the exgenus deaths thrugh public health and scial measures. As a result the differences in mrtality between the cuntries wuld be reduced and the rates wuld differ less than thse f the ther Eurpean cuntries. Table 1. Infant Mrtality Rates, 1955-1981 /per 1 000 live births/ x _, German Czecn- Year Bulgaria.,. Demcratic Hungary Pland Rmania Yugslavia Republic 1955 1960 1965 82.4 45.1 30.8 34.1 23.5 25.5 48.9 38.8 24.8 60.0 47.6 38.8 82.2 54.8 41.4 78.2 74.6 44.1 112.8 87.7 71.8 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 27.3 24.9 26.2 26.2 25.5 23.1 23.5 24.0 22.2 19.8 20.2 22.1 21.7 21.6 21.3 20.5 20.8 21.0 19.7 18.8 17.6 16.6 16.8 18.5 18.0 17.6 15.6 15.9 15.9 14.0 13.1 13.1 12.9 12.1 12.3 35.9 35.1 33.2 33.8 34.3 32.8 29.8 26.2 24.4 24.0 23.2 20.8 33.4 29.7 28.6 26.1 23.7 25.1 24.0 24.5 22.5 21.1 21.3-49.4 42.4 40.0 38.1 35.0 34.7 31.4 31.2 30.3 31.6 29.3 55.5 49.5 44.4 44.0 40.9 39.7 36.7 35.6 33.8 33.6 32.8 x See Figure 1, Annex I. indicatesfiguresnt available

Table 2. Early Nenatal Mrtality Rates 1955-1980 / per 1 000 live brn A 279 Year Bulgaria GDR Hungary Pland Czechslvakia Rmania Yugslavia 1955 1960 1965 1970 1975 1979 1980 17.1 9.9 8.4 9.0 9.0 7.3 12.8 10.5 14.6 13.3 13.9 11.7 19.9 16.2 12.8 11.2 9.7 7.3 6.9 22.3 22.1 23.6 24.5 23.3 16.1 15.3 19.3 16.9 13.7 14.3 12.0 10.6 14.4 8.8 6.2 11.0 7.7 6.8 6.4 20.5 18.2 18.0 15.5 14.2 13.1 x/ 1978 fr Czechslvakia, Rmania and Yugslavia Table 3. Perinatal Mrtality Rates 1955-1980 / per 1 000 live births / Year Bulgaria GDR Hungary Pland Czechslvakia Rmania Yugslavia 1955 1960 1965 1970 1975 1979a/ 1980 29.6 22.3 18.3 19.0 17.1 14.5 24.8 20.9 22.8 20.7 20.2 18.2 38.7 32.5 25.8 21.8 17.6 14.3 13.6 38.7 35.5 35.0 34.5 31.6 24.3 23.1 33.2 29.6 25.0 24.4 21.0 17.3 32.8 25.0 20.7 24.4 18.0 15.9 15.2 31.8 28.6 28.1 24.9 21.8 20.7 x/ 1978 fr Czechslvakia, Rmania and Yugslavia

280 Table 4. Infant Mrtality Rate by Birth Weight / per 1 000 live brn / Birth weight / grams / Czechslvakia 1970 1978 German Demcratic Republic 1970 1978 Hungary 1970 1978 Pland 1978-1000 1000-1499 1500-1999 2000-2499 -2500 2500 + Ttal 972 641 238 66 200 10 22 1000 579 206 60 173 9 19 160 114 10 6 19 13 970 647 269 67 230 13 36 905 546 163 42 162 8 24 690a 141 155 11 23 a/ 600-900 grams - indicates figures nt available Table 5. Infant Deaths by Majr Causes, 1970 and 1978 Causes f death Bulgaria Czechslvakia GDR Pland Hungary Rmania Yugslavia Infective diseases Diseases f nervus system Respiratry diseases Cngenital anmalies Perinatal causes Other natural causes Accidental Ttal Infective diseases Diseases f nervus system Respiratry diseases Cngenital anmalies Perinatal causes Other natural causes Accidental Ttal Percentage Distributins 1970 a / 7.4 1.8 46.2 11.5 24.4 5.4 3.3 100.0 5.6 2.3 38.7 11.8 27.6 10.5 3.5 100.0 1.2 2.6 15.3 19.7 51.0 7.7 2.5 100.0 1978 0.9 2.5 12.8 21.1 53.0 5.0 4.7 100.0 4.2 4.2 6.8 19.6 57.0 5.1 3.1 100.0 4.2 2-7 7.0 22.6 53.4 7.1 3.0 100.0 5.2 3.4 10.6 17.1 60.7 2.0 1.0 100.0 3.2 3.4 7.9 21.2 58.6 3.6 2.1 100.0 5.9 3.7 20.1 15.0 39.9 14.1 1.3 100.0 7.5 3.3 12.8 22.1 43.7 8.2 2.4 100.0 12.9 4.1 46.4 7.1 21.2 5.6 2.7 100.0 7.1 4.4 46.3 12.3 19.5 6.4 4.0 100.0 11.3 1.8 16.8 4.6 23.0 41.8 0.7 100.0 11.6 1.3 15.4 7.1 35.1 28.6 0.9 100.0 a/ 1973 fr the GDR NB: The specified cause-f-death grups pertain t items f the Internatinal Classificatin f Diseases, 9th Revisin.

281 Table 5/a. Infant Deaths by Majr Causes, 1970 and 1978 Causes Bulga- Czech- Hun-.. Rma- Yugf death ria Slvakia UUK gary ana nia slavia Infective diseases Diseases f nervus system Respiratry diseases Cngenital anmalies Perinatal causes Other natural causes Accidental Ttal Infective diseases Diseases f nervus system Respiratry diseases Cngenital anmalies Perinatal causes Other natural causes Accidental Ttal a/ 1973 fr the GDR * Per 100 000 live births Infant Mrtality 202 48 260 313 666 150 91 2 730 134 56 929. 284 662 250 83 2 398 Rate by 19702/ 27 58 338 435 1 129 171 55 2 213 1978 16 47 240 396 994 94 90 1 877 Cause f Death* 66 66 105 305 886 79 48 1555 55 35 91 295 699 94 39 1 308 186 123 380 613 2 178 1 74 35 3 589 3 77 82 193 517 1427 88 52 2 436 2 195 122 667 496 324 469 44 317 168 74 288 497 983 185 54 249 636 201 2 296 351 1050 275 134 4 943 216 133 1402 371 589 196 120 3 027 629 100 932 255 1 277 2 318 35 5 546 414 47 546 254 1 250 1013 33 3 557

283 TRENDS OF PERINATAL AND INFANT MORTALITY IN SWEDEN AND IN OTHER NORDIC COUNTRIES AND THEIR ASSOCIATION WITH DEMOGRAPHIC AND SOCIO-ECONOMIC VARIABLES Anne-Marie BOLANDER Statistics Sweden Stckhlm Infant mrtality has always been regarded as a gd indicatr f the sciecnmic status f a cuntry, a regin r a ppulatin grup. It may therefre seem as a paradx that the main reasn fr the extremely lw perinatal and infant death rates in the Nrdic cuntries prbably is that they have managed t eliminate r anyway decrease the influence f sci-ecnmic differences as regards antenatal care, bstetrical and pédiatrie surveillance f the delivery and access t sufficient nenatal care afterwards. There are evidently ther reasns fr the steadily decreasing death rates in the first perid f life. Sme f them are results f a changing fertility pattern, thers f a well functining family planning system, cmbined with the legal right f early abrtin. But befre I g int such details, I will try t give an utline f the mrtality trends in early life in fur f the Nrdic cuntries. Iceland with less than 5000 births and 50 infant deaths a year has nt been included fr numerical reasns, althugh its lw levels and favurable trends in this dmaine are well cmparable with thse f the fur ther cuntries. Trends and traits f perinatal and infant mrtality in fur Nrdic cuntries The verall trends f infant mrtality since the 1920s are demnstrated in figure 1 and table Í. The differences between the fur cuntries becme smaller and smaller the lwer the rates are, here illustrated n a semilgarithmic scale, taking int accunt the relative differences. The leading psitin f Sweden, btained and maintained since the last wrld war, seems nw t be threatened by

284 i s s s 's s s ag s a g ~ s I 1 O Cs 5b U.! / / 1 ï 1 / / # 1 / / / /1 / / 1 1 y 1 /I / i r i 1/1 i / f / / A II i I 1* (TALin s ' ** * / 1/ y / / i / i / n/l V/ / / /!1 Os S -2 1 ^11 D Ü I S 8 S 2 S S

285 3 & "5 s 2 ^r M in 00 r4 v ^ ô vi ^ c r>* vi ^' ô r^ ri ï r-* < w m «9 m il r j í vj «í ô r j í vj «*-< m Os r* ON <n - d O Ö O I * <O - irt O* ÍN **1 î en r4 «ci ri NlN -- T **ï «-^ ^* O * *í> r-^ r-^ ri ri có ri ri -! <- «m m ^r N * -OM(nq» in r* -* s j _4 «<-ï m d ri ri ««-^ d «-««-d a 1 a îrr u a Ci» s Os s vi rt * w r» Os ^ fí ví ^ ^T f*í ri ri r r< t r* r~ r^ vi r^ * vi ^ c*î ri ri ^; * *rt * # 00 00»n ^f vi ^ ri ri jtnic^mín«^ \in<n<n^nn *ñ ri -4 J2 -vtv»\p«r 3 Os O\ O\ O* O* w-t m O «n <ns0vr»r^ MV0O s Os Os O* SON ^ONOsOsOsONOsC

286 PER 1000 BIRTHS prenatal r late fetal mrtality 40 30 DK SF S N >ERI NATAL.MORTALIT 20 10 9 8 7 6 SF DK S N LATE FETA MORTALITY te v NORWAY DENMARK FINLAND SWEDEN NORWAY DENMARK SWPOFN FINLAND 1951/55 1956/60 1961/65 1966/70 1971/75 1976/80 FIGURE'2. Perinatal and late fetal mrtality in fur nrdic cuntries, 1951-1980 Late fetal deaths (stillbirths) and early nenatal deaths, frming tgether perinatal deaths, per 1000 births = perinatal mrtality Late fetal deaths (stillbirths after 28 weeks f gestatin) per 1000 births

287 1000 LIVE BIRTHS 1951/55 1956/60 1961/65 1966/70 1971/75-1976/80 FIGURE 3. Mrtality in different parts f the first years f life in fur nrdic cuntries, 1951-1980 Deaths rates per 1000 live births by 5-year perids

288 Finland. The ranking rder between the cuntries is als demnstrated in figures 2 and 3 with the trends f perinatal and infant mrtality, split up in parts accrding t age at death. Pssible explanatins t these shifts have been advanced recently and will be cmmented n later. Sme ther traits, hwever, need further cmmentary, such as the Nrwegian trend f late fetal mrtality, shwing a favurable level and trend until the end f the 1950s, then fllwed by a very slwly descending slpe. One is inclined t attribute this t the fact that fetal deaths in Nrway are reprted already frm the 16th week f gestatin, cmpared t the 28th in the ther Nrdic cuntries. The late fetal deaths, hwever, are cunted frm 28th week accrding t the internatinal reccmendatins als in Nrway. Anyhw, this prcedure may cause a mre cmplete registratin f stillbirths in Nrway than in the ther cuntries, and might even bring abut a mre thrugh registratin f live births at a gestatinal age f less than 28 weeks. These kinds f prblems make internatinal cmparisns smewhat dubtful. The respnsible Nrwegian pediatricians deny that the reprting system is the main cause f the differences between the Nrwegian stillbirth rates and thse f ther Nrdic cuntries as there are ther factrs, such as the birth weight distributin, which indicate a true excess rate in Nrway. Anther feature, bserved frm figure 3 n infant mrtality, is the recent change f the trend f pstnenatal mrtality, bvius in all the cuntries except Finland. One f the explanatins is that the intensive care during the nenatal perid prlngs life and pstpnes death t the secnd mnth f life f infants nt viable in the lng run. Fr Sweden anther explanatin culd be that the large prprtin f infants t immigrant parents, especially frm suthern Eurpe and Asia, may run a higher risk f dying in the pstnenatal perid, cmpared t infants f Swedish parents, than in the nenatal perid, when they are mre supervised and therefre receive the same prtectin by the health care system as the Swedish babies. There is als an increasing number f mthers with narctic and alchlic prblems in Sweden, wh are less accessible fr preventive care, althugh intense effrts have been made in rder t give them extra supprt. Prblems in internrdic and internatinal cmparisns f perinatal mrtality The fact that differences in registratin f fetal deaths have caused prblems in the cmparability f Nrdic stillbirth rates has already been mentined. These kinds f prblems have als cmplicated internatinal cmparisns and made them smewhat dubtful. Anther interesting illustratin f such difficulties was given in the WHO study f Scial and Bilgical Effects n Perinatal Mrtality, based n the births in 1973. The perinatal death rates, divided int late fetal and early nenatal rates, are illustrated in figure 4 and table 2 fr the eight

289 I ON ^ vi tñ g 11/3 V^ 00 Vf f«i M ~ VO VO a 3 00 t-; ó vi J n (»1 ; ; s-. : m 2 r- t _ c s <J 3 <s > «n (S " i \ 73 rt S 75 'S en; is i c Tí CPS 00 «s S h* u aa 2 X u T3 Cnt V3 2 jy Ti ^ U O M" r* «** h; O\ ^ O\ m N <s n ~ Tf (ij fi O^ Sj.. t * ** rñ N O 00 00 î vd VO vi " s 11.6 141 - ^^ ^^ a id rta!lity: S tal m c Peri c fet S S rt Uli: cu CN u eat a 73 i a cn) U Tab Mal S û 2 weu cd i-j I IA c 73 z u e 1-3 tu 1 00 s a c

290 M 000 30 HUNGARY M i CU1A AUSTRIA INGLAND 1 WALES M r : : % \ \\ I" : " JIL DEATH LAU t»blt NEONATAL RATE FETAL 0167 121 3» 187 hun hn tn hn F a M \ ;; f 1 IBI r LATE FARLYNfONAfAL FETAL (H6> O I 23 24 167 M F : i 1*1 E FETAL hua 1! : ij H 11 In M \ I-\ : l rf i I iiî! ' El!l LATE ÍACUfJltQüA^^» FETAL 0-167 0-21 24-167 NEW ZEALAND USA SWEOEN a DEATH «ATE 4.ATE f ARLY NEONATA LATE r>rly NEONATAL LAT gably FETAL & O 123 24 167 FETAL 0-16) O ' 3 24 167 FETAL 0-16J h h h h t il, E Y 1 23 24 167 FETAL O 161 hn hn hun i_ul O I 2Í 24-167 h h FIGURE 4. Late fetal and early nenatal mrtality by sex and age at death in 8 cuntries, 1973

291 participating cuntries by male and female rates with a subdivisin n age at death fr the early nenatal grup. The different size f the late fetal bars cmpared t the bars shwing the death rates during the first week f life and especially during the first hur and day pints at an unequal interpretatin and applicatin f the internatinal definitin f live births. One way f aviding the effect f such lack f cnfrmity in the cmparisns is t use perinatal rates instead f splitting them in pre- and pstnatal death rates. Even the definitins f early and late fetal deaths, based n such an arbitrary variable as gestatinal age, can cause prblems, shwn by the Nrwegian example with a mre cmplete registratin f the brder line cases arund the 28th week f gestatin. Perhaps a mre secure indicatin f gestatinal age can be achieved by ultrasnic diagnstics in the future, imprving the cmparability f late fetal mrtality. An interesting bservatin, als illustrated by figure 4 and table 2, is the different sex pattern in prenatal mrtality with almst equal male and female rates, cmpared t the male excess mrtality in the early nenatal perid. A strng male excess in the sex rati f late fetal mrtality may indicate that the classificatin f live brn children, nt surviving their first day f life, may be falsely reprted as late fetal deaths. This is bviusly the case f Japan, where the graph clearly demnstrates an underreprting f deaths in the first hur and day f life, prbably cmpensated fr by t high numbers f late fetal deaths, als indicated by the unexpected male excess in the Japanese stillbirth rate. This shift f births frm the livebrn t the stillbrn grup brings abut a deficiency in the nenatal death rate, als making infant mrtality rates smewhat t lw. As regards the Nrdic cuntries this type f misclassificatin,. causing impairment in the cmparability, seems less prbable as practically all the cnfinements take place in maternity hspitals with a thrugh medical registratin. Sex differences in prenatal and infant mrtality It has already been pinted ut that the sex pattern can be used t detect misclassificatins f live- and stillbirths, as demnstrated in the WHO study, but the main purpse f the graph has been t demnstrate sex differences, based n data frm the riginal tabulatins f the study. Table 3 is taken frm a new editin f the 1978 reprt, hwever, recently published in a revised and mdernised frm as a supplement t the Saudi Medical Jurnal 1983. Except fr Japan the sex pattern is very similar in the participating cuntries with equal male and females rates fr late fetal deaths and a marked male excess fr early nenatal deaths, which seems less prnunced in the deaths f the first hur f life. One f the attempts t explain this pattern refer t the different hrmnal set up f newbrn bys and girls, where the by is n lnger prtected by his mther's hrmnes as in his uterine life. Anyhw, the higher survival rates f girls seem t cunterbalance the male excess in the sex rati f live births, at

292 PER 1000 LIVE BIRTHS 40 MALES FEMALES 20 " :^ 10 * S 4 v X x^* \ PERINATAL 1 MORTALITY INFANT MORTALITY EARLY NEO- NATAL MORTALITY 2 1 03 > ^ \ POST-NEO- NATAL 'MORTALITY LATE NEO- XATAL MORTALITY,t 1MMU 19MM0 1»M/70 1971/75 197C/M FIGURE 5. Trends f infant and perinatal mrtality in Sweden, 1951-55-1976-80 Per 1000 births

293 PER 1000 LIVE BIRTHS 10 P0STNE0NATAL DEATH RATE LATE NEONATAL DEATH RATE EARLY NEONATAL DEATH RATE PER 1000 BIRTHS FIGURE 6. Late fetal and infant mrtality in Sweden, 1976-80

294 PER 1000 LIVE BIRTHS 3 7th-12Ui anth 2ntf-Cth anth 8th-28U«diy lit-7th d*y Stillbirth! r L*te fctil deaths fr«28th week f.gestatin PER 1000 BIRTHS FIGURE 7. Mrtality befre and after birth in fur nrdic cuntries, 1980 Infant mrtality in the early nenatal, late nenatal and pstnenatal perid f life, the latter being divided int the 2nd-6th and the 7th-12th mnth f life. The death rates are cunted per 1000 live births Late fetal death rates are cunted frm the 28th week f gestatin per 1000 live and stillbirths

295 PER 100 000 LIVE BIRTHS XVII ACCIDENTS REMAINDER OF DISEASES VI'.NERVOUS SYSTEM I: INFECTIONS VIII:RESPIRATORY 300 XIV:CONGENITAL MALFORMATIONS 200 100 XV:CERTAIN PERI- NATAL CAUSES DENMARK. FINLAND NORWAY SWEDEN FIGURE 8. Infant mrtality in brad grupings f causes f death in fur nrdic cuntries, 1980

296 least t sme extent. The trends and the sex differences f male and female mrtality in the perinatal perid and in different parts f the infant year can be seen in figure 5, shwing a marked male excess. The sex differences are in this cntext nly demnstrated fr Sweden (figures 5 and 6) but the picture is prbably the same in the ther Nrdic cuntries. Thanks t the semilgarithmic scale f the curve chart the changes in the sex pattern by time are easily detected, as any changes in the sex rati are indicated by a divergence in the parallelism f the curves. There is a male excess mrtality in all parts f the infant year, evidently less prnunced in the late and pst-nenatal perids and mre bvius in the early nenatal perid. In the late fetal mrtality, demnstrated in figure 6 by the bars belw the base line, the male excess is very slight. These sex differences make it essential and sensible t split the perinatal mrtality int late fetal and early nenatal death rates, especially when such risk factrs as birth weight and preterm delivery, which have marked sex differentials, are studied. The birthweight f bys are in general higher than that f girls. Bys have als a higher weight-specific nenatal mrtality rate whereas the late fetal mrtality seems mre independent f weight differences (Karlberg, Ericsn, 1979). The same type f bar-illustratin f the perinatal and infant mrtality fund fr Sweden in figure 6 is given fr the Nrdic cuntries in figure 7 withut specificatin by sex. Sme characteristics f the Nrdic rates It is true that the Nrdic cuntries can be regarded as an entity in many health plicy aspects. The similar pattern in perinatal mrtality with the exceptin f the earlier mentined slight differences in the late fetal death rate in Nrway gives evidence f a well functining maternity and child health system, leaving rm fr nly small sci-ecnmic differences. Slightly mre prnunced are the differences in the pstnenatal mrtality, althugh almst neglectable in internatinal cmparisns. With the traditinal divisin f the first year f life in early, late, and pstnenatal perids, it is easy t verlk hw few f the deaths that take place in the ten last mnths r in the secnd half f the infant year, as pinted ut at the tp f the bars. T sme extent the pattern is als reflected in the bars f figure 8, where infant mrtality is given by cause f death by sme f the ICD main sectins. The lack f cmparability is bvius, hwever, t judge frm the different size f the remainder grup in Nrway and even in Denmark and frm the nncnfrmity t the nenatal mrtality level in Nrway f the cngenital malfrmatins. Cause-f-death cmparisns n an internatinal level is a dubtful undertaking in many ways and even within a cuntry the causecding creates prblems in cmparability. A Swedish investigatin f the 1979 perinatal deaths pints at 10 t 15% f the deaths being impssible t cde n the

297 9 SI 3 8 8 FIGURE 9. Ttal and age-specific fertility rates in Sweden by 5-year age-grups and 5-year perids in the 20th century

298 AGE-SPECIFIC FERTILITY RATE PtrlOOO watn TOTAL FERTI- LITY RATE 2000 1500 1000 DENMARK FULANO NOUAT SUCK* FIGURE 10. Age-specific fertility rates in fur nrdic cuntries. 1980

299 bases f the medical birth certificate, the death certificate and the malfrmatin register, withut access t hspital jurnals and autpsy prtcls. The rle f demgraphic changes It has ften been stated that the decline in perinatal mrtality t a great extent is the result f demgraphic changes such as shifts in the age-distributin f mthers and a much lwer birth rder distributin than befre the time f efficient family planning. Undubtedly there is a great change in the fertility pattern in Sweden, as demnstrated in figure 9 by the ttal and age-specific fertility rates by five-year perids frm the beginning f the century. There has evidently been a strng cncentratin f maternal age t 20 t 35 years with very few births n either side f these limits. An attempt t estimate the impact n perinatal mrtality f the tw kinds f changes in the fertility pattern, maternal age and parity, was dne in Sweden (Meirik, Smedby and Ericsn 1979) sme years ag. Starting frm the births in 1953/55,1963/65 and 1973/75 the authrs calculated the influence f the cncentratin f maternal age and the lwering f birth rder n the perinatal mrtality t be 9% f the decrease frm the first t the last perid. The percentage distributin f births in Sweden in these perids accrding t age f mther and birth rder in table 3 is taken frm the abve-mentined article, which clearly demnstrates the enrmus change in the fertility pattern in Sweden frm ne perid t anther. In relief t that stands the decrease in perinatal mrtality due t these changes, f less than lov. It is bvius that the decline can nly be explained t a minr extent by changes in the fertility pattern. Similar changes have taken place in all the Nrdic cuntries. The age-specific fertility is illustrated in figure 10. Mre detailed infrmatin fr thse wh are interested in the Nrdic ttal fertility and abrtin trends, are given in tables 4 and 5 and figure 11 n reprductin and legal abrtins. Influences f maternal age and birth rder n perinatal mrtality in Sweden In rder t shw the effect f maternal age and birth rder n perinatal mrtality, data frm the Medical Birth Register f Sweden fr the years 1977 t 1981 were cmpiled and the apprpriate death rates and percentage distributins were cmputed accrding t these tw variables, separately, shwn in table 6. They are presented in the frm f graphs in figures 12 and 13 fr maternal age and in figures 14 and 15 fr birth rder r parity. The histgrammes illustrate the prprtinate distributins f ttal births, late fetal deaths and early nenatal deaths and cumulative percentages are printed n the tp f each age grup r birth rder bar. The semilgarithmic curves represent the perinatal, late fetal and early nenatal death rates accrding t maternal age and birth rder, respectively. The distributin f births by age f mther (figure 12) shws that early pregnancies, belw the age f 20 years, are very rare in Sweden with a percentage

300 UtHRAKK r 1 RIAHU HUKHAT )NtUtH M 30 um.-. n i- - i,,,,,.., -,, jv 25 25 20-1 1 1 t.,......a 20 J5 _.... 1. 15 10 _., J.. _. i,.. _., 5 j, J S i? i l i t n i n i i n i l l í t i i í t i i i i i AGE IS- 20-2S- 30-35- 40-15- 20-25- 30-35- 40-15-20-25-30-35-40-15- 20-25- 30-35- 40-19 24 29 34 39 44 19 24 2) 34 39 44 19 24 29 34 39 44 19 24 29 34 39 44 AGE-SPECIFIC AUKTION»ATES PE«1000 VOU IN FOUR NOROIC COUKTRJES. 1980 400 OENHARK FINLAND NORWAY SWEDEN 400 300 300 200 200 100 100 1975 76 77 78 79 80 75 7Í 77 78 79 80 75 76 77 78 79 80 75 76 77 78 79 80 FIGURE 11. Trends andlevels jlegal abrtins in furnrdic cuntries, 1975-1980, in numbers f legal abrtins per 1 000 live births

Table 3. Percentage distributin f births in Sweden 1953-56, 1963-65 and 1973-75 by age f mther and birth rder 301 Perid Age f Birth rder Ttal mther 1 2 3 4 5 1953-55 -19 20-24 25-29 30-34 35-39 40-6.4 15.4 11.0 4.8 1.7 0.4 0.8 8.0 10.9 7.9 3.0 0.8 0.0 2.0 4.8 5.3 3.0 1.0 0.4 1.6 2.3 1.9 0.8 0.1 0.8 1.8 1.9 1.4 7.2 25.9 29.1 22.1 11.5 4.4 Ttal 39.7 31.4 16.1 7.0 5.9 100 1963-65 -19 20-24 25-29 30-34 35-39 40-9.5 18.3 10.3 3.0 1.0 0.3 1.2 10.1 12.1 6.3 2.1 0.5 0.1 2.2 5.1 4.8 2.4 0.7 0.4 1.5 2.0 1.5 0.5 0.1 0.6 1.2 1.3 0.8 10.8 31.1 29.6 17.3 8.3 2.8 Ttal 42.4 32.3 15.3 5.9 4.0 100 1973-75 -19 20-24 25-29 30-34 35-39 40-6.8 19.9 14.6 3.8 0.8 0.1 0.6 10.0 16.8 6;6 1.3 0.2 0.0 1.5 5.7 4.5 1.3 0.2 0.1 1.1 1.4 0.7 0.2, 0.0 0.3 0.6 0.6 0.2 7.4 31.5 38.5 16.9 4.7 0.9 Ttal 46.0 35.5 13.2 3.5 1.7 100

302 c- 1 S O i t ^ * «s r» r-» Oi ^ «n m v «^ vt n r* Q - «i i> OCONPIOOOM t O O * r-oo r-r- r< # rm <s s s M M r» * -< ^ *n a q a fn<nt^tma ^r r^ r-_ f^ «s N M q t «c "^ Ç " O H " ^ N M rj r>' H in» «rj r^ ^ O V vi Q d ri ^' a " t^ «r~ r- «m 3 r*«i«cirt«n»n w* r» r- r* c- «n «^,>?,??, S? 1 I I! "TS 2 >> --«OÓÓO cis3?; «0 0 5 S Q -qf <qf so %D 7 91 9 80 4 65 1 55 9 54 M 0> ri 1- V 00 fi r* viincn-^ 55ÍS2**«SRSS^"'"' * * * ^ m 2 108 2 135 7 O 116 87 S 3S 06. 14. 14. m tn M t ««r* ^ s 7 6 123 96 1 117 D 105 00 $ 105 ^ * r* D 6 1 82 86 7 9 67 2 64 70 KS325 ^ O s HOIOMMOO *WMh;0 00 0 n«00o0n(n 00 O tn «O 00 OO I si* i 3 «S I s - c I U I = i. 1 "S S?I I A QOQOvtQ 'C jlljl 3ïS' S ; O S. -.. Î&Ç-n' 0 -'«

303 N «s r-;»* > N it 5 P. "î *? î **. ) * f*l O\ f* f«j ^J Os > VO -»«M M ^f * <O I M f*l fï f*> <*l **1 fl ev>minmm i-r» r» «v \ Qi ^ t «n«'» f; r- t»er-_ ««xi ri ~ i! \»» ^ 't se i-^ wi 05 <n «n î ^ i n ^ r r-^ r-' v r~' ô ô 000090 ; 5i «00 00 00 t- t-; i wi * 1*" S»JN«iq «nq«0-0 t»1nmt- TJTONCSOOOOO Ovíjjj rj t~v*«ñri!t~'i~>«ncñ r^r^c^ícj «N t- N <t n íl! l«t-_ i; M in 00 «i r< m 00 < a - 00 r* v M q j ^ «s N is2>r <s w» v O «n 1 * wr- <n ri en m m m <3 m 4 *^i s^i *^* ^ * ^rfl *»* ^*4 * 'Ï CO

304 s: S a 1 8 G CO I m O O O O s I I 00 O VOO <0O ^ ^ - H < ics O O O O O có 00 n VO O -H i/im r»»n 't -^SN"' rí > - H T t O i < Or SE O,,: v 00 v «*1 N *» v <rt -^ v «.S TO c^ s -s. Il S X) <L> c c II crt i-i u X> a c 4j cs VO Ü rt H 1> *«S 2 1 u. Xj? a u4> 'S. O u Ö x: O 'S bo rt >. ni S ON! Si ös 2! <t OO 00 00 s 36 v «VO rí (S Ov n r) f^ «5 -i. * - M m «> r ON<O *O<O 3 P '-" OÍ 1^ Eír-- gi>: 2^ 2t^ N. N rí n vo v 00 O q " es r» VO VO ó rn "O 4.0 u X) *: xi 7s i e >. O 3 rs II = 9 =S»-g = S ' 2 s S ; O 3 " 2 «E -S cae c3es3cae>3iae'i<-'(-ir-'" 2 «I w 4 c u S5 O 1 * Tfí CU 2 5 8 CU.t Si I VO n 00 N i ë.j ë.w 8.

305 ca et O V G S I OO O O = 8 S 1O «-<t c q d q d O II II II es a. 3 \ D T3 2 fi VO O r- «S fi q 00 M> C x; u t: "a.s u 1) (Z) Xj «ri fi f i s f> 00 (S " t' d C c3 73 ^ 1 v ON fi G eu O ti 5 c 1. s _ ta "O c S S -g XI -, (S fi r- O «s f» f-! r~ ;_; fi fi fl fn fi ON q «ri fi.ß 73 1 «5 5-2 Xt «.tî VO u X> J2 'S. >. S E «H «S x

306 f nly 5 fr the last 5-year perid, seemingly a steadily decreasing prprtin. Childbearing after the age f 35 years is slightly mre cmmn, i.e. 8% f ttal and live births. Such pregnancies are a bit mre risky, hwever, with 12% f the stillbirths and 10% f thse early nenatal deaths, wh were brn t mthers f 35 years r lder. Only 1% f the ttal births belng t pregnancies f mthers f 40 years f age and lder cmpared t 2% f the still-births and 1.5% f the early nenatal deaths, i.e. the deaths during the first week f life. As can be seen frm the death rate curves (figure 13) the lwest perinatal mrtality is in the maternal age grup 25-29 years, where als the highest prprtin f births are fund. The death rates in the last maternal age grup are based n nly a few deaths p«r year which explains the use f dtted curvelines. Late fetal mrtality increases faster by maternal age than early nenatal mrtality. The pattern is very similar fr the risks accrding t birth rder. This is mainly explained by the strng crrelatin between these tw variables. Undubtedly the mst risky cases are the nes f first babies in late pregnancies, but it shuld be emphasized that this is a very selected grup. Cmpared t ther cuntries Sweden seems t have a lw risk gradient accrding t maternal age and birth rder and als a lwer relative frequency f births in the lwest and highest maternal age grups. Births f higher rder than 2 are als relatively few and nt very risky (Cf. figure 14 and 15)., The cncentratin f the births t a relatively narrw age span f fecundable wmen has had a very great effect n the reprductin rate, thugh its impact n the perinatal mrtality has been f less imprtance. The factrs that have cntributed a great deal t the decrease in fertility, tgether with the bvius desire t have fewer children per family, are the generally recgnized and widespread use f cntraceptives t btain an efficient birth cntrl and the pssibility f crrecting failures thrugh legal abrtins. The result in the Nrdic cuntries, where induced abrtin became free and legalized in the early part f the 1970s, has been a decreasing number f births far belw what is needed fr full replacement and pssibilities f planning the cnfinement t a cnvenient time f the year, preferably t the spring mnths, as well as t a suitable age f the mther. In Sweden the attitude f almst all wmen is nt t have childen, until they have a permanent jb. This in turn may in times f unemplyment cause sme difficulties at a certain age t get jbs that enables them t get paid maternity leave after sme time. If they pstpne their childbearing t lng, n the ther hand, this may create prblems in their family life and may als have the effect that a secnd child never is brn. It is very cmmn in ur Nrdic cuntries fr wmen t renunce their jbs in rder t stay at hme and take care f their children except fr the paid r subsidized time f leave accrding t the law, the length f which varies very much frm ne cuntry t anther.

Cumulative percentages are given alng each curve x 35 30 25 20 15 10.' a.sy- -.., h i ; 5.02/ i : i 69.4 X A \ \ \ L92.2X \ ft \ 100.02 1 r». AGE OF MOTHER-19 20-24 25-29 30-34 35-39 40-44 45* X in?n IS in «i 30.3X/ t i,. /. 1 i ; / S. 64.5 2 * TOTAL BIRTHS 99.OX S \?9. 91 n : r+ AGE OF MOTHER-19 20-24 25-29 30-34 35-39 40-44 45* X 30 / 34.3 Xy h 15 10 i i / i 6.92/ i \ \87.6X ; i \ LATE FETAL DEATHS \97.8X! \ : ^67.7X \ EARLY NEONATAL DEATHS A \90.3X \ : \ \98.5X!! " *! ^99.82 i vl^_j.x AGE OF M0THER-19 20-24 25-29 30-34 35-39 40-44 45* FIGURE 12. Percentage distributins f ttal births, late fetal deaths and early nenatal deaths by age f mther in Sweden, 1977-1981 307

308 Per 1000 60 40?n 10 8 6 pm» Si y 4 1 AGE OF HOTHER-19 20-24 25-29 30-34 35-39 40-44 45+YEARS FIGURE 13. Perinatal, late fetal and early nenatal mrtality by age f mther in Sweden, 1977-1981

309 Cumulative percentages are given alng each curve It v< M O 1 bj Z >- _J AC «t UJ ^ M 40 M 4 iuj d I m "+*?. DO s* ^ * M\92.6X CD en»«r» í / : [ TOTAL BIRTHS M O en FIGURE 14. Percentage distributins f ttal births, late fetal deaths and early nenatal deaths by parity in Sweden, 1977-1981

310 Per 1000 R0 60 40 20 PNM 10 8 6 4 ^ * *. > Z~ / / LFM ENM? 1 PARITY 1st 2nd 3rd 4th 5th- Perinatal deaths per 1 000 births pnm ^. Late fetal deaths per 1 000 births lfm _, Early nenatal deaths per 1 000 live Births enm FIGURE 15. Perinatal, late fetal and early nenatal mrtality by parity in Sweden, 1977-1981

311 Hw t measure sci-ecnmic and ther differences in maternal and child health in cuntries with lw perinatal mrtality and few deaths All these demgraphic changes and scial measures in the health care system, aiming at a better health f mther and child, will nt be dealt with here, as the effect n perinatal and infant mrtality prbably is t small t be detected, at least in a shrt perspective. Sme studies in Sweden have clearly demnstrated the difficulty t use fetal and nenatal death rate t indicate sci-ecnmic differentials in the ppulatin. In general such measures have t be cmbined with data n birthweight and gestatinal age t increase the sensitivity and give analytical supprt t the cnclusins in cmparisns where perinatal mrtality is t crude an index t measure health plicy effects and results f imprvement in antenatal care, delivery and care f the infant. In rder t achieve mre infrmatin abut the relatin between birthweight and perinatal mrtality and als between gestatinal age and the crrespnding rates the same surce f data fr 1977-1981 as fr the maternal age and parity was used t cmpile and cmpute the apprpriate prprtinate distributins and death rates, shwn in table 7. The graphs accrding t birth weight are presented in figure 16 and 17, the frmer shwing the percentage distributins f ttal births, late fetal and early nenatal deaths and the latter the crrespnding deathrate curves n a semilgarithmic scale. The histgram n ttal births clearly demnstrates a cncentratin f the cases t a birthweight between 3000 and 4000 grams. Only 4.4% f the births weigh less than 2500 grams and n mre than 3% weigh 4500 grams r mre. Only 2 per 1000 have a lwer birthweight than 1000. Of the stillbrn children this weight grup represents 8% and f the early nenatal deaths almst 20%. Abut 25% f the late fetal deaths and hear 40% f the first week deaths weigh less than 1500 grams. The risk cnditins accrding t birth weight can als and preferably be studied frm the death curves f perinatal, late fetal and early nenatal mrtality. Half f the live births f less than 1000 grams survive their first week f life. The prprtin f stillbirths in the lw weight grup f ttal births is 1 f 5. One shuld expect arund the same rate as amng the early nenatal deaths, hwever. The explanatin is prbably the lack f cmparability between registered live births and late fetal deaths r stillbirths, where the frmer nes, thse alive at birth, are registered irrespective f the duratin f pregnancy, while the stillbirths are being cunted as abrtins befre the 28th week f gestatin. These distributins underline the imprtance f using birth weight as a cmplementary measurement f risk in the analyses f perinatal materials, especially as regards the premature infants. There is bviusly n similar risk level at the ther end f the weight scale, the very heavy babies, t a certain

312 s 00 fï 00 O 100. d O O r- r- 100. d O 100. VO ^. 00 ON v O 100. i-' vq OO.. cd u * \ C 00 ON { ve births a nsweden. T3 S 2 S'a 9 S 1 U cd 60 T3 cd c 8.«a a C cd cd h- «g> «i X> 2 Ë rt 3 e (^ «_ m ON «t t- m 00 VO en tn «S 00 00 VO 847 0.9 ON r-l O 00 en d vq ri 00 fi 34. 33. m ri d d 323 504 ri «s r- ON fi fi O r- rn tr, <s en f> <s 00 00 <N 787 0.8 VO m en d VO 34. 33. </ > ri d d ^^ fi m O ^* ON VO S r- VO ir> en r d d m fi ON 00 en fi VO "î VO 14.5 VO 00 f» ON «N en < 00 f~ fi d d ri fi r-' fi ON d ON 13.2 r- OÑ ^^ v (S ON "' fi ri O ri H fi d 133.2 f»; fi f> «s ON fi fi -î O 00 VO (N VO (N 71.3 (N VI VI 00 fi 2 fi 00 d ON d fi vq 00 66.6 CN VO <S VO f^! "1 g.tí 'C «il ««.is r- x> Ü D. >. H U!5 u u td u (0 (i eu a-j D.W.

313 3 O H al ON O ' 694 8 d d «q q v d 25 d <^i G\ ON d <r! ri ri S 73 S 2 c 2 u lal 'S a ca 00 ON 77- ON VO VO 00 ON r- ^ VO 00 (S O ^í" rn m i i ^^ in t H _' <N ~' --i I a IS O X rths edén x> u a ccj "(3 ti O c.2 3.O *c ts 3 u c Cß rati _e 8 «-» B Ou > si i *O 00 ts -^ VO O ON <N _ 0O " d ON Tt OO _ m. O 00 V0 O S- ON «s ^^»-^ OO ON V^ r** * ^ r- -< "1 v r- - ON 00 -«Í «3 ^ CS >r> "» ON 00 d 00 TJ- ^ ON VO ci OÓ OÑ v VO VO -*' < t- ci -- ON 8 S <s ON ci ON S q v = È 2 S vi 'S S s T3 i rt * a» S " c- I 2-ë SS 2d VO > ON " i 05 5Î 8 u S e r- ij 'S. >. S Ë m H 8 3 E

314 extent depending n increased means f bstretic supervisin and interventin. The crrespnding graphs accrding t gestatinal age, figures 18 and 19, give at large the same relatins as the distributins and rates by birthweight. The lack f cincidence in the registratin f live and stillbirths f less than 28 weeks f gestatin is, hwever, bvius. The live births are registered withut regard t the gestatinal age, whereas the stillbirths f less than 28 weeks are cunted as spntaneus abrtins. Sme f these cases f stillbirths with afterwards crrected duratin f pregnancy are nt easy t exclude frm the registratin, nr frm the statistical backgrund f these graphs. The great similarity between the tw variables, birth weight and gestatinal age, indicate the pssibility f having a better base fr analysis frm a crsstabulated material. This has evidently been dne but nly fr brader gruping f weight and f weeks f gestatin. As can be seen frm the percentage distributins the amunt f cases at bth ends f the curves are very small. In the weight grup 5000 grams and ver there were nly 12 perinatal deaths during the 5-year perid, giving a rather high death rates, which is the reasn fr the dtted cntinuatin f the curves. Anther explanatin related t the percentage distributins may be needed, as in the backgrund material there are always sme cases with unknwn data as t the variable in questin. In rder t indicate the amunt f such cases they are given in the end value f the cumulative percentage as the remainder t add up t 100.0%. Sme explanatins t the favurable psitin f Sweden The questin why Swedish perinatal mrtality is s lw cmpared t that f ther cuntries and still cntinues t decrease is nt an easy ne, but it cannt be entirely verlked in this cnnectin. The plitical ambitin in Sweden since mre than 50 years has been t guarantee equal access, regardless f incme, t the best pssible health care, especially in the field f mther and child health and f bstetric services. The health care system is strngly decentralized and in spite f this the maternal and child care is very unifrm. The cperatin between bstetricians and pediatricians plays a great rle and the fact that practically all deliveries take place in hspitals with access t pédiatrie surveillance, if necessary in nenatal intensive care units, guarantees a high and even quality. Thanks t the cmplete medical birth registratin, intrduced in the whle cuntry in 1973, detailed infrmatin is btained, making it pssible t evaluate different bstetric and pédiatrie measures and t identify and estimate risk factrs. The pssibility f refering the infants t grups accrding t birthweight and gestatinal age facilitates the identificatin f the special risk grup «small fr date». This is a very imprtant variable in the analysis f

315 * 35 in Cumulative percentages are given alng each curve?5 20 IS 10 5 0 X 0.21 <M%2 2~~1 IS.?«," /! # 48.9 Ï I! mm m 83 3% TOTAL BIRTHS *^ \! \ \ \97.1X!\ \. ; \99.7X BIRTH 1000-1500- 2000-2500- 3000-3500- 4000-4500- 5000 rams WEIGHT-999 1499 1999 2499 2999 3499 3999 4499 4999 4 ver?n 10 5 0 8.4$/ i i 24 4 % A "50 Q # * 4 Ï 7 2 ; 1 Ï 8 5-4 Ï ; j *94-3X LATE FETAL DEATHS T\97.6X! BIRTH 1000-1500- 2000-2500- 3000-3500- 4000-4500- 5ÛÛÛ grams WEIGHT-999 1499 1999 2499 2999 3499 3999 4499 4999 4 ver 25 20 19 2X 38.9X EARLY NEONATAL DEATHS 15 10 bit. 1*64. "* ; < OX 74.9X 85.2X ^2.5 X 5 *V95.1 X j 95.8% 96. 0 BIRTH 1000-1500- 2000-2500- 3000-3500- 4000-4500- 5000 grams WEIGHT-999 1499 1999 2499 2999 3499 3999 4499 4999 4 ver FIGURE 16. Percentage distributins f ttal births, late fetal deaths and early nenatal deaths by birth weight in Sweden, 1977-1981

316 Pep 800 600 400 1000 Sv 200 100 80 60 40 s \.» \\ \» x \ 20 10 8 6 \X \\\ \\N \\ w\ :. \ \v \ \ Ml, PNM 1.8.6 - - * ;LFM ENM.4 - -.2.1 BIRTH- WEIGHT 1000-.1500-2000- 2500-3000- 3500-4000- 4500-5000- GRAMS -999-1499 -1999-2499 -2999. 3 499 3999 4499 4999 FIGURE 17. Perinatal, late fetal and early nenatal mrtality by birthweight in Sweden, 1977-1981

317 Cumulative percentages are given alng each curve 45 85.9X TOTAL BIRTHS / 35 30 25 40.7% I (- \ 4 10 f 1 I \ W.7X 20 \ j 0.4X 0.8X y.íjjt^y \ S \ i ^ ii. GEST -27 28-29 30-31 32-33 34-35 36-37 38-39 40-41 42-43 44-45 46 weeks AGE '. tlmre 15 10 7 Ji ***T :"" 'i! 60.7XJ2. 43.6X^**f*^^ 29.1 X**^ 17.2X_^*>**^ 1 ^*V.93.1X < LATE FETAL 7.8X DEATHS 99.4 X *=»_L. GEST. -27 28-29 30-31 32-33 34-35 36-37 38-39 40-41 42-43 44-45 46 weeks AGE -»mre 15 10 1 U8.9X \ 10.31»^^39.71 m i 48 SX 58 69.9t 81 7 X 93. 5X V EARLY NEONATAL 8X DEATHS 99.0X GEST. -27 28-29 30-31 32-33 34-35 36-37 38-39 40-41 42-43 44-45 46 weeks ACE * *vre FIGURE 18. Percentage distributins f ttal births, late fetal deaths and early nenatal deaths by length f gestatin in Sweden, 1977-1981

318 Per 1000 800 600 400 200 100 80 60 40 20 "x^ h 1\ X X "X - PERI IATAL DEATHS PER 1000 BIRTHS PNH.. LATE FETAL DEATHS PER 1000 BIRTHS LFM \x X X \ \ \ \ \ X y \ \ r NEONATAL DEATHS PER 1000 LIVE BIR1fHS K \\» x PNN X. X r Em.2.1 CESTATIWUL.27 28-29 30-31 32-33 34-35 36-37 " 38-39 40-41 42-43 44-45 46-/WEEKS FIGURE 19. Perinatal, late fetal and early nenatal mrtality by gestatinal age in Sweden, 1977-1981

319 perinatal mrtality and mrbidity, especially in cmparisns as t the size f the risk grup f premature infants. One can say that lw birthweight indicates gd pédiatrie care, and that lw late fetal death rates are signs f gd bstetric care. Similar parameter valued fr thse f very heavy weight is mainly a sign f gd bstetrics. This analytical instrument may require specificatin by sex t be a perfect tl. The essential requirement, hwever, is a natinal register f infants by birthweight and gestatinal age f the kind that has been set up in Sweden, Denmark and Nrway but nt yet in Finland. Cngenital malfrmatin register Anther kind f natinal register in Sweden is the cngenital malfrmatin register, which als creates a useful tl in the evaluatin f health interventin prgrammes in the child health field. An increase f Mrbus Dwn has recently been detected amng babies f yung mthers. If this is a real increase is hard t tell. One explanatin might be that s few yung wmen give birth t children in ur days, that these mthers may frm a negative selectin as t risk factrs. One must always be pen fr the appearance f such artefacts in strngly selected ppulatin grups. Sci-ecnmic differences in perinatal mrtality It has been pinted ut earlier that perinatal mrtality is nt sensitive enugh t measure minr differences. In rder t determine the influence f sciecnmic factrs n perinatal mrtality, birthweight and duratin f pregnancy, the infrmatin frm the medical birth register n each infant was linked t such census data as ccupatin, incme, natinality f the mther, type f family and husing standards, t frm a new register fr research purpses. This register was divided int three grups, the first being a very privileged ne with high incme, privately wned huse, married r chabitating parents, Swedish natinality and prfessinal ccupatinal status, the secnd an intermediate grup and the third ne a cntrast t the first accrding t the variables chsen. These three grups were then cmpared as t level f perinatal mrtality, prprtin f lw birth weight (less than 2 500 g) and f cngenital malfrmatins. The cmparisns were made with and withut adjustment fr age f mther and parity. The result was that the perinatal mrtality did nt differ significantly between the mst and the least privileged grup. On the ther hand did birth weight and incidence f preterm as well as psterm births shw true differences between these tw sci-ecnmic extreme grups.

320 Perinatal mrtality is bviusly assciated with the quality f prenatal, antenatal and nenatal care and f the bstetric and pédiatrie treatment. This study gives evidence f a very lw sci-ecnmic gradient in Sweden as regards access and quality f maternal and child health facilities. Birthweight and similar measurements are evidently als related t individual characteristics, such as smking habits, height f parents etc. Quantitatively, these factrs d nt seem t be f great imprtance in this cuntry. This attempt t discuss perinatal mrtality and its assciatin with health prgrammes in the Nrdic cuntries is nly meant t give sme ideas f cnditins in cuntries with lw risks and minr sci-ecnmic differences. Pst-nenatal mrtality, n the ther hand, seems t be mre sensitive t sciecnmic variables, but the differences seldm becme statistically significant because f the small number f deaths after the first week r mnth f life. References Karlberg P, Ericsn A,: Perinatal mrtality in Sweden. Analyses with internatinal aspects. Acta Paediatrica Scand, Suppl 275, 1979:28 Meirik O, Smedby B, Ericsn A,: Impact f changing age and parity distributins f mthers n perinatal mrtality in Sweden, 1953-1975 Internatinal Jurnal f Epidemilgy, 1979:8:4, 361-364 Rth G,: Better perinatal health. Sweden The Lancet, Dec. 1, 1979:1170-1172 Ericsn A, Erikssn M, Westerhlm P, Zetterström R,: Pregnancy utcme and scial indicatrs in Sweden (Persnal cmmunicatin, 1982) Yearbk f nrdic statistics: 1982 The Nrdic Cuncil, Nrdic Statistical Secretariat Nrstedts, Stckhlm 1983 Scial and bilgical effects n perinatal mrtality: A WHO Reprt. Vlume 1. 1978. Reprduced in Saudi Medical Jurnal, Vlume 4 1983. Supplement Number 1

321 SECTION VI GENERAL OTHER TOPICS Brief ntes t describe the psitin f England and Wales cncerning sciecnmic differential mrtality (A.Jhn FOX) Quelques réflexins tirées du séminaire de Paris sur «l'influence des plitiques sciales et de santé sur l'évlutin future de la mrtalité» (Jacques VALLIN) Hw gd are the data? Sme methdlgical pints and a quality assessment prgram in Switzerland (Fred PACCAUD and Christph MINDER) Sme features f mrtality in the 1970s in Hungary (Peter JOZAN) A nte n scial inequality f death in mre develped cuntries (Harald HANSLUWKA)

323 BRIEF NOTES TO DESCRIBE THE POSITION IN ENGLAND AND WALES CONCERNING SOCIO-ECONOMIC DIFFERENTIAL MORTALITY A.Jhn FOX Prfessr f Scial Statistics The City University, Lndn, United Kingdm Intrductin The fllwing ntes utline the main pints that will be made at the third meeting f the netwrk f researchers interested in sci-ecnmic differentials in mrtality. It fllws the same headings as the prgramme which has been circulated. Classificatin f sci-ecnmic status The UK has a lng histry f analysing mrtality data by sci-ecnmic grups. This ges back t the wrk f Farr in the middle f the last century* 1 ). In the early part f this century Stevensn intrduced the Registrar General's Scial Classes* 2 ) (brad grups f ccupatin, ranked accrding t «standing in the cmmunity» and the wealth and skill implied). In the 1950s an alternative gruping f ccupatins int Sci-Ecnmic Grups (SEGs) was intrduced; this was nt a ranking f ccupatins, but is ften used in cllapsed frm as an apprximatin t Scial Class* 3 '. Anther apprach has been t rank ccupatin by measuring prestige, scial standing r scial netwrks* 4-5 - 6 ). A review f the rigins and uses f the Registrar General's scial classes will be circulated at the meeting* 7 ). The latest ccupatinal classificatin in the UK is summarised in a recent article in Ppulatin Trends ). Early wrk als attempted t grup peple using husing and educatin based measures. The presentatin I will make n the different classificatins will lk at:

324 (a) why we measure inequalities; (b) the availability f infrmatin relevant t different measures f sciecnmic status; (c) the scpe f different classificatins; (d) the cst f cllecting and cding the data and the reliablity f the cding; (e) cntinuity in terms f measurement f histric changes; (f) the ppulatin distributin; (g) the discriminatry pwer f different measures; (h) interactins between different measures, and (i) mbility. Much f the discussin has already been published in Fx and Gldblatt's reprt n Sci-Demgraphic Mrtality Differentials^) (Chapter 13). Attempts have als been made t classify gegraphic areas accrding t their sci-ecnmic characteristics. These appraches will be described under eclgical studies. Census-based prspective studies A summary f the full reprt n Sci-Demgraphic Mrtality Differentials will be circulated at the meetingd. This reprt describes mrtality in 1971-75 fr ne per cent f the ppulatin f England and Wales in relatin t the full range f Census characteristics f the ppulatin in 1971. It describes differentials by ecnmic activity (ecnmic psitin, ccupatin, scial class, wmen's wn scial class and transprt t wrk); by husehld structure (including marital status, family structure and institutin status); by husing (including tenure, access t amenities, access t cars and their interactins); by gegraphic area (regins, urban-rural aggregates etc.); by migratin histry (including distance migrated in perid 1966-71 and pattern f migratin); by cuntry f birth (including when entered England and Wales and parents' cuntries f birth); and by marriage and fertility histry. New prjects are incrprating mrtality data up t 1981, lking at cancer incidence and survival, migratin and scial mbility. The latest additin t the data set is infrmatin abut the sample's 1981 Census characteristics. This prgramme f wrk, jintly cnducted by the Office f Ppulatin Censuses and Surveys and the Scial Statistics Research Unit at City University, is described in a shrt dcument circulated at the meetingud. Eclgical Studies As is clear frm the review f scial classificatin, there was cnsiderable interest in area differences as well as ccupatinal differences in mrtality in the Registrar General's Office in the last centuryi 7 ). Wrk n healthy districts is but

325 ne example. Recently, a number f research grups have returned t this aspect f area mrtality data and are attempting t fllw up gegraphic differences t understand better the effects f, fr example, lcal industry (e.g. MRC Envirnmental Epidemilgy UnitW) r lcal envirnment (e.g. nitrates have been studied by the MRC Envirnmental Mnitring Unit< 13 ), water hardness by the Ryal Free HspitaK 14 ) and pllutin by St Thmas's Hspital). Use f scial area classificatins such as ACORN (a Classificatin f Residential Neighburhds) is als increasing. This is similar t an apprach used in the USA in which census tracts are gruped by mean incme. Here gruping is based n cluster analysis f sme 40 census variables fr each small Prjects using the OPCS Lngitudinal Study are nw trying t cmpare industrial and area characteristics, t lk, fr example, at better-ff peple in pr areas and pr peple in better-ff areas* 16 ). Infant mrtality Infant mrtality is included in all the abve analyses f mrtality by scial class r by area f residence and is als subject t mre regular systematic analysis because f the regular matching f infant death recrds with birth recrds. A useful illustratin f this type f apprach is the review by Adelstein, MacDnald-Davis and WeatheralK 17 ). OPCS als wrks in clse cllabratin with utside grups such as the Natinal Perinatal Epidemilgy Unit at Oxfrd, wh are cllabrating, fr example, in further analyses f the OPCS Lngitudinal Study data n infant mrtality (see fr example, McDwall, Gldblatt and Summary This shrt review has attempted t indicate the main thrust f research in England and Wales n the tpics t be cnsidered by the meeting in May 1983 in Rme. The attached references and papers circulated at the meeting amplify n the pints made. References 1. Farr, W. (1875). Supplement t the Thirty-Fifth Annual Reprt f the Registrar General in England. Lndn. 2. Stevensn, T.H.C. (1923). The scial distributin f mrtality frm different causes in England and Wales, 1910-1912, Bimetrika, XV. 3. Glass, D.V. (1947-8). A nte n the ccupatinal gruping used in tabulating the 1939 births. Ppulatin Studies, Vl. 1, n. 3.

326 4. Mser, CA. and Hall, J.R. (1954). The Scial Grading f ccupatins, in Glass, D.V. (ed.) Scial Mbility in Britain. Rutledge, Kegan and Paul Ltd. 5. Hpe, K. and Gldthrpe, J.H. (1974). The Scial Grading f Occupatins: Oxfrd Studies in Scial Mbility. Oxfrd University Press..6. Stewart, A., Prandy, K. and Blackburn, R.M. (1980). Scial Stratificatin and Occupatin. Hlmes and Meier Publishers, New Yrk. 7. Leete, R. and Fx, A.J. (1977) Registrar General's scial classes: rigins and use. Ppulatin Trends, 8, 1-7. 8. Bstn, G. (1980). The 1980 Classificatin f ccupatins. Ppulatin Trends. N. 20, 9-11. 9. Fx, A.J., Gldblatt, P. (1982). Sci-DemgraphicMrtality Differentials: OPCS Lngitudinal Study 1971-75, Series LS N.l., HMSO, Lndn. 10. Fx, A.J., Gldblatt, P. (1982). Sci-demgraphic differences in mrtality. Ppulatin Trends, N. 27. Spring 1982, 8-13. 11. Scial Statistics Research Unit (1983). A brief intrductin. SSRU, The City University, Lndn. 12. Gardner, M.J. (1982). Paper prepared fr Meeting n Uses f Rutine Statistics t Detect New Occupatinal Carcingens. Internatinal Agency fr Research in Cancer and City University, December 1982. 13. Fraser, P. Beral V. and Chilvers, C. (1978). Mnitring disease in England and Wales: methds applicable t rutine data cllecting systems. J. Epid. and Cmm. Health, 32, 294-302. 14. Pcck, S.J. Shaper, A.G. Ck, D.G. et al. (1980). British Reginal Heart Study: gegraphic variatins in cardivascular mrtality and the rle f water quality. B. Med. J. 280, 1243-9. 15. Webber, R.J. (1977). The classificatin f residential neighburhds. See fr example, Ppulatin Trends, n. 11, 21-26. 16. Adelstein, A.M., Mcdnald Davis, I.M. and Weatherall, J.A.L. (1980). Perinatal and infant mrtality: scial and bilgical factrs 1975-77. Studies in Medical and Ppulatin Subiects N. 41, HMSO, Lndn. 17. Fx, A.J., McDwall, M., Gldblatt, P. (1981). Emplyment during pregnancy and infant mrtality. Ppulatin Trends N. 26, Winter 1981, 12-15.

327 QUELQUES RÉFLEZIONS TIRÉES DU SÉMINAIRE DE PARIS SUR «L'INFLUENCE DES POLITIQUES SOCIALES ET DE SANTÉ SUR L'ÉVOLUTION FUTURE DE LA MORTALITÉ» Jacques VALLINO Institut Natinal d'etudes Démgraphiques, Paris, France En reprenant ici quelques réflexins que m'nt inspiré le Séminaire rganisé à Paris, du 28 février au 4 mars 1983, par l'institut Natinal d'etudes démgraphiques (INED) et l'unin Internatinale pur l'étude scientifique de la ppulatin (UIESP) sur les plitiques de santé, je dépasserai assez largement le cadre des sciétés industrielles puisque ce Séminaire traitait aussi bien des pays en dévelppement que des pays dévelppés. Cette réunin était la trisième et la dernière du genre, rganisée par la Cmmissin de l'uiesp sur les «facteurs affectant la mrtalité et la durée de la vie». Une première avait traité, à Fiuggi, Italie, en mai 1980, des «aspects bilgiques et sciaux de la mrtalité»u). La secnde avait abrdé, à Dakar, en juillet 1981, les prblèmes de «Méthde de cllecte et d'analyse pur les études sur la mrtalité»»). Le titre du Séminaire de Paris «influence des plitiques sciales et de santé sur l'évlutin future de la mrtalité» était d'évidence trp ambitieux pur qu'n puisse imaginer qu'il dnne cmplètement répnse à la questin psée. 11 s'agissait surtut de suligner ainsi l'imprtance de l'enjeu. Juger de l'influence des plitiques à venir, avec ns myens de démgraphes, c'est essentiellement juger de l'influence des plitiques dans le passé et tenter d'extrapler. Ainsi ramenée à de plus justes prprtins, la questin reste (*) Organisateur de Séminaire tenu a Paris en mars 1983, par l'inep et l'uiesp, sur l'influence des plitiques sciales et de santé sur l'évlutin future de la mrtalité. (1) Bilgical and Scial Aspects f Mrtality and the Length f Life. Edited by S.H. Prestn, Liège, Ordina Editin, 1982. (2) Methdlgies fr the cllectin and analysis f mrtality data. Edited by J. Vallin, J. Pllard and L. Heligman, Liège, Ordina Editin, 1984.

328 cependant difficile. A plusieurs reprises, la cmmunauté des natins a slennellement affirmé, ntamment par la vix de l'organisatin Mndiale de la Santé (OMS) lrs de la cnférence d'alma Ata en 1978 que «la santé est un drit fndamental de l'hmme» u encre, que «l'btentin de plus haunt niveau de santé pssible est un des plus imprtants bjectifs sciaux à l'échelle mndiale». Mais ù se situe «le plus haut niveau pssible»? S'agit-il de garantir à chaque habitant de la planète le niveau de santé atteint par les individus les plus favrisés du pays le plus favrisé? Cet bjectif risque alrs de rester hrs de prtée pur des lustres. S'agit-il au cntraire de faire partut ù c'est pssible ce qui est pssible quand c'est pssible? Il serait alrs facile de se truver assez d'impssibilités pur se satisfaire pleinement du peu qui aura été btenu. La réalité dit se situer entre ces deux extrêmes. Au curs des trente dernières années, d'immenses prgrès nt été réalisés dans le dmaine de la lutte cntre la mrtalité. Partut l'espérance de vie a augmenté. Dans les pays industriels, la mrtalité infantile encre assez élevée au lendemain de la secnde guerre mndiale, s'est littéralement effndrée, tmbant dans plusieurs pays au-dessus de 10 / O, ce qu'n n'aurait jamais pu imaginer il n'y a même pas 20 ans. Pur l'ensemble des pays en dévelppement, les Natins Unies estiment aujurd'hui la vie myenne à 57 ans; sit près du duble de ce qu'elle était dans la plupart de ces pays avant la deuxième guerre mndiale. Il suffirait d'attribuer cet indéniable succès glbal aux plitiques sanitaires pur parler de succès et même de trimphe. Un examen plus apprfndi de la situatin appelle cependant à plus de prudence. Tut d'abrd, l'évlutin de la mrtalité, glbalement très psitive, peut inquiéter par certains aspects. Malgré les prgrès d'ensemble, et nus rejignns là directement le thème de la réunin du CICRED, les écarts se snt creusés. C'est en premier lieu le cas des différences entre les pays dévelppés et les pays en dévelppement. Dans les années 70 ntamment, alrs qu'une reprise vigureuse de la baisse de la mrtalité se manifeste dans la plupart des pays industriels, bien des pays en dévelppement marquent le pas. Mais c'est aussi le cas des différences entre pays du Tiers mnde. Ce dernier cncept, n le sait n'a plus grand sens aujurd'hui tant les situatins de pays en dévelppement snt diverses. Cela est vrai de la mrtalité cmme de bien d'autres phénmènes écnmiques et sciaux. Certains pays nt prgressé beaucup plus vite que prévu, tel quel Cuba dnt l'espérance de vie atteint désrmais un niveau cmparable à celle des pays eurpéens. D'autres, au cntraire, nt stagné (certains disent même reculé), ntamment en Afrique trpicale u en Asie. Les différences entre pays industrialisés eux-même nt eu tendance à s'accrître dans les années 70 malgré une phase d'hmgénéisatin dans les années 60. On ne sait d'ailleurs pas très bien dire ce qui est le plus étnnant de la reprise des prgrès après la crise des années 60, dans les pays ccidentaux, de la crissance rapide et cntinue de l'espérance de vie japnaise, u du recul de la vie myenne en URSS

329 et dans la plupart des pays de l'estd). Mais si les écarts se snt creusés entre les pays, ils se snt également, semble-til, creusés à l'intérieur de chaque pays entre les catégries sciales. C'est ce qui a pu être bservé en France grâce à la cnduite d'une secnde enquête lngitudinale réalisée à partir du recensement de 1975(2). Mais cela est également vrai dans bien des pays en dévelppement et ntamment dans ceux ù la mrtalité est la plus frte. Aucun de ces pays n'ignre ttalement les techniques médicales les plus sphistiquées, mais celles-ci ne bénéficient qu'à une infime partie de la ppulatin dnt la mrtalité n'est guère différente des schémas eurpéens alrs que l'ensemble des masses rurales reste parfis à l'écart de tut prgrès sanitaire. On peut dire, pur résumer et sans trp défrmer la réalité, que les prgrès nt, à quelques rares exceptins près, davantage prfité aux plus favrisés et beaucup mins aux mins favrisés. Est-ce bien là le résultat attendu des plitiques de santé? Mais ces résultats snt-ils vraiment ceux des plitiques de santé? Là encre le séminaire de Paris nus incite à la prudence. Les experts nt lnguement discuté des effets des prgrammes d'actin sanitaire. Cncernant les pays en dévelppement, ils nt été unanimes à cntester l'efficacité des prgrammes dits verticaux. Qu'il s'agisse de la lutte cntre la malaria, des campagnes de vaccinatins u des prgrammes nutritinnels, partut, les grands prgrammes, décidés d'en haut et mal intégrés aux besins réels et qutidiens de la ppulatin nt mntré une faible efficacité. Les mêmes experts nt été unanimes au cntraire à vanter les mérites des prgrammes de sins de santé primaire encuragés par la cnférence d'alma Ata (qui ne faisait en la matière que cnsacrer les rientatins prises par la Chine dans les années 50 avec ses médecins aux pieds nus). Mais là encre, prudence: il ne suffit pas de décréter d'en haut un tel prgramme. La stratégie des sins de santé primaire suppse une réelle décentralisatin de l'actin et une réelle participatin de la ppulatin. Trp suvent elle a échué en raisn des pesanteurs scilgiques et administratives. Ce qui réussit à Cuba u à Csta Rica semble ainsi n'avir aucun effet à Haïti, aux Philippines u au Sénégal. S'agissant des pays dévelppés, n a certes pu nter un réel succès en matière de mrtalité infantile. Mais la liaisn avec les prgrammes d'actin n'est pas tujurs évidente. De même, la mrtalité cardi-vasculaire a cnsidérablement diminué dans bien des cas, mais là ù des recherches nt pu être cnduites sur l'efficacité des prgrammes d'interventin, n ne nte guère de différence entre l'évlutin btenue dans les znes d'actin et celle bservée dans les znes témins. II semble tutefis qu'en matière d'accidents (accidents du travail, (1) On se référera utilement ici au dcument présenté au séminaire de Paris par Jean Burgeis- Pichat. (2) Vir le dcument présenté ici par Guy Desplanques.

330 accidents de la circulatin) les mesures de préventin puissent être d'une grande efficacité. L'exemple du Japn qui a pu ainsi réduire de mitié sa mrtalité rutière est frappant à cet égard. Mais nus smmes lin ici des plitiques prprement sanitaires (limitatin de vitesse, prt de la ceinture, renfrcement du permis de cnduire, etc.). On purrait tut aussi bien imaginer interdire l'alcl u le tabac, réglementer la cnsmmatin de graisses animales, etc.. et btenir ainsi une frte réductin de la mrtalité par cancer u par maladies cardivasculaires. Mais de telles mesures n'auraient aucune chance d'abutir à de bns résultats sans un large cnsensus scial, sans qu'elles n'entérinent en fait une réelle évlutin des meurs et dès lrs, elles n'auraient plus aucune raisn d'être. Le séminaire de Paris s'est dnc également penché sur cette questin beaucup plus vaste et cmplexe des relatins entre l'évlutin de la mrtalité et celle des plitiques écnmiques et sciales en général. Et la répnse est encre lin d'être évidente. On peut certes retenir cmme une piste de recherche, la cnstatatin faite par Miltn Remer en cmparant deux à deux des pays de même niveau sci-écnmique et de même culture (tels que les Etats-Unis et le Canada, l'autriche et l'angleterre, la Belgique et les Pays-Bas, l'australie et la Nuvelle Zélande, l'allemagne de l'ouest et l'allemagne de l'est,...). Chaque fis, dans la lutte cntre la mrtalité, de meilleurs résultats paraissent avir été btenus là ù les plitiques écnmiques et sciales repsaient sur une répartitin plus équitable des ressurces. On peut faire aussi la même remarque à prps du Kerala, l'un des états les plus pauvres de l'inde et ayant néammins réussi à dnner à sa ppulatin une espérance de vie beaucup plus élevée que d'autres états plus riches. On purrait encre cmparer glbalement la Chine et l'inde, u Cuba et Haïti, etc. Ce type de cmparaisn a cependant ses limites. L'évlutin récente de la mrtalité dans les pays de l'est appelle ntamment à la prudence. Au minimum cnvient-il de ne pas cnfndre l'idélgie fficiellement affichée et les plitiques effectivement cnduites sur le terrain. Mais il semble surtut que la réalité sit assez cmplexe pur interdire tute cnclusin hâtive. Que ce sit au travers d'études de cas (Csta Rica, Sénégal, Japn, France, Plgne) u au travers de tentatives d'analyse cmparatives, la seule certitude qui ait pu être mise en évidence lrs du séminaire de Paris est bel et bien ntre manque d'util adéquat pur mener à bien ce type de réflexin: qu'il s'agisse de la définitin des cncepts, des méthdes d'bservatin et de cllecte des dnnées, u des instruments d'analyse, nus n'en smmes encre qu'aux premiers balbutiements. Semblant vulir mettre les buchées dubles avant que ne passe le siècle ù nus vivns, l'oms a récemment lancé un très beau slgan: «La santé pur tus en l'an 2000». Les cnclusins du séminaire de Paris nus bligent hélas à penser qu'il ne peut s'agir là que d'un idéal vers lequel n dit s'effrcer de tendre. Les bjectifs chiffrés snt frcément plus réalistes. Il faudra déjà bien des effrts, ntamment plitiques, pur btenir, cmme le suhaitent les Natins Unies, que d'ici à la fin du siècle plus aucun pays n'ait une espérance de vie inférieure à 60 ans. Suppsns cet bjectif atteint, il resterait encre beaucup à faire, cmme le mntre l'expérience récente des pays industrialisés.

331 HOW GOOD ARE THE DATA? SOME METHODOLOGICAL POINTS AND A QUALITY ASSESSMENT PROGRAM IN SWITZERLAND Fred PACCAUD and Christph MINDER Federal Office f Statistics Switzerland University f Bern Switzerland 1. Intrductin Althugh researchers generally are aware f prblems related t the quality f data, such as causes f death and sci-ecnmic variables, few demgraphic studies take effectively int accunts thse prblems in the discussin f results. Studies dealing with small numbers f events (like in smaller cuntries r when studying death during active life) are particularly subjected t these prblems, because the validity f the results partly depends n the number f events surveyed. Furthermre, studies using unlinked data (as in the usual crsssectinal analysis) are faced with prblems f reductin f pwer f analysis, hence with a lw prbability ffindinganything, if quality f the data is t bad. Swiss data are bviusly prne t such prblems. Thse are, hwever, f general interest in the field f sci-ecnmic differentials f mrtality. 2. The relative risk Any kind f cmparative ratis (CMF, SMR, etc.) is basically related t the cmputatin f a relative risk, which can be expressed as: Pr(MJF) (1) RR = -T Pr(M/F) that is, the prbability t get the disease M (e.g. t die frm a particular cause f death) when expsed t the factr F (e.g. a particular sci-ecnmic status) cmpared with the prbability t get M when nt expsed t F.

332 The estimatin f this relative risk usually neglects the distinctin between Pr(MJF) and Pr(M) when the prprtin f F is small enugh. Thus, (1) becmes: RR = Pr(M F) Pr(M) The usual expressin t cmpute RR (frm (1 bis)) is: RR = p(m F) (1 bis) 1 1 (2) p(m) p(f) that is, fr example, the bserved cause-specific mrtality rate in a particular ccupatin cmpared with the expected ne, cmputed frm the cause-specific mrtality rate in the whle ppulatin (p(m)) and frm the prprtin f the ppulatin having this ccupatin (p(f). 3. Frmal relatinship between apparent and true relative risk When ne cnsiders the pssibility f misclassificatin f M and/r f F, the relative risk has t be regarded as an «apparent» risk (RRQ) which is related t the «true» relative risk (RRtfV). Quality assessment has t give a frmal relatinship between RR a and RR and then t make a quantitative estimate f this relatinship. The magnitude f RR a, cmpared t RR(, is a cmplex functin f the quality f M (the quality f cause f death statistics, say), the quality f F (the quality f sci-ecnmic variables, say) and the quality f the interactin between M and F (the quality f cause f death in a particular sci-ecnmic grup, say). Quality f data can be described in terms f sensitivity (prprtin f true psitives) and specificity (prprtin f true negatives). Thus, ne has t get bth sensitivity and specificity fr each term f the expressin (2), in rder t get the relatinship between RR a and RR(. Let's drp the tedius algebraic manipulatin; the fllwing expressin gives the frmal relatinship between the apparent prprtin f W (t be replaced by (M/F) r (M) r (F)) n ne hand, and the true prprtin f W, the sensibility and the specificity f Wn the ther hand. p\v a = (Se w + Sp w -l)pw t + (1- Sp w ) (3) where: Wt be replaced by (M/F), (M) r (F) pw a = apparent prprtin f W = true prprtin f W (1) Quality f data will here be defined in a very restrictive sense, i.e. nly thrugh misclassificatin f events in the varius categries f the variables; ther quality-related prblems (duratin f expsure e.g.) will be neglected.

Se w = sensitivity f W Sp w = specificity f W 333 (nte that the fur last terms lie between 0 and 1); if Se w = Sp w = 1, thus n misclassificatin prblem ccurs and pw a = pw(. When defining:... and (3) can be expressed'as: A w = Se w + Sp w 1 (4) B w = 1-Sp w, (5) pw a = A w. pw t B w (3 bis) Ging back t the expressin (2), the apparent relative risk will be: P(M/F)a RRn = p(m)a. p(f) a (6 bis) Thus RR a can be expressed as a multiple f RRt- RR a = $.RR t (7) where $ is (btained by replacing the terms n the right f (6) by the expressin (3 bis)): - P(M/F) t + B( M /F) p(m/f) t P(M)t A M.p(M)f p(f) t. (8). P(F)t '+ $ equals unity when bth sensitivity and specificity f the three terms equals unity and, cnsequently, RR a equals RR(. $ als equals unity (r is clse t unity) when there is sme cmpensatin between the three terms f (8). The frmulatin f <, given by (8), des nt give a gd idea f what can happen t explain such cmpensatin. Let's make a simplifying assumptin: the specificity is generally clse t unity when dealing with small enugh gruping f M and f F; s ne can equalize specificity with unity in expressin (4) and (5). Thus:

334 and: A j 1 =* Sex BT~ O and (8) becmes: Se(M F) (8 bis) (8 bis) makes it bvius that: $ is clse t 1 if: SefAf/f) = Se(M) r, in ther wrds, if the errrs in F and in M are mutually independent epwill be greater than 1 (and then, RR a verestimates the true relative risk) if quality f data is greater in the particular cmbinatin f M and F cnsidered. This can bviusly ccur when cause-f-death quality is better in a particular sci-ecnmic grup than in general ppulatin; Symetrically, $ underestimates the true relative risk if quality f cause f death is wrse in the particular sci-ecnmic grup cnsidered than in the general ppulatin. 4. Discussin f ther cnsequences f classificatin errrs These cnsideratins, hwever useful, are apprximate nly, in that quantities entering $ in (8) are all subjects t randm variatin and therefre their ratis will nt have expectatin exactly equal t the rati f this respective expectatin (A, p(w) and B in the example f $). Anther remark wrth making relates t (8 bis) which reflects the (apprximate) unbiasedness f RR a when the errrs in the classificatins are independent. The errrs will nevertheless entail an increase in the variance f RR. It can, hwever, be cnjectured, that the usual estimate f the variance f RR will in fact adjust fr this inflatin, the resulting effect thus will be a visible and estimable lss f precisin f the estimate f RR, nt a mre insidius invisible lss.

335 ' 5. The quality cntrl prgram at the Swiss Federal Office f Statistics (SFOS) T btain sme idea f the frequency and magnitude f varius types f errrs in the mrtality recrds, a prject was started as a cllabratin f the Departement f Scial and Preventive Medicine f the University f Berne (DSPM/Bern) and SFOS. This prgram is cncerned with varius pieces f infrmatin n the death recrd, as well as with varius phases f the prcessing f death certificates, and therefre is cnducted in three parts. Part 1: Cding study in the SFOS The death certificate, as well as its prcessing path, have been described in [1], which als cntains a gd set f references n this tpic. The cding substudy is cncerned with the quality f cding frm the (usually handwritten) frm t ICD-8 cdes. In SFOS, tw cders withut medical educatin are charged with this task. In the study, a sample f abut 660 1981 death recrds, stratified by disease grups t include rare diseases as well, was selected. The same certificates were recded by the SFOS cders and by a medical dctr well acquainted with ICD- 8. The cmparisn f the tw cdings by the cders gives a pssibility t estimate cder cnsistency, while the cmparisn f the riginal cding with the medical expert cding enables us t detect systematic shifts and bad cding practices. We have the hpe that the results f this study will induce SFOS t perfrm sme checking n a regular basis, and thus gradually imprve the mrtality data. A similar apprach is used in the US mrtality statistics ffice. Part 2: Cmparisn f hspital and mrtality data In Switzerland, a (private) assciatin f hspitals cllects n a vluntary basis, hspital diagnses. As these are, as a rule, based n patients recrds, and cmpleted after autpsies, they shuld be fairly reliable as t cause f death infrmatin. Prblems will include, hwever, selectin amng the up t 20 diagnses pssible per hspital case. Mrtality and hspital data can be cmputer-linked by using birth and death-dates, plus eventually sme infrmatin abut place f living, sex, cnfessin, etc. Preliminary investigatin indicates a gd pssibility fr this linkage. This part f the study cvers the reliability aspect f the cmpletin f the death certificate by the attending dctr. The methd has a few drawbacks: it can nly establish cncrdance/discrdance between the tw surces f data and it des nt give an independent assessment f the same evidence regarding a death as wuld be btained by having a panel f experts reassess the medical recrds f a deceased persn. Mrever, the study nly checks ut the quality f cause-f-death infrmatin fr persns having died in hspitals-likely the

336 segment with the mre reliable infrmatin in the first place. Despite f these drawbacks, this relatively cheap methd f quality cntrl will likely give sme wrthwile insight. Similar cmparisns have been made in the UK and US. Part 3: Cmparisn f Mrtality ccupatinal data with the Swiss Wrkers Accident Insurance (SUVA) data. Similar in idea t Part 2, this substudy arrives at a quality assessment f the ccupatinal infrmatin by a cmparisn with the fairly accurate death statistics f SUVA. The advantages and drawbacks are similar t thse fund in Part 2. Hwever in additin, the SUVA statistics cvers nly deaths f active wrkers (abut 1000 per year ut f a ttal f 60 000 deaths), whse ccupatinal status infrmatin n the death certificate is likely better than average: abut 75% f all deaths ccur in the ver-65 age bracket f largely ecnmically inactive peple, whse ccupatinal infrmatin will be f nly dubtful value. Hwever, the study will again invlve fairly little effrt, and therefre be well wrth executing. A better alternative, which, fr reasns f privacy prtectin, may be harder t execute, wuld be a cmparisn f mrtality ccupatinal infrmatin with census ccupatinal infrmatin fr, say, peple deceased in 1981 (i.e. after the 1980 census). References 1. PACCAUD F. Qualité des statistiques de causes de décès: Prblèmes actuels et perspectives. Szial-und Präventivmedizin, 27, 154-160, 1982

SOME FEATURES OF MORTALITY IN THE 1970'S IN HUNGARY 337 Peter JÓZAN Hungarian Central Statistical Office, Budapest 1. The Current Level f Mrtality In Hungary during the last five years, the crude death rate was, n average, 13.3 per thusand annually. This value is high in cmparisn either t the recent level f mrtality f the industrialized cuntries r t the crude death rates f the ppulatin f Hungary during the 1960's. At the beginning f the eighties, in Eurpe nly the German Demcratic Republic had a higher crude death rate than Hungary. Hwever, it is wrth while mentining that the prprtin f ld peple is cnsiderably bigger in the GDR than in Hungary. During the lastfiveyears, the crude death rate was annually n average 13.9 per thusand in the German Demcratic Republic. Arund 1980, the expectatin f life at birth fr the ppulatin f the wrld was 62 years, f Eurpe (withut the Sviet Unin) 72 years, f Hungary 69 years. Arund 1980, amng 33 industrialized cuntriesa) Hungary was in the 32nd place in terms f life expectancy fr males; cncerning the expectatin f life at birth fr females Hungary was in the 31-32nd place with Yugslavia and nly Rmania had a lwer value. Between 1978-1982, peple died in Hungary yearly n 142,000 average. In 1982 the number f deceased peple was 144,000. The crude death rate was 13.5 per thusand. Only in 1946, just after the Secnd Wrld War, was mrtality higher. a) Austria, Belgium, Bulgaria, Czechslvakia, Denmark, Finland, France, German Dem. Rep., Fed. Rep. f Germany, Greece, Hungary, Iceland, Ireland, Italy, Netherlands, Nrway, Pland, Prtugal, Rmania, Spain, Sweden, Switzerland, United Kingdm (England and Wales, Nrthern Ireland, Sctland), Yugslavia, Sviet Unin, Canada, United States f America, Israel, Japan, Australia, New Zealand.

338 2. The Secular Trend f Mrtality in the 20th Century The main features are as fllws: a) The perid f bservatin can be divided int tw different parts: i. Between 1876-1965 the secular trend f mrtality declined (natinal mrtality data have been available since 1876). Therefre the crude death rates were the lwest in the first half f the 1960's in Hungary, ii. Between 1966-1982, the secular trend f mrtality increased. b) The age- and cause structure f mrtality has changed. c) The mrtality has always been high in Hungary in internatinal cmparisn. Ad a. During the 20th century the level f mrtality has changed as fllws: The crude death rate decreased frm 36.5 per thusand t 10.2 per thusand between 1876-80, 1961-65, then increased t 13.5 per thusand by 1980-1982. The expectatin f life at birth fr males was 36.6 years in 1900-01, it increased t 67.0 years by 1961-65. Later it decreased slightly: in 1976-80 it was 66.7 years and in 1981 66.0 years. Hwever the cntributins f the age grups t these increases were substantially different. Between 1900-01-1981 the males' expectatin f life at birth increased by 29.6 years 3 ). The cntributins f age grups t this gain were as fllws: Age Age Age Age grup grup grup grup 0-14 15-39 40-59 60-x 22.1 years 5.0 years 1.1 years 1.4 years It is remarkable that since 1960 the cntributins f the age grups 15-39,40-59, 60-x were negative. In the age grup 40-59 this negative cntributin was as high as 0.3 year between 1960-1970 and 1.5 year between 1970-1981. In sum it means a negative cntributin f 1.8 year ver the last tw decades. The expectatin f life at birth fr females was 38.2 years in 1900-01, it increased t 71.7 years by 1961-65 and t 73.3 years by 1976-80. In 1981 it was 73.4 years. Amng females all age grups cntributed psitively t the increase f 35.2 years in life expectancy between 1900-01-1981. The differences in the cntributins were slightly smaller in the female than in the male subppulatin, yet they remained significant. The cntributins f age grups were as fllws: age age age age grup grup grup grup 0-14 15-39 40-59 60-x 21.6 years 6.8 years 3.0 years 3.8 years a) Calculated by applying the frmulas used in the decmpsitinal prcedure in «Levels and Trends f Mrtality since 1950»; United Natins, New Yrk 1982; p. 11.

339 It is astnishing and at the same time enigmatic that the age grup 40-39 in bth sexes gained the least frm the lengthening f life expectancy. This is by n means a Hungarian speciality. Similar ccurrences culd be bserved in sme ther cuntries t. The epidemilgic transitin has started later in Hungary than in the cuntries f Nrth-Western Eurpe. First f all the substantial imprvement in the quality f life has been respnsible fr the declining secular trend in mrtality and fr the radical change in the structure f mrbidity and mrtality. Besides this, the impact f preventive public health measures and, t a smaller degree, the cnsiderable increase in the effectiveness f curative medicine have been decisive in the cnquest f the ften fatal infectius diseases and cnsequently in the lengthening f life expectancy at birth. Ad 2. The unfavurable change in the secular trend f mrtality during the last seventeen years has been caused by many factrs. The demgraphic determinants f the rising trend in mrtality have been:. 1. the aging f the ppulatin; 2. the change in age-specific mrtality rates. If the age distributin were the same in 1980 as in 1960, the crude death rate wuld be 10.2 per thusand in 1980, just the same as it was in 1960. Hwever cmparing the five year averages, the crude death rate f the perid 1976-1980 wuld be slightly higher than that f 1960-1964 (1960-1964: 9.7; 1976-1980: 9.9 per thusand). Between 1960-1980 the aging f the ppulatin cntinued with cnsiderable pace. It can be argued that the unfavurable change in the age distributin, first f all the increase f the prprtin f the 60 years ld and lder, has been respnsible fr the rising trend in mrtality during the last fifteen years. In fact parallel with aging f the ppulatin, a much mre cmplex prcess tk place: namely the expected and cnsiderable decrease f certain age-specific death rates and the unexpected and almst as imprtant increase f sme ther nes; the latter happened mainly amng males. Ad 3. The mrtality experience f Hungary in cmparisn with the mrtality experience f ther industrialized cuntries always prved t be unfavurable during the 20th century. This can be shwn by cmparing the crude death rates, and even mre s by cntrasting the life expectancies at birth f mainly Eurpean cuntries. Frm the turn f the century up t the present the expectatin f life at birth has always been lnger in mst f the industrialized cuntries than in Hungary. The prbabilities f survival in the Hungarian ppulatin imprved in a larger degree than in thse ppulatins which have had higher prbabilities f survival; hwever the gap, cncerning the life expectancy at birth, between Hungary and the mre develped cuntries remained, and even increased recently. At the turn f the century the life expectancy at birth fr the Hungarian male

340 subppulatin was 36.6 years. Only Spain and Czarist Russia had lwer values: 33.9 and 31.4 years respectively, amng the bserved cuntries. The life expectancy fr Hungarian females was 38.2 years at the beginning f the 20th century. Only in Spain and in Czarist Russia were the values lwer than in Hungary. Females in Spain culd expect t live 35.7 years at birth while in the case f females in Czarist Russia, the expectatin f life was 33.4 years. The psitin f Hungary in internatinal cmparisn, cncerning the life expectancy at birth, has nt imprved since the turn f the century, even recently it has deterirated. Eighty years ag the Hungarian male subppulatin was in the 23rd place amng 25 develped cuntriesa) regarding its expectatin f life at birth; at present it is in the 24th place. The Hungarian female subppulatin was in the 23rd place at the turn f the century and at the end f the seventies it has cme dwn t the last place. 3. The Age Structure f Mrtality The mrtality rate is the highest at the beginning and end f life, it is the lwest in childhd, in the age grup f 5-14. At the end f the 1970's the level f infant mrtality was equal by and large with the mrtality f the 63-64 years ld. Earlier infant mrtality represented large relative weight, recently the biggest prprtin f death ccurs in lder ages, especially ver seventy. In 1920-1921, infants represented 2.7 per cent f the ppulatin, but they amunted t 28.6 per cent f all deaths. In 1960 they had a share f 1.5 per cent f the ppulatin and accunted fr 6.9 per cent f all deaths. In 1981 children under ne year represented 1.3 per cent f the ppulatin and 2.1 per cent f all deaths. The prprtin f the age grup f 1-14 in the ppulatin decreased frm 27.9 per cent t 20.8 per cent during the last sixty years and parallel with it (but mainly nt as a cnsequence f it) its share in all deaths became insignificant at the beginning f the 1980's. Likewise the relative weight f yung adults in mrtality decreased t a fractin between 1920-1980. As against this the prprtin f the age grup f 4-59 increased in all deaths, by and large, parallel with the grwing relative weight f 40-59 year-ld peple in the ppulatin. Hwever the mst imprtant phenmenn, besides the fall in infant and childhd mrtality and due t it, was the extremely big increase f the prprtin f ld peple, 1») first f all peple ver seventy, amng the deceased, which was much greater than the pace f aging. In 1981 three-quarters f the deceased peple were 60 years ld and ver and the 70 years ld and ver, wh represent nly 8.8 per cent f the ppulatin, a) Austria, Belgium, Bulgaria, Czechslvakia, Denmark, Finland, France, German Dem. Rep., Germany, Fed. Rep. f, Hungary, Iceland, Ireland, Italy, Netherlands, Nrway, Spain, Sweden, Switzerland, United Kingdm (England and Wales, Nrthern Ireland), Sviet Unin, United States f America, Japan, Australia, New Zealand. b) 60 years ld and ver.

341 amunted t 57.8 per cent f all deaths. The radical change in the age structure f mrtality is a favurable phenmenn. In any case it is an advantageus develpment that amng thse wh are under 60, and they represent abut 82 per cent f the ppulatin, nly less than ne-quarter f all deaths ccurs. In the last ne and a half decades r s the age specific mrtality rates decreased under 30 and increased ver 30. The mst significant decrease, in abslute terms, culd be recgnized in childhd. Over 30 the age specific mrtality rates increased in every age grup. Cmparing the recent level f mrtality with the death rates f fifteen years ag r s, the cnditin f the 40-44 year ld males deterirated mst. In 1960-1964 the mrtality rate in this age grup was 3.3 per thusand, in 1981 it rse t 6.4 per thusand. The increase is 94 per cent. The age specific mrtality rates f the 30 year ld males and ver at the end f the 1970's and the beginning f the 1980's, by and large, are the same as they were abut three decades ag. In certain age grups the level f mrtality is as high again as it was in the 193O's. Nevertheless in the backgrund f the rather similar age specific death rates the pattern f causes f death in the thirties and at the turn f the seventies/eighties is different. The age specific mrtality rates f females are lwer in every age grup than that f males. The age specific mrtality rates f females, except amng the 40-59 years ld, decreased in every age grup during the last ne and a half decades r s. Yet amng the 40-59 years ld females, likewise amng males in the same age, but t a much lesser degree, the mrtality rate increased in the last ten-fifteen years r s. It is wrth mentining that the unfavurable trend amng females started abutfiveyears later, since the early seventies. The highest increase culd be fund in the age grup f 50-54 years; it was 1.3 per thusand and it meant a 24 per cent relative grwth cmpared t the perid f 1965-1969. The rising trend in mrtality in the age grup f 40-59 caused annually abut 3150 male and abut 750 female «excess» deaths n average in 1975-1979 (these are deaths which wuld nt have ccurred if the age specific death rates had remained unchanged since the early sixties). Tgether these 3900-4000 r s «excess» deaths represented nearly 3 per cent f all deaths. It is highly prbable that mst f these deaths culd have been avided by preventive care and effective treatement. It has already been mentined that the mrtality f the ppulatin f Hungary has always been high by internatinal standards. A detailed cmparisn can be carried ut by measuring the age specific mrtality rates in different ppulatins. In 32 develped cuntries^ the male and female age specific mrtality rates in a) Austria, Belgium, Bulgaria, Czechslvakia, Denmark, Finland, France, German Dem. Rep., Germany, Fed. Rep. f., Greece, Hungary, Iceland, Ireland, Italy, Netherlands, Nrway, Pland, Prtugal, Rmania, Spain, Sweden, Switzerland, United Kingdm (England and Wales, Nrthern Ireland, Sctland), Yugslavia, Canada, United States f America, Israel, Japan, Australia, New Zealand.

342 ten age grups have been cmpared arund 1965 and 1980. Amng the 32 cuntries the psitin f Hungary was bad in almst every age grup arund 1965 and it became wrse arund 1980. Imprvement can be fund nly in the age grup f 1-4 years. Recently the age specific mrtality rates in infancy and ver 25 years are s high that Hungary is in the 28-32. places alternately in the rank rder. 4. The Cause Structure f Mrtality The cause structure f mrtality has radically changed during the 20th century. The substance f change has been the decline f deaths caused by infectius diseases and the rise f deaths due t neplasms, diseases f the circulatry system and vilence. Arund 1920 every fifth, in the early eighties nly every hundredth persn died f infectius diseases. Recently neplasms amunted t similar prprtins as the infectius diseases represented six decades ag. In 1981 53 per cent f all deaths were caused by diseases f the circulatry system and abut 9 per cent t vilence. The tw latter main grups f diseases amunted t 10 and 3 per cent respectively 60 years befre. As has already been mentined mrtality was the lwest in the early sixties. Between 1964-1980 in the male subppulatin, the increase in mrtality after standardizatin was the largest in the grup f respiratry diseases. Hwever it shuld be mentined that in 1980 there was a serius influenza epidemic in the cuntry with abut 6 000 «excess» deaths, mrever the cause-specific mrtality rate f chrnic bstructive pulmnary disease (including emphysema) has been rising steadily since the early sixties. The high rise in mrtality due t diseases f the digestive system can be explained by the grwing frequency f deaths caused by chrnic liver disease and cirrhsis. The frequency f vilent deaths increased by abut 50 per cent; the rising trend in mtr vehicle traffic accidents and suicide were mainly respnsible fr the increase. In the grup f neplasms the mderate rise in the mrtality rate is largely due t the grwing frequency f cancer f the lung and bwels. The increase in mrtality in the grup f diseases f the circulatry system was als mderate; principally the rising trend in ischaemic heart disease and cerebrvascular disease was respnsible fr the increase. The frequency f deaths caused by infectius diseases decreased t a fractin. In the grup f vilent deaths mre than furfifths, amng the deaths f the digestive system furfifths r s, in the grup f diseases f the respiratry system mre than twthirds, amng the neplasms abut twthirds, whilst in the grup f diseases f the circulatry system mre than half f the increase in mrtality was independent f the aging f the male subppulatin. Althugh the

343 increase in the frequency f deaths in the grup f neplasms and diseases f the circulatry system was less than in ther grups, this had the greatest impact n the secular trend in mrtality, since these tw grups amunted t 74 per cent f all deaths in 1980. Amng females the frequency f deaths due t diseases f the respiratry system increased in the greatest degree. Then fllwed the mrtality rate in the grup f injury and pisning. The rise in the frequency f deaths caused by diseases f the digestive system was mderate and in the grup f neplasms was small. Ntwithstanding that in the grup f diseases f the circulatry system the crude death rate increased mderately, the standardized mrtality rate decreased slightly. The frequency f deaths caused by infectius diseases diminished t a fractin. In thse fur grups in which the increase in standardized mrtality ccurred, the prprtins f increase independent f aging were as fllws: XVII. Injury and Pisning: 54 per cent; IX. Diseases f the Digestive System: 47 per cent; VIII. Diseases f the Respiratry System: 45 per cent and II. Neplasms: 18 per cent. Amng females the trend in cause-specific mrtality rates was much mre favurable than amng males. There is a strng crrelatin nt nly between age and prbability f death but als between age and cause f death. T put it differently the chances t die f an accident, lung cancer, mycardial infarctin r strke, ther things being equal, depend first f all n age. Analysing the latest available data it can be fund that amng males under 40 years vilent deaths are the mst frequent, e.g. in the age grup f 20-24 years they represent abut 72 per cent f all deaths. Yet ver 40 years, diseases f the circulatry system becme the mst frequent cause f death. The prprtin f this main grup f diseases increases gradually and ver 64 years it already amunts t mre than 50 per cent f all deaths. Amng the few deaths in childhd the relative weight f neplasms is cnsiderable, e.g. in the grup f 5-9 years ld bys they represent abut ne-quarter f all deaths. Nevertheless malignant diseases ccur mainly in ld age. Their imprtance grws gradually and in the age grup f 55-69, 26-28 per cent f all deaths is due t neplasms. The diseases f the respiratry system have tw peaks: ne in childhd and anther ver 70 years. The diseases f the,digestive system amunt t the highest prprtin (8-9 per cent) in the age grup f 40-54 years. Amng females vilent deaths have much less imprtance, yet this is the leading cause f death under 30 years. Between 30-54 years deaths due t neplasms pssess the biggest relative weight; later n with aging, this grup cmes just after the diseases f the circulatry system as a killer. In lder age the diseases f the circulatry system are the mst frequent cause f death and ver 75 years 65-75 per cent f all deaths are due t failures in circulatin. The diseases f the respiratry system principally in childhd and yung adulthd,

344 whilst the diseases f the digestive system in the age grup f 40-54 years represent the highest prprtin f all deaths. As a result f gradual change in the cause-specific mrtality rates the current cause structure f mrtality can be characterized by the grwing relative weight f multifactrial, chrnic diseases. Mrever the cause structure f mrtality as presented hides a rather imprtant feature f death, because f the inadequacy f methdlgy regarding the study f mrtality. Death, especially in the case f ld peple, is resulting frm multiple causes. The causes f the diseases are well knwn in certain cases. E.g. it has already been prved that there is causal relatinship between the spread f smking in the ppulatin and the frequency f lung cancer. Furthermre there is a strng crrelatin between the level f alchl cnsumptin and cirrhsis f the liver. It is wrthwhile mentining that smking and alchlism have an impact als n the develpment f sme ther diseases. In regard f ther diseases the pathgenesis is even mre cmplicated and it is difficult t find ne r tw causes which can be exclusively respnsible fr the develpment f the disease. E.g. diseases f the circulatry system are par excellence multifactrial in character. In the pathgenesis f these diseases first f all the way f life and perhaps genetic factrs can be decisive. Amng many thers lack f physical excercise, unhealthy eating habits (ver-feeding), frequent and prlnged stress can have an impact n the develpment f ischaemic heart disease and cerebrvascular disease. These diseases develp very slwly, fr years, smetimes fr decades withut any serius symptms. It means that the current cause specific mrtality rates regarding these diseases are cnsequences f harmful health practices started sme decades befre. Therefre preventin and effectual medical care f chrnic diseases and ailments are the mst imprtant means in the decrease f mrtality. In the declining years the weariness f different rgans is prevalent. In the case f the elderly, nt nly the heart r lung are sick but the whle human rganism disintegrates. This qualitatively new situatin bviusly needs a qualitatively new apprach. The develpment f geriatric care is the adequate respnse t this recent and mdern challenge f life. The strategy f decreasing mrtality has three curses: 1. disease riented; 2. age riented; 3. scially riented. The disease riented plicy deals with the preventin and medical care f diseases. The age riented plicy means the geriatric care f the aging ppulatin. The scially riented plicy is interested in thse grups f the ppulatin in which mrtality has a higher level than in the ppulatin in general.

345 A NOTE ON SOCIAL INEQUALITY OF DEATH IN MORE DEVELOPED COUNTRIES Harald HANSLUWKA Chief Statistician Glbal Epidemilgical Surveillance and Health Situatin Assessment Wrld Health Organizatin, Geneva Intrductin Over the past tw decades discussin n health prblems in mre develped cuntries (in the fllwing abbreviated as MDCs) has been mre r less dminated by cncern fr the «cst explsin» in the health sectr. Nt infrequently, knwledgeable persns respnded t questins n pririties in the health sectr with a simple reference t the rising csts f health care. Hwever, a mre rigrus examinatin f the main prblems cnfrnted by MDCs suggests that rising health care csts cnstitute nly part, thugh undubtedly an imprtant ne, f a much mre cmplex situatin. Increases in health expenditure, fr example, have t be seen in the light f the varius cntributing factrs, such as inflatin, mre widespread use f sphisticated medical technlgy, the changing demgraphy f the MDCs with its distinct trend twards «aging ppulatins» (i.e., increases, bth in abslute and prprtinate terms, f the ppulatin aged 65 and lder) and the cntinuus cncentratin f death at the tw extremes f life, the perinatal perid and ld age, where medical interventin is mre cmplex and mre expensive. Nwadays the risk f perinatal death is, in sme MDCs, higher than in the subsequent 50-60 years f life and abut 50% f all deaths ccur at age 75 and lder, i.e., sci-medical effrts fcus t an ever-increasing extent n these tw age grups. Already in 1980 the nrmal life expectancy (the mdal value in the d x clumn f the life NOTE: The views expressed are thse f the authr and d nt necessarily reflect the findings r plicy f WHO. The authr gratefully acknwledges the assistance f Mr T. Nakada, Cnsultant t WHO.

346 table) was in several cuntries 80 r higher fr males and arund 85 fr females. Whereas the abve picture crrespnds t widely viced views abut negative aspects f psitive health develpments, it has gradually becme apparent that, in additin t these cncerns which are likely t increase in imprtance with time, there have emerged a number f present day issues, requiring immediate attentin. (i) Ecnmic prgress nt nly has psitive effects but als generates its wn prblems with ptentially adverse effects n health such as, fr instance, by envirnmental pllutin. (ii) The refutatin f a smewhat simplistic belief in a mechanistic cnvergence f mrtality experience amng MDCs. Whereas sme cuntries, after a perid f stagnatin r even temprary deteriratin, have resumed their dwnward trend, in thers n signs f imprvement are yet in sight (generally speaking this statement hlds fr male mrtality and, t a much lesser degree, als fr infant mrtality), a develpment which cannt be accunted fr by differences in the level f mrtality. As a result, MDCs nwadays present a mre hetergeneus picture than abut tw decades ag, a develpment accunted fr primarily by the relatively unfavurable curse f mrtality in sme Scialist cuntries f Eurpe (including the USSR) with their relatively substantial increases in male adult mrtality. (iii) Whereas mrtality frm cardivascular diseases (particular crnary heart diseases) played a significant rle in the recent reductin f verall mrtality in sme cuntries, its failure t decline ges a lng way twards explaining the unfavurable perfrmance in thers. The debate abut the causes underlying this divergency in the behaviur f cardivascular mrtality still cntinues^). Hwever, with regard t the ther leading cause f death grup, malignant neplasms, the verall picture is pretty unifrm thrughut the develped wrld, namely, ne f a general failure t match expectatins fr a breakthrugh. Despite enrmus effrts and allcatin f huge resurces t research and medical care, malignant neplasms are mre and mre the number ne scurge f MDCs, and ne where n significant reductin can presently be anticipated. This verall unsatisfactry perfrmance f cancer research and cancer cntrl prgrammes has naturally given rise t a questining f anti-cancer strategies and the explratin f pssible alternatives, such as the rediscvery f the «preventin» apprach, withut having yet yielded tangible results. The dual challenge f lung and breast cancer, t qute the tw mst imprtant sites, ffers few, if any, signs f cmplacent ptimism, their unfavurable trend vershadwing whatever prgress has been made with regard t ther sites such as stmach and cervix uteri. Lung cancer is a strikingly infrmative example f the difficulties f translating knwledge abut risk factrs (i.e. tbacc smking) int successful preventive actin. (iv) Even in the mst advanced cuntries, there still exist pckets f ppulatin subgrups with cmparatively pr perfrmance. As a cnsequence f a general,

347 idelgical mvement twards equalizatin f life chances and the prclamatin f health as a universal right, (ften interpreted in a mre restrictive sense as «right f access t health care») a certain preccupatin with «scial inequality f death» has ensued. A rapidly grwing literature attests t emtin-laden cntrversy abut facts, their interpretatin and plicy implicatins^2). T sample a few cmments, nt f prfessinal pliticians, but f respected schlars wh genuinely strive t cut thrugh the causal web: (a) «Cette inégalité sciale devant la mrt est, à cup sûr, une mauvaise nte pur la sciété cmtempraine évluée»; and «... diminuer les écarts que nus jugens indignes d'une sciété qui se vante u du mins se prpse d'assurer l'égalité entre les cityens?»< 3 ) (b) «... n trace is fund either in the US r in Britain f any reductin in scial inequality in respect f death; mrever, this inequality seems t have clearly wrsened in France...»( 4 ); and (c) «Health is ne facet f the scial system and few indices illustrate better than health the inequalities that reside in class scieties» and «... the affluence f the develped wrld has nt dispelled the disparities in health amng the scial classes»< 5 ). Such statements must, in ur s plitically sensitized wrld, tempt ne t questin nt nly the rganizatin and delivery f medical care but, ultimately, the whle fabric f sciety, their value premises and idelgical fundatin. Selected Issues in the Interpretatin f Scial Inequality f Death A series f critical questins emerges frm the abve which fr cnvenience's sake are gruped under three headings: (1) Questins f Philsphy (Idelgy); (2) Questins relating t the Effectiveness f Health Service Interventin; and (3) Questins f Statistical Methdlgy. (1) Questins f Philsphy (Idelgy). They center n the basic issue f whether scial class differentials in mrtality and, beynd it, in ill-health are avidable r nt. It may (and, in fact, has been) argued that such inequalities are rted in the very structure f sciety and are a mere reflectin f its lack f distributive justice and equity. Hwever, even if ne's utlk is less rigrusly egalitarian and ne is inclined t cncede that cmplete equality is an elusive gal, the vexing questin remains whether prevailing differentials are already the best that can be attained r whether the margin fr further imprvement is still substantial (and hw t g abut it in the mst effective and efficient way). (2) Questins relating t the Effectiveness f Health Service Interventin. Frm the persistence f scial class differences in mrtality ne may cnclude that effrts t make health care available and within the physical and financial reach f all strata f the ppulatin have failed r, t put it mre acrimniusly: that the expansin f health services, the better knwledge abut interventin

348 strategies, and the tremendus achievements f bimédical research have nt benefitted all segments equally. Fr England and Wales it has been cmmented that «the failure f relative inequality measures t imprve fr any grup is surprising in view f the intrductin f the Natinal Health Service in 1948, a Service that has prvided virtually 100% subsidy fr mst preventive and curative health measures»* 6 ). Accrdingly, the questin has been raised «whether the Natinal Health Service has ttally failed in a main purpse during its generatin r mre f life?»* 7 ). Such questins seem t imply a certain cnfidence in the effectiveness f health care interventin, a cnfidence which is neither generally accepted nr slidly backed up by research*»). One may argue that prvisin f health care t disadvantaged grups cnstitutes nly a palliative measure withut striking at the rt f inequality, i.e., the structure f sciety. This cntrversy als brings up the issue f hw t evaluate health interventin prgrammes, i.e., in terms f their impact n mrtality (the mst rigrus test) r rather in «peratinal» (prgrammatic) terms such as imprved utilizatin f health services and mre humane patient care, questins beynd the scpe f this paper. Hwever, reasning alng these lines, i.e., awareness f the limitatins f health service interventin, may explain the categrical dictum that «... data n scial class differences can nt be used as a datum pint against which t measure the impact ver time f the Natinal Health Service and ther services n the health differential grups in ur cmmunity»* 9 ). (3) Questins f Statistical Methdlgy. The very sensitivity f such inequalities, particularly at a time when thrughut the develped wrld a distinct tendency twards retrenchment f scial security prgrammes is emerging, requires a judicius assessment f the available evidence. Questins arise such as (a) Are scial class differentials in MDCs genuine r a statistical artefact? and (b) Des the available evidence n a widening f the gap (r, at least, the absence f any imprvement) during the past decades stand up t statistical critique? Befre entering int a discussin f these pints, it is well t bear in mind that cmments n the magnitude and, mre s, n the directin f change ver time, are usually based n the experience f a few cuntries nly, their experience being accepted as mre r less typical fr mdern sciety. Uses f infrmatin n scial inequality f death Scial inequality is being studied by schlars frm varius disciplines such as public health, epidemilgy, demgraphy, scilgy and scial administratin, all f them having their wn specific interest in this subject. Statistics n sciecnmic differences in mrtality, based n a classificatin f individuals by relevant characteristics have traditinally been cmpiled fr the fllwing purpses: (1) identificatin f risks assciated with an individual's wrk and/r his wrk envirnment; (2) sciecnmic epidemilgy; and (3)

349 scietal mnitring. In the first tw cases, the infrmatin is t prvide clues fr further fllw-up studies, zering in n specific ccupatin grups and etilgical hyptheses. Fr scietal mnitring, a relatively recent develpment, at least with regard t its terminlgy, sciecnmic differences in mrtality cnstitute a significant and highly relevant «scial indicatr». Amng ther ptential uses, ne may mentin their relevance t setting quantitative targets, the estimatin f «preventable» deaths, the frmulatin f assumptins in prjectins, the identificatin f grups at differential risks, decisin-making n pririties and resurce allcatin, etc. Sme general prblems in the analysis f differential mrtality The fllwing des nt purprt t present an in-depth discussin f the varius prblems and ptential pitfalls encuntered in the study f differential mrtality in general r scial class differentials in particular. Hwever, a cndensed review f sme f the main issues in differential mrtality studies may be apprpriate t place the discussin int its prper perspective. They relate primarily t the study f scial inequality f death, based n sciecnmic characteristics f individuals; hwever, sme aspects are relevant als t ther areas f differential mrtality such as differences by sex, eclgical analysis etc. The list belw grups under a few brad headings the main prblems: (i) Cnceptual aspects such as the lack f a theretical framewrk, issues related t the definitin and delineatin f scial classes (r sciecnmic grups) as well as related classifactry questins; (ii) Data base aspects such as cnsistency between numeratr/denminatr infrmatin, i.e., allcatin f ne and the same individual t the same scial class in the ppulatin at risk as well as in death registratin; (iii) Aspects f research strategy such as crss-sectinal vs. lngitudinal analysis f the experience f the varius strata f the ppulatin (characteristics f the deceased at the time f death may nly inadequately reflect his life time experience particularly when chrnic diseases predminate) and inclusin r exclusin f ppulatin beynd the wrking age (usually taken as 65 years and lder). (iv) Aspects f measurement such as chice f summary indexes and apprpriate standard ppulatins fr cmparisns including ther issues related t the measurement f «excess risk»; and (v) Aspects f interpretatin, such as the imprtance t be attached t natural and scial selectin prcesses, t individual life style patterns etc. Pervading these difficulties are, t a substantial extent, the largely unreslved issues f cmparability between cuntries and cmparability within a cuntry ver time. Questins such as whether in cuntry A scial inequality f death is

350 greater than in cuntry B r whether differentials in a cuntry have cntracted r nt, have their wn plitical explsive and pse a frmidable challenge t research. One f the mst severe critiques levelled against the way scial class differences in mrtality have traditinally been studied in England and Wales cncerns the principles and prcedures f classificatin: «The grups are s defined as t be kept cntinuusly apart in their health experience s lng as we have scial mbility in ur sciety»* 10 ). In this cntext it is interesting t nte that the results f such studies may, inter alia, depend n the number f subgrups identified as shwn by Presin O and Vallins. This debate had, amng thers, the beneficial effect f stimulating new imaginative develpments in research strategy and techniques f data cllectin which nce fully perative will cnstitute a very pwerful tl fr scietal mnitring* 13 ). A wrd f cautin must be inserted that evidence n scial inequality f death is nt simply rejected because f the frmidable methdlgical and technical issues invlved, i.e. by switching frm uncritical acceptance and sweeping cnclusins t the disregard f facts nly because the infrmatin may nt measure up t expectatins f reliability and unambiguity. T handle imperfect data and make the best f it, is a challenge familiar t all dealing with the quantitative study f scial phenmena. Sme aspects f measurement In recent years, the number f articles* 14 ), prpsing different measures f inequality has rapidly increased, by itself a telling prf f the limitatins, advantages and shrtcmings encuntered in the search fr an impartial and infrmative summary measure f s cmplex a matter as «inequality». Tw psitive develpments can be nted in this cntext, namely (a) the grwing realizatin that crude measures such as a cmparisn f mrtality in the lwest scial class t the perfrmance f the highest are, at best, uncnvincing*'?) and very frequently, misleading; and (b) the cmpilatin f several indices and their validatin by inspecting their cnsistency ffers a much sunder basis fr assessment and decisin making. Hwever, there are als ther issues invlved. Infant mrtality is taken as an example t demnstrate certain aspects f measurement and interpretatin. It ffers the dual advantage that it is a universally accepted sensitive indicatr f scihygienic cnditins and that it is exempt frm mst f the prblems assciated with the study f sciecnmic differentials at adult r ld age. In many MDCs, particularly in Western and Nrthern Eurpe, but als in Japan

351 and in the English speaking verseas cuntries, infant mrtality nwadays is within a range f 0.5% and 1.5%. T put it differently, in these cuntries apprximately 99% (r even mre) survive the first year f life. There is n denying the human tragedy invlved in every premature and preventable lss f a child. Hwever, ne cannt but feel that it is challenging cmmn sense t disregard r belittle the tremendus achievements f mdern sciety by bringing dwn infant mrtality frm 20% r mre t 1 % r less within a few decades. (There is als an ccasinal cautining that medical technlgy increasingly keeps alive infants f pr health and with defects which are beynd remedy, a subject matter fr which at present there is little slid evidence t either back it up r refute it.) The impressive reductin in the level f infant mrtality is als reflected in Prestn's and cllabratrs' cmments n the slpe f relatins between class and mrtality in England and Wales, where they cncluded that «belnging t a lwer class invlves less sacrifice in terms f the abslute excess mrtality in 1970-72 than earlier but it invlves mre sacrifice in prprtinate terms»< 16 ). The essential prblem f chsing an apprpriate scale fr the assessment f mrtality differentials is, by implicatin, raised, i.e., abslute versus relative advantage. In the late 1950s a cntrversy arse in the epidemilgical literature regarding the first reprts n the assciatin between smking and healthd?) including the measurement f «excess risk», depending n whether «successes» r «failures» are cunted. In the case f infant mrtality, there are tw pssible utcmes, namely either survival (the success) r death (the failure). (It is interesting t nte that what is knwn as «life table» in ne cuntry, is the «mrtality table» in anther). An examinatin f this prblem led t the cnclusin that «different methds prvide estimates f quite different magnitude and mrtality rates always have, n the ther side f the picture, cmplementary success rates. When the cmplementary rates are f quite different levels, any relative cmparisn f the results is greatly affected by the chice f the denminatr in the cmparisn...» and «... relative mrtality, relative survival and abslute differences are equally valid cmparisns, each with its wn meaning. Hwever, since they may give very different impressins f the bservatins, it may be well always t cnsider several cmparisns»^8). Using data fr England and Wales as an example, Table 1 presents infant mrtality rates fr the five scial classes ver a perid f almst 60 years (n data have been published fr the years arund the 1961 Census); Table 2 cntains the average annual rates f decrease. The tw tables serve as backgrund t the fllwing expsitin but it may be wrth nting that the mst impressive reductins are recrded fr the «middle classes», i.e. classes II, III, and IV. Likewise, the striking imprvement in the late 1970s, encmpassing all scial classes, shuld be nted, pinting t the imprtance f the time frame f the study.

352 T appreciate the magnitudes invlved the fllwing cmparisn is instructive: " f legitimate live brn assigned t each f the scial classes in England and Wales Scial Class I II III IV V 1921 02 15 45 23 15 1978/ 08 21 49 16 05 This cmparisn als highlights anther essential issue in trend analyses f scial class differentials in mrtality, namely the changes in the scial class make-up f the ppulatin (denminatr). Table 3 shws the develpment f varius indices' (a shrt descriptin f the main features f each f these indices is given in the appendix A). The main pint t be made here is their cnsistency, suggesting that up t 1970-72 the cut-ff date fr mst f the research quted in the previus part scial class differences in infant mrtality have persisted, r may even have wrsened. (Hwever, extensin f the time frame f the study t 1978-79 indicates a lessening). Table 4 presents the same indices, their cmputatin, hwever, having been based nt n the failures but n the successes, resulting in a remarkably been cnsistent and straightfrward trend twards greater equality in survival. Frm the pint f view f scial plicy, a case can be made fr using either f the tw as yardsticks fr measurement f change. T put it succinctly: «Fr the plitician, the ability t chse whichever statistic gives him the answer he desires is pssibly very cnvenient)^19 ). A mre lenient (and mre psitive) interpretatin suggests that clear frmulatin f study bjectives (and hyptheses t be tested) is indispensable fr chsing the mst apprpriate measures. T recapitulate briefly sme pssibilities fr measuring differential risk, the perfrmance f scial classes I and V in England and Wales is cmpared fr 1921 ) In additin, at the suggestin f Prfessr J. Häuser (Zurich) Atkinsn's index has been cmputed fr tw levels f E, the measure f the relative sensitivity t transfer at different levels, namely E = 1 (i.e. relatively lw sensitivity) & E = 2 (relatively mre weight is given t transfers at the lwer end f the distributin than in the case f E= 1). The results are in line with and thus reinfrce the abve cnclusins (fr details see A. Atkinsn: On the Measurement f Inequality, Jurnal f Ecnmic Thery 2, p. 244 ff. 1970). In fact, the Atkinsn index shws clearly the imprtance t be attached t «weights» (i.e. the scial welfare functin). As Nakada has pinted ut, all the indices cmputed may be misleading if the Lrenz curves d nt intersect (unpublished nte).

353 and 1970-72 as a demnstratin f the kind f impressin ne may get depending n the particular measure adpted and prving nce mre the imprtance f using varius measures and checking them fr cnsistency. A. Mrtality based apprach 1921 1970-72 1. Rati f V t I 2. Rati f I t V 3. Difference in rates 4. Preventable death in %* B. Survival based apprach 1. Rati f V t I 2. Rati f I t V 2.53 0.40 59 60 0.94 1.07 2.65 0.38 19 62 0.98 1.02 In shrt, the survival rates cnvey the impressin f a cnvergence f differentials, whereas the ratis f the mrtality rates pint t a widening whse extent hwever is mre dramatic when relating class V t class I than vice versa. Estimating the number f infants whse death might have been avided if the sciecnmic circumstance f class I had prevailed, suggests that practically n change had ccurred. It als cnveys a different psychlgical impressin t state that the rate fr class V is tw and a half times that f class I rather than saying that the rate f class I is 60% lwer than that f class V.. In ne f the few internatinally crdinated investigatins, the «Scial and Bilgical Effects n Perinatal Mrtality» have been studied. In the discussin f the results, it was stated that «N tw cuntries handle this cncept (i.e., sciecnmic gruping) in exactly the same way». Therefre, the analysis was limited t sme measures f sciecnmic status as used in the participating cuntries and «... nt t make cmparisns between them ther than f a qualitative nature»^). The principal findings f this study in which Austria, Cuba, England and Wales, Hungary, Japan, New Zealand, Sweden (fr which n pertinent infrmatin was available) and the USA participated were: (i) With the pssible exceptin f Hungary, each cuntry shwed a gradient by father's ccupatin, rising mre r less cntinuusly frm the prfessinal and technical and administrative grups t the agricultural and prductin grups (the grups were frmed n the basis f the Internatinal Standard Classificatin f Occupatins); * Cmputed n the assumptin that the «excess» as given in line 3 cnstitutes the «preventable» cmpnent in Scial Class V infant mrtality.

354 (ii) In Cuba, a fairly clear sciecnmic gradient culd be detected when the discriminant variable was mther's educatin but nt when it was mther's ccupatin. Turning t adult mrtality, ne may refer t Chiang and Pllard< 21 ) wh have lately cmmented n the cmplicated relatinship between mrtality and expectatin f life and its implicatins fr analyzing trends in differentials. It was shwn that equal abslute reductins in the frces f mrtality cause a widening f the differential in life expectancy at birth and that changes in expectatin f life may be expressed as a weighted functin f mrtality changes f individual ages plus the interactin effects f thse mrtality changes. Such interactin effects may influence trends in differentials in life expectancy. Pllard cncluded, therefre, that «it is dangerus t use the expectatin f life fr this purpse (i.e., mrtality differentials) but, in case the main interest is n survivrship rather than mrtality, the use f the expectatin f life is clearly apprpriate». Fr illustratin f this pint, ne may refer t a recent statement by Prestn and cllabratrs^), namely that relative measures f the inequality f mrtality in England and Wales have nt imprved between 1921/23 and 1970/72 but shw a «clear deteriratin» (if the analysis is based n thefivescial classes it is less marked when based n 182 ccupatin grups). They als pinted ut that fr males there is a wrsening when using «ne abslute measure» but nt fr wmen and children. In cntrast, Silberi 27 ) in an examinatin f health inequality in England and Wales, (cvering the century between the early 1860s and 1960s) arrived at the cnclusin that «inequalities befre death are less imprtant tday than they were in the past; this imprvement being parallel t the average number f years lived». This cntradictin reflects the differences in the time span cvered and, mre imprtant, in the methds f measurement. Therefre the cmputatin f mre than ne index and preferably als the use f mre than ne discriminant variable are advisable. This useful apprach has been adapted fr instance by Fx and Gldblatt in their recent lngitudinal study f sciecnmic mrtality differentials in England and WalesG 4 ). Checks fr cnsistency and a lk at the prblem frm bth sides, the psitive ne f survival and its cmplementary negative aspect (life expectancy and «survival rates» may be regarded as «psitive health indicatrs»*«) may shed further light. Studies f sciecnmic differences in mrtality have usually nly cvered infancy and mrtality at wrking age (generally defined as age 15 t under 65). Hwever, the wrking age accunts nwadays fr nly a relatively mdest prprtin f all deaths (in many MDCs, less than 30% f males and less than 20% f female deaths). There is sme scepticism, hwever, abut extending the scpe f enquiry int ld age, partly because f prblems f methdlgy and interpretatin but als because f dubts cncerning the plicy relevance f an analysis f differentials beynd let us say age 80 and lder (similar

' - ',.... : - " 3 5 5 questins are ccasinally raised cncerning the practical value f cause f death statistics in very ld age). Hwever, current effrts in several MDCs t lwer the age f retirement underline the imprtance f nt ignring this aspect which may be f rising imprtance in the years ahead. T summarize, sme f the salient pints t be cnsidered in the study f scial inequality f death are listed belw: (1) Axis f classificatin, i.e., whether the gruping by scial class r sciecnmic grup is based n educatin, ccupatin etc.; (2) Cmparability f these classificatins in time and/r amng cuntries; (3) Shifts (differences) in the scial class cmpsitin f the ppulatin;. (4) Number f classes (grups) distinguished in the investigatin; (5) Chice f standard and summary index (such as methd f standardizatin etc.); (6) Scale used (abslute r relative);.,.... (7) Measurement f survival (length f life) r mrtality; (8) Time span cvered by the study. A prper understanding f the evlutin als requires a decmpsitin int the factrs respnsible, i.e., an identificatin f the directin and pace f change in each f the classes (sub-grups) in rder t arrive at apprpriate plicy cnclusins. It is imprtant, t, t assess differentials within a given cuntry in relatin t the natinal perfrmance, i.e., hw far they affect the standing (and ranking) f the cuntry in cmparisn t thers at a similar level f develpment. Tw factrs cme in here, namely (i) the level f mrtality in each identified subgrup and (ii) their numerical weight, the natinal rate being a weighted average f the levels recrded fr the individual sciecnmic grups. A verdict such as that between 1960 and 1975 England and Wales has dne «substantially less well than any ther cuntry» (i.e. amng thse MDCs studied) with regard t lwering its infant mrtality, whereas France has significantly imprved its psitin, must be duly cnsidered when appraising a cuntry's perfrmance* 26 ). Cnclusins 1. The mere availability f infrmatin severely inhibits sweeping generalizatin n the extent and directin f scial class differentials in mrtality in MDCs. Althugh mre recently studies f differential mrtality in the 1970s have been carried ut in a number f cuntries and even mre cuntries have plans t examine the situatin in the early 1980s, claims f stagnatin r even aggravatin f inequalities in mrtality usually draw n the experience f France, the United States and, abve all, Britain, three cuntries whse representativeness fr the grup f MDCs is pen t dubt. Hwever, the very existence f sciecnmic

356 differentials in mrtality and in the length f life thrughut the MDCs can nt be disputed. 2. As van Pppel has pinted ut, the gains t be expected frm an eliminatin f reginal differences in Western and Nrthern Eurpe wuld apprximate thse t be expected frm the cnquest f malignant neplasms^?). The cllectin f pertinent infrmatin as an integral part f scietal mnitring shuld, therefre, be given much mre attentin than hithert. It is t be stressed that new develpments in data cllectin strategies make it feasible t derive pertinent infrmatin with relatively little extra cst. Such schemes, currently being develped, inter alia, in England and Wales and France and the Nrdic cuntries ffer a wide range fr plicy relevant analysis f which the study f scial inequality f death cnstitutes but a part, albeit an imprtant ne. 3. In view f the crucial rle f indices f health in the assessment f inequalities and inequities in sciety, great care shuld be exercised t avid pitfalls and errneus interpretatin. By spelling ut clearly the bjectives f an investigatin and presenting a balanced picture, making full use f ur statistical armamentarium, the range f uncertainty and ambiguity can be significantly narrwed dwn. 4. The study f the magnitude and evlutin f differential mrtality pses many and as yet largely unreslved prblems. Genuine differences in interpretatin f findings cannt be ruled ut nr blatant abuse. As an example f the prblems encuntered, it was stated that «there are als numerus anmalies which are nw an enigma fr ur understanding, e.g., why are the prer Italian regins experiencing the lwer mrtality levels?»* 28 ). 5. Differentials in mrtality reflect nly a part f the prblem, particularly in MDCs with generally lw mrtality levels (this is nt t belittle still existing gaps amng segments). Hwever, ne must stress the imprtance f mving beynd mrtality and f investigating differences in ill-health (mrbidity and disability) as well as in the physical and intellectual develpment during childhd. T identify fr instance the cntributin f differences in disease incidence and survival experience t differentials in mrtality prvides valuable infrmatin fr apprpriate remedial actin. By adpting this brader apprach, the task f alerting public cnscience will be facilitated and a firmer fundatin laid fr the executin f apprpriate plicies. 6. The fight against scial inequality f death is being waged n tw frnts. On the ne hand, there are effrts t change the scial class cmpsitin f the ppulatin s as t be mre in line with ne's plitical philsphy (and, generally speaking, reduce the numerical imprtance f the mre disadvantaged scial grups) and n the ther hand, there are the «direct» steps t reduce mrtality in the varius segments f the ppulatin, particularly amng thse with an «excess» mrtality. It is imprtant t distinguish clearly between these tw aspects.

357 7. Sight shuld nt be lst f the tremendus achievement twards equalizatin f life chances made and still being made in the MDCs. This shuld nt be cnsidered as an invitatin fr cmplacency, particularly at a time f retrenchment f scial prgrammes. Hwever, t ignre the psitive aspects f the develpment and fail t place the sciecnmic grup differentials in the brader perspective f the natinal trends and levels may turn ut t be the wrng strategy. 8. Ultimately the debate abut scial class differentials in mrtality (and by implicatin, health) will centre n the questin whether inequality in ill-health is avidable r nt. And even if cmplete equality were Utpian, hw much prgress is still feasible? Perinatal and infant mrtality are examples f achievements which, a few decades ag, were cnsidered beynd reach. References Intrductin Amng the mre recent surces n methdlgical issues and recent findings t be cnsulted are: (i) Prceedings f the meeting n sciecnmic determinants and cnsequences f mrtality, El Clegi de Mexic, Mexic City, June 1979, WHO and UN, Geneva 1980; (ii) Inequalities in Health Reprt f a Research Wrking Grup, DHSS, Lndn 1980; (iii) J.P. Surault: L'Inégalité devant la mrt, Ecnómica, Paris, 1979; (iv) E. Lynge: Sciecnmic Differences in Mrtality in Eurpe, parts I t III, Cmmittee f Experts n Mrtality and Mrbidity (DE-MM), Cuncil f Eurpe, March 1983 and (v) Sciecnmic Differentials in Mrtality in Industrialized Scieties, CICRED, UN and WHO, Vls. I and II, 1981 and 1982 respectively. 1. See fr instance, Prceedings f the Cnference n the Decline in Crnary Heart Disease Mrtality, Bethesda, Octber 1978, US Department f Health, Educatin and Welfare, NIH Publicatin N. 79-1610, May 1979 and Z. Pisa, K. Uemura: Trends f mrtality frm ischaemic heart disease and ther cardivascular diseases in 27 cuntries, 1968-1977; Wrld Health Statistics Quarterly, Vl. 35, N. 1, 1982, p. 11. 2. Because f limitatins impsed by the availability f pertinent data, the fllwing sectins mre r less refer t the mre develped cuntries withut the scialist cuntries f Eurpe. 3. A. Sauvy: Preface p. VII and IX t P. Surault: L'Inégalité devant la mrt; Ecnómica, Paris, 1979. 4. J. Vallin, quted by G. Myers in his discussant statement. Prceedings f the meeting n sciecnmic determinants and cnsequences f mrtality, El Clegi de Mexic, Mexic City, June 1979, WHO and UN, 1980, p. 378. 5. M. Susser: Industrializatin, urbanizatin and health: an epidemilgical view; in IUSSP Internatinal Ppulatin Cnference, Manila 1981, Vl. 2, p. 292 f. 6. S. Prestn and Cllabratrs: Effects f industrializatin and urbanizatin n mrtality in develped cuntries; IUSSP Internatinal Ppulatin Cnference, Manila 1981, Vl. 2, p. 254. 7. Sir J. Brtherstne: Inequality: Is it Inevitable? in Equalities and Inequalities in Health, Lndn 1975, p. 77. 8. See fr stance Martini and Cllabratrs: Health indexes sensitive t medical care variatin: Internatinal Jurnal f Health Services, Vl. 7,1977, p. 293 ff; and O. Andersn: Health Care Can there by Equity? New Yrk 1972, p. 158; J. Cllins: The cntributin f medical measures t the decline f mrtality frm respiratry tuberculsis Demgraphy, Vl. 19, N. 3, 1982, p. 404 ff and C. Stewart: Allcatin f resurces t health Jurnal f Human Resurces, Vl. 6, 1971, p. 103 ff.

358 9. See reference 7, P. 89. 10. See fr instance T. Valknen as quted in Sciecnmic Differentials in Mrtality in Industrialized Scieties, Vl. 2, CICRED 1982, p. 9 and the cntributins by W. Brass, J. Fx, G. Myers and J. Vallin published in the Prceedings f the Meeting n Sciecnmic Determinants and Cnsequences f Mrtality, El Clegi de Mexic, Mexic City, June 1979, WHO and UN 1980 and R. Leete and J. Fx: The Registrar General's Scial Classes: the rigins and uses. Ppulatin Trends, 1977, p. 1 ff. ll.seeref. 6, p. 251 13. See fr instance, J. Drewnwski: Scial Indicatrs and Their Applicatin fr Measuring the Prgress f Develpment WPR/W6/HFA/82.6, WHO Reginal Office fr the Western Pacific, Manila 1982 and J. Fx and P. Gldblatt: 1971-1975 Lngitudinal Study: sci-demgraphic mrtality differentials Office f Ppulatin Censuses and Surveys, Series LS, n. 1. Lndn, 1982. 14. See fr instance the bibligraphy n measures f diversity and their applicatin cmpiled by B. Dennis and cllabratrs: A bibligraphy f literature n eclgical diversity and related methdlgy Eclgical Diversity in Thery and Practice, Vl. I, 1979, p. 319 ff. 15. As ne f its glbal indicatrs fr mnitring prgress twards Health fr All by the Year 2000, WHO has selected infant mrtality fr «all identifiable sub-grups», a nt t frtunate frmulatin. Cuntries are being requested t give «at least» the range between the best and wrst rate (withut sllicking abslute figures). 16. See ref. 6, p. 251. 17. M. Sheps: Shall we cunt the living r the dead? The New England Jurnal f Medicine, 1958, p. 1210 ff. and: An Estimatin f Sme Methds f Cmparing Several Rates r Prprtins Bimetrics, Vl. 15, 1959, p. 87 ff. See als J. Berksn: Smking and lung cancer: sme bservatins n tw recent reprts; J.A.S.A., Vl. 53, 1958, p. 28 ff. and Smking and Health: Reprt f the Advisry Cmmittee t the Surgen General f the Public Health Service; Washingtn, D.C., 1964. 18. See reference 15, M. Sheps, p. 1212. 19. J. Pllard: Methdlgical Issues in the Measurement f Inequality f Death; in Mrtality in Suth and East Asia A Review f Changing Trends and Patterns 1950-1975. WHO/ESCAP, Manila 1982, p. 544. 20. A WHO Reprt n Scial and Bilgical Effects n Perinatal Mrtality, Vl. I, 1978, Budapest. See in particular Chapter 8, p. 87 ff. 21. The Life Table and Its Applicatin (in press); The Life Table and Its Relatinship t Mrtality, Macquarie University, Schl f Ecnmic and Financial Studies, Research Paper N. 247,1982; see als K. Hanada: Indices fr Measurement f Inequality in the Distributin f Length f Life; unpublished dcument, WHO, Geneva, 1982. 22. See reference 6, p. 251. 23. Health and Inequality: Sme Applicatins f Uncertainty Thery. In Scial Science and Medicine, Vl. 16, N. 19, 1982, p. 1663. 24. See ftnte 11. 25. See fr instance: Develpment f Indicatrs fr Mnitring Prgress twards Health fr All by the Year 2000, WHO Geneva, 1981, p. 35. 26. Twnsend, P. and Davidsn, N.: Inequalities in Health, Penguin Bks, 1982, p. 93. 27. Prceedings f the 1979 Mexic City Cnference, p. 351 ff. 28. Glini, quted in Sciecnmic Differential Mrtality in Industrialized Scieties, N. 2, CICRED, Paris 1982, p. 9.

Table 1. Infant Mrtality (per 1,000 live brn) by Scial Class in England and Wales 359 Year (s) I II Scial Class III IV V All Classes 1921 1930-32 1949-53 1970-72 1978-79 38 33 19 12 10 55 45 22 14 10 77 58 29 16 12 89 67 34 20 14 97 77 41 31 18 79 61 29 17 12 NOTE: I = prfessinal ccupatins II = intermediate III = skilled ccupatins IV = semi-skilled ccupatins V = unskilled ccupatins SOURCE: Registrar General's Decennial Supplement fr 1921, 1930-32, 1949-53, 1970-72. Mrtality Statistics Perinatal and Infant: Scial and Bilgical Factrs 1978, 1979. Table 2. Annual Rates f Change (%) in Infant Mrtality by Scial Class in England and Wales Year(s) I II Scial Class III IV. V All Classes 1930-32/1921 1949-53/1930-32 1970-72/1949-53 1978-79/1970-72 1978-79/1921 1.6 5.4 2.4 2.2 2.3 2.1 7.1 2.3 4.2 3.0 2.8 6.7 2.7 4.6 3.2 2.9 6.6 2.7 4.4 3.2 2.3 6.2 1.4 6.8 2.9 2.5 7.1 ' 2.7 4.8-3.2 NOTE: I = prfessinal ccupatins II = intermediate III = skilled ccupatins IV = semi-skilled ccupatins V - unskilled ccupatins

360 Table 3. Indices f Inequality f Infant Mrtality in England and Wales Year (s) D Indices f Inequality (based n infant mrtality) G ID CV SDLN THEIL 1921 1930-32 XlO 3 909 913 XlO 3 91 87 XIO 3 65 67 xlo 3 172 166 xlo 3 192 175 xlo " 158 140 1949-53 906 94 64 185 187 170 1970-72 1978-79 895 918 105 82 74 59 236 170 205 155 248 135 NOTE: D Drewnwski's index G Ginil's cefficient ID Index f dissimilarity CV Cefficient f variatin (weighted) SDLN Standard deviatin f lgarithms (weighted) THEIL Theil's index Table 4. Indices f Inequality f Infant Survival (up t 1 year f age per 1,000 live-brn) in England and Wales Year (s) D Indices f Inequality (based n infant survival) G ID CV SDLN THEIL 1921 1930-32 1949-53 1970-72 1978-79 xlo 3 992 994 997 998 999 XlO * 78 57 28 18 10 XlO-4 56 44 19 13 7 xlo 4 148 109 56 41 21 xlo 4 147 109 56 41 20 xlo 7 1085 586 154 78 16 NOTE: D Drewnwslci's index G Gini's cefficient ID Index f dissimilarity CV Cefficient f variatin (weighted) SDLN Standard deviatin f lgarithms (weighted) THEIL Theil's index

361 5 Í S t u. es ' S I s -g- s Q Si e» 8-a O O il >? S a-g "H * C J <s Is V) O O # 5 *- 3 c.2 ä " 'S «ä O T3 a u S 3 cl Ë 3. S 2 60 S C nt 8 S I II 8üC S'il 3 es g 'C 3 ~ U 0 «I U 1 S O Ë «E w S3 <X ' 3 <L> Î t I U a U I.,-2«111 nde cu Q ient u u m 'S 8 u.s es O U E 1l c 'g Q a 2 S 52. H 3=3' < te l u

Tip. Artigiana Multistampa Snc - Rma, 1984