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Mortality in Developed Countries
Statistics on causes of death are reported annually to the World Health Organization (WHO) by countries with vital registration systems. These countries--primarily developed* countries--include Australia, Canada, Israel, Japan, New Zealand, Union of Soviet Socialist Republics (USSR), United States of America, all of Europe (except Albania), and certain Latin American countries. This report compares mortality data for the latest year available (ranging from 1984 through 1987) among 33 North American, European, and other selected developed countries (Table 1). These countries have a combined population of approximately 1.2 billion, or one quarter of the estimated world total in 1986. Death rates are standardized for age but not for race/ethnicity or sex.
In the selected countries, approximately 11 million persons died annually from 1984 through 1987, an age-standardized all-cause death rate of 905.2 per 100,000 population per year (Table 1). Mean life expectancy at birth was 73.7 years and ranged from 69.7 years in Hungary to 79.1 years in Japan (Table 1). Average life expectancy at birth was 77.2 years for females and 70.1 years for males.
Approximately 3.3 million (30%) deaths annually were due to heart disease, 2.3 million (21%) to cancer, 1.5 million (14%) to stroke, 0.9 million (8%) to chronic respiratory diseases, and 0.8 million (7%) to violent causes (i.e., intentional and unintentional injuries). An estimated 1.5 million (14%) deaths annually are attributed to cigarette smoking.
Years of potential life lost before age 65 (YPLL) (3) is a measure of premature mortality that considers only deaths occurring before age 65 and more heavily weights deaths at younger ages. In the selected countries, 3.4 million (31%) deaths occurred in persons less than 65 years of age. YPLL varied greatly among these countries, from 3334.3 per 100,000 population in Japan to 10,257.5 per 100,000 population in the USSR (Table 1). Rates of YPLL were particularly high in eastern Europe. Adapted from: World Health Organization, Wkly Epidemiol Rec 1989;64:103-7, by Div of Surveillance and Epidemiologic Studies, Epidemiology Program Office, CDC.
Editorial Note: Mortality in countries included in this report constitutes 22% of the estimated 50 million deaths worldwide in 1986. Although data are reported for these countries for different years, the comparison of mortality is unlikely to be affected by yearly changes in the rate and distribution of causes of death. Selection of countries for the present analysis reflects the availability of mortality information. However, reference to these countries as "developed" is based on definitions published in 1963 (1) and may not reflect current socioeconomic characteristics.
Comparison of mortality characteristics of different countries assists health planning and the generation and investigation of epidemiologic hypotheses. International studies, such as studies of the association of aflatoxin and primary liver cancer (4), can reveal a range of exposure levels and disease rates not found in individual countries. However, although death registration is virtually complete in these countries, reporting of cause of death is not uniform either among or within European countries or the United States (5,6). Only comparison of all-cause mortality among developed countries is likely to be accurate. Demographic heterogeneity also constrains the comparison of populations.
The estimate of 1.5 million deaths annually attributed to cigarette smoking in the selected countries is based on population-attributable fractions associated with cigarette smoking in the United States (7) and applied to mortality rates in other developed countries. Because cigarette smoking among adults is more prevalent in Europe than in the United States (8,9) (Table 2) and because European cigarettes contain more tar (11), this method may underestimate the proportion of deaths attributable to cigarette smoking in the developed world.
The United States ranks as 13th lowest in all-cause age-adjusted death rate per 100,000 population among these 33 countries. Although the proportion of deaths from cancers is higher in the United States than in the other 32 countries combined, trends in U.S. cancer mortality are similar to those in the other countries (12). Compared with other countries, the United States also has a greater proportion of deaths from heart disease; however, between 1973 and 1983, mortality from heart disease declined more rapidly in the United States than in any other developed country (13).
The United States has the highest per capita gross national product (GNP) and health-care expenditure (10)--each more than double the median among the other countries (Table 2). However, among these countries, the United States has the median (17th highest) life expectancy at birth and ranks 10th highest in YPLL. Further efforts should be directed toward understanding the relationship of GNP, health-care expenditures, and risk-factor prevalences to mortality outcomes in the developed world.
Further surveillance of risk factors for mortality worldwide (14) could provide broader insight regarding the public health importance of different risk factors in the reduction of mortality. The range of mortality outcomes described in this report suggests that much premature mortality can be eliminated. The large number of deaths attributable to cigarette smoking indicates that reduction of this risk factor would substantially increase life expectancy in the developed world.
World population prospects as assessed in 1963. New York: United Nations, 1966. (Population studies, no. 41).
2. Waterhouse J, Correa P, Muir C, Powell J, eds. Cancer incidence in five continents. Vol III. Lyon, France: International Agency for Research on Cancer, 1976.
3. CDC. Premature mortality in the United States. MMWR 1986;35(no. 2S).
4. Wogan GN. Dietary factors and special epidemiological situations of liver cancer in Thailand and Africa. Cancer Res 1975;35:3499-502.
5. Kelson M, Farebrother M. The effect of inaccuracies in death certification and coding practices in the European Economic Community (EEC) on international cancer mortality statistics. Int J Epidemiol 1987;16:411-4.
6. Gittlesohn A, Senning J. Studies on the reliability of vital and health records. I. Comparison of cause of death and hospital record diagnoses. Am J Public Health 1979;69:680-9.
7. CDC. Smoking-attributable mortality and years of potential life lost--United States, 1984. MMWR 1987;36:693-7.
8. Commission of the European Communities. Survey: Europeans and the prevention of cancer. Brussels, Belgium: Commission of the European Communities, 1987.
9. NCHS. Smoking and tobacco use: United States, 1987. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, 1989; DHHS publication no. (PHS)89-1597. (Vital and health statistics; series 10, no. 169). 10. Bureau of the Census. Statistical abstract of the United States, 1989. 109th ed. Washington, DC: US Department of Commerce, Bureau of the Census, 1989. 11. International Agency for Research on Cancer. IARC monographs on the evaluation of the carcinogenic risk of chemicals to humans: tobacco smoking. IARC Monographs, 1986;38:54--66. 12. Stanley K, Stjernsward J, Koroltchouk V. Cancers of the stomach, lung and breast: mortality trends and control strategies. World Health Stat Q 1989;41(3/4):107-14. 13. World Health Organization. World health statistics annual, 1987. Geneva: World Health Organization, 1987. 14. WHO MONICA Project Principal Investigators. The World Health Organization MONICA Project (monitoring trends and determinants in cardiovascular disease): a major international collaboration. J Clin Epidemiol 1988;41:105-14. *The United Nations refers to countries as "developed" that had a gross reproduction rate of less than two in 1963. The gross reproduction rate is "the average number of daughters that would be born per woman and would survive to the end of her reproductive period in accordance with the prevailing age-specific fertility rates" (1).
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