**2. Long-term trends in mortality: The Czech Republic, France, and United States**

**1. Introduction**

140 Senescence - Physiology or Pathology

advances only.

1

expectancy at birth in the Czech Republic,1

30 and 80 using temporary life expectancy indicator.

All results are related to the territory of the current Czech Republic

Kitagawa and Hauser [1] did the first one of the most complete studies of mortality differentials by socioeconomic status (SES) in the United States. They found that higher SES groups exhibited lower rates of all-cause mortality than did lower SES groups. Later on, the Black Report on Inequalities in Health [2] published by the Department of Health and Social Security in the United Kingdom launched debates about widening socioeconomic inequalities in mortality. Significant differentials in mortality by SES had been identified despite a tremendous increase in life expectancy at birth after the World War II. Since then, many studies have pointed out the differences in mortality by socioeconomic status [1, 3–8]. Moreover, time trends in socioeconomic inequalities in mortality have shown a widening of the gap, in relative terms, in Europe as well as in North America [9–12]. Education, occupational status, and income are the most widely used indicators of socioeconomic status. In reality, socioeconomic stratification reflects benefits or returns of a given educational attainment. Therefore, education has become one of the most commonly used indicators of socioeconomic position. The reasons for its use are that educational level can be determined for all individuals (including older people and women). Educational attainment is normally completed by the early adult years and does not change later in life [13]. The educational level can be considered as a proxy not only for the socioeconomic position/class but also because better‐educated people lead a healthy lifestyle and can be more efficient consumers of health care. They are also more likely to take advantage of new technologies especially in treatment and prevention [6, 14, 15]. Therefore, the inverse association between education and mortality risk (the gradient) has been evidenced in many studies as well [6, 16–19]. Educational attainment is also a concrete indicator (compared to occupation)

for policymakers when deciding the health or social policies and investments [15].

Educational inequalities in mortality are large in Central and Eastern Europe [20]. Mortality levels are particularly high among low educated men as well as women in the Czech Republic. Therefore, we assume that on average, higher levels of schooling cause people to live longer. The main purpose of our study is to find out to what extent the shifts in population structure toward higher education or mortality reduction based on the shifts of death rates toward one higher educational degree will impact on temporary life expectancy between ages 30 and 80. Changes in education‐associated excess mortality aimed at lowering the risks present a challenge for social and health policies. For instance, Woolf et al. [21] showed that more lives would be saved by eliminating education‐associated excess mortality than by medical

The contribution will address the following issues: First, to show long-term trends in life

in life expectancy at age 30 by education for selected European countries. Third, to present three scenarios that will show how shifts (in population structure or in mortality rates) toward a higher education contribute to the change in all-cause mortality level between ages

France, and USA. Second, to illustrate differentials

In 2012, US life expectancy at birth reached 81.2 years for women and 76.4 years for men [22]. These figures can also be found in the Czech Republic in 2015 [23] where women's life expectancy at birth was almost the same reaching 81.4 years and slightly shorter for men with 75.8 years (Czech Republic 2012: men 75.0; women 80.9). However, in the United States, the life expectancy at birth for both women and men is not as long as in France [24]. In 2012, French women lived 4 years longer than their American counterparts—84.8 years versus 81.2 years—and for men, the figures were 78.5 and 76.4 years, respectively. Looking back to the history, more particularly before the World War II, the situation was the reverse and US males and females enjoyed better survival [25]. Since the 1980s, life expectancy has increased much more slowly in the United States compared with France and the lag behind France is widening (**Figure 1a** and **b**).

The American slowdown is especially marked among women. Current US lower life expectancy at birth compared to French one is for instance explained by the fact that although the United States are world leaders in technological and medical innovation, not all inhabitants benefit equally. Unlike Europe, a large proportion of the US population have no health

**Figure 1.** a) Trends in life expectancy at birth since 1920, males. b) Trends in life expectancy at birth since 1920, females.

insurance, and their access to health care is limited [25]. Despite the recent slowdown, US healthcare expenditures exceed those of other high‐income countries in Europe [26]. The high cost of US healthcare may to some extent explain the higher levels of mortality compared to the high income population of Europe. In July 2014, The Lancet journal published a series of contributions on the health of Americans [27]. According to the authors, a fragmented healthcare delivery system, social environments (differences in health outcomes according to race, education, region), and individual risk factors (health-related behavior: obesity, smoking, physical inactivity, alcohol use, diets low in fruits, and vegetables) play an important role for length of life.

The Czech Republic manifests four dissimilar stages of mortality development (**Figure 1a** and **b**): before World War II; between World War II and mid‐1960s; from the mid‐1960s to the mid‐ 1980s; and from the mid‐1980s until now [28]. During the interwar period up to the mid‐1960s, male and female survival in the Czech Republic was close to the levels observed in France [29]. However, age‐specific mortality rates at that time were different in both countries. Before WWII, a high infant mortality rate in the Czech population was counterbalanced by a lower mortality at adult ages. Between World War II and the mid‐1960s, the situation reversed and the upward trend of life expectancy at birth accelerated mainly because of the decrease in infant mortality rate, while adult and old age mortality had not changed too much. In the Czech Republic from 1950, all health services were nationalized, provided free of charge, and were accessible to anybody according to the new law. Particular attention was paid to child and mother. The comprehensive network of services was established for children and preventive vaccination and medical check‐ups became compulsory. The "health‐extensive approach"—a large number of medical staff with limited expenditures for equipment, drugs, and maintenance—was successful in reducing and controlling communicable and infectious diseases. Later on, the emergence of new degenerative diseases required a "health intensive approach" involving specialized training, sophisticated equipment, and expensive procedures and drugs. Despite growing awareness among the medical profession, health systems were not able to adjust to the changing health needs of the population. Therefore, the trend of increased mortality started in the mid‐1960s and affected most of the population of Central and Eastern Europe including the Czech Republic. The deterioration was particularly marked for the elderly and middle-aged adults and primarily for men. A substantial part of the mortality increase was attributable to an "epidemic" of heart diseases. To a lesser degree, an increase in cerebrovascular diseases, lung cancer, and cirrhosis of the liver was noticed [29]. For instance, by the mid‐1980s, the mortality rate from cardiovascular and cerebrovascular diseases was twice as high in the Czech Republic than in France [29]. It appears that the negative mortality development in the Czech Republic since the mid‐1960s can be interpreted as an accumulation of previous problems (relatively high mortality of the elderly) and of inapt solutions for new ones (rising intensity of degenerative diseases). From that time, the gap in life expectancy between the Czech Republic and France or USA began to widen rapidly. Since the mid‐1980s a new favorable trend in mortality has appeared in the Czech Republic, a new mortality decline has been initiated [28]. From the medical perspective, the use of cardiovascular drugs and the number of operations such as invasive heart surgery increased considerably. In addition, the structure of treatment shifted from traditional medicines to the new generations of drugs. The surgical and invasive procedures such as coronary artery bypass grafts, valve replacements, and angioplasties have also significantly increased [30]. The period of transition, beginning after 1989 and accompanied by political, economic, social, and behavioral transformations, has had a different impact on health conditions in former socialist countries. The Czech Republic escaped "Eastern European mortality crisis" [31] and its health situation improved more rapidly. However, the time delay of the Czech Republic in the reduction of mortality rate compared to France is too big, and therefore, the recent improvement in survival rates has not diminished the gap between both countries and life expectancies at birth have followed an almost parallel trend.
