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Personnes âgées et vulnérabilité, populations vulnérables, autant de thèmes dont l’actualité deviendra de plus en plus brûlante, sous l’effet du double phénomène de vieillissement qui marque l’histoire récente des populations humaines : vieillissement biologique, que depuis toujours tout individu vit dans sa chair et dans son esprit, et vieillissement démographique, qui depuis moins de deux siècles affecte peu à peu toutes les populations humaines, au fur et à mesure qu’elles opèrent leur tra...

Dans les pays les plus avancés, la mort survient de plus en plus aux grands âges. En France, par exemple, en 2016, 73 % des décès féminins se sont produits après 85 ans, alors que ce n’était le cas que de 41 % en 1975 et même seulement 25 % en 1950. Alors que le sujet paraissait jadis anecdotique, des chercheurs s’interrogent de plus en plus sur ce que peuvent être les causes de décès aux grands âges. Beaucoup, cependant, estiment que la question est relativement vaine car plus l’âge avance, plus les causes sont multiples ce qui rend d’autant plus difficile la détermination d’une cause principale tandis que de leur côté les médecins déclarants posent souvent des diagnostics flous. Il est vrai que le nombre de décès dont la cause est mal définie, voire non déclarée, augmente avec l’âge, mais il nous semble néanmoins que les certificats médicaux de cause de décès portent de plus en plus d’informations exploitables jusqu’à des âges très avancés dans beaucoup de pays, dont la France. Dans le même temps, la précision des âges au décès recueillis par la statistique de l’état civil, longtemps assez défaillante aux grands âges, s’est beaucoup améliorée au cours des dernières décennies. Nous tentons donc ici de suivre l’évolution de la mortalité française par cause et par âge au-delà de 90 ans, depuis la fin des années 1970, tant pour les hommes que pour les femmes. Non seulement, l’étude confirme que la mortalité diminue à tous les âges, y compris les plus élevés, et quel que soit le sexe. Elle nous permet aussi d’évaluer le poids de chacun des grands groupes de causes (cancers, maladies du cœur, autres maladies de l’appareil circulatoire, maladies infectieuses et respiratoires, diabète, démences et maladies neuro-dégénératives, autres maladies, accidents et sénilité), dans ce recul de la mortalité aux âges élevés et donc dans la montée des espérances de vie à 90 ans, ainsi que le rôle qu’ils jouent dans la différence d’espérance de vie entre les sexes dont l’évolution, même aux grands âges s’est récemment retournée.

The causes of death reported on the death certificates of the oldest old are generally seen as unreliable, and as thus providing little useful information on the process leading to death. However, in advanced countries, a majority of the people who die each year are relatively old, and the level of detail provided on medical certificates about the causes of death among this older population is improving. At the same time, scholars are becoming increasingly interested in studying not just the initial cause of death, but multiple causes of death, thereby taking all of the information reported on the certificate into account. This study demonstrates that in a country like France, the cause-of-death pattern evolves regularly until around age 105. The share of people dying of circulatory diseases tends to be quite stable over the age range, while the share of individuals dying of cancer is declining, and the share of people dying of respiratory/infectious diseases is rising. Furthermore, among people who die at very old ages, a typology of multiple causes of death highlights the growing importance of ill-defined causes, while opening the door to an interesting discussion about the concept of cause of death in the supercentenarian population. Instead of representing an ill-defined cause, senility could be considered an actual cause of death. This suggests that daily care is more crucial to the survival of the oldest old than any conventional medical care or treatment. Supercentenarians tend to be so frail that any minor health event or brief lapse of attention on the part of their caregivers can be lethal.

The purpose of this study is twofold. Firstly, it attempts to exhaustively identify cases of French supercentenarians and semi-supercentenarians and to validate their alleged age at death. Secondly, it seeks to uncover careful patterns and trends in probabilities of death and life expectancy at very old ages in France. We use three sets of data with varying degrees of accuracy and coverage: nominative transcripts from the RNIPP (Répertoire national d’identification des personnes physiques), death records from the vital statistics system, and “public” lists of individual supercentenarians. The RNIPP stands out as the most reliable source. Based on all deaths registered in the RNIPP at the alleged ages of 110+ for extinct cohorts born between 1883 and 1901, errors are only few, at least for individuals who were born and died in France. For alleged semi-supercentenarians, age validation on a very large sample shows that errors are extremely rare, suggesting the RNIPP data can be used without any verification until age 108 at the minimum. Moreover, a comparison with “public” lists of individual supercentenarians reveals a single missing occurrence only in the RNIPP transcripts since 1991. While the quality of vital statistics data remains quite deficient at very old ages compared to RNIPP, the analytical results show a significant improvement over time at younger old ages. Our RNIPP-based probabilities of death for females appear to level-off at 0.5 between ages 108 and 111, but data becomes too scarce afterwards to assess the trend. Also, we obtain a quite low life expectancy value of 1.2 years at age 108.

L’évolution de l’espérance de vie dans les pays baltes est instructive car elle nous renseigne sur les liens qu’il peut y avoir entre les avatars géopolitiques qu’a connus cette région à la lisière de l’Empire russe puis de l’URSS et le déroulement de la transition sanitaire. Largement en avance sur la Russie lors de leur première indépendance, l’Estonie, la Lettonie et la Lituanie ont payé très cher leur intégration forcée à l’URSS. C’est seulement à partir de 1995 que les nouvelles politiques mises en oeuvre dans le cadre de leur seconde indépendance puis de leur entrée dans l’Union européenne ont permis à ces pays de prendre le chemin d’une remontée durable de l’espérance de vie et d’une convergence vers les standards ouest-européens.

After the time of the Great Duchy of Lithuania and that of their inclusion to Russian Empire, the three Baltic countries got their first independence after WWI, but WWII forced them to enter the Soviet Union for almost five decades before getting their second independence and resuming with market economy, to finally join the European Union. Such strong historical changes caused major impacts (either positive or negative) on the implementation of the health transition in the region, quite interesting to document, but they also produced dramatic changes in the quality and the accuracy of information required to compute mortality indicators. The aim of this article is to briefly summarize existing knowledge on mortality in the Baltic region for the past two centuries, but focusing more precisely on the consequences of getting in and then getting out of the Soviet system in terms of health and survival.

Introduction and Aims. Eastern Europe is known to suffer from a large burden of alcohol-related mortality. However, persisting unfavourable conditions at the national level mask variation at the sub-national level. We aim to explore spatial patterns of cause-specific mortality across four post-communist countries: Belarus, Lithuania, Poland and Russia (European part). Design and Methods. We use official mortality data routinely collected over 1179 districts and cities. The analysis refers to males aged 20–64 years and covers the period 2006–2014. Mortality variation is mainly assessed by means of the standardised mortality ratio. Getis-Ord Gi* statistic is employed to detect hot and cold spots of alcohol-related mortality. Results. Alcohol-related mortality exhibits a gradient from very high levels in northwestern Russia to low levels in southern Poland. Spatial transitions from higher to lower mortality are not explicitly demarcated by national boundaries. Within these countries, hot spots of alcohol-related mortality dominate the territories of northwestern and western Russia, eastern and northwestern Belarus, southeastern Lithuania, and eastern and central Poland. Discussion and Conclusions. The observed mortality gradient is likely associated with the spread of alcohol epidemics from the European part of Russia to the other countries, which appears to have started more than a century ago. Contemporary socioeconomic and demographic factors should be taken into account when developing anti-alcohol policies. The same is true for the peculiarities of culture, norms, traditions and behavioural patterns observed in specific geographical areas of the four countries. Reducing alcohol-related harm in the areas identified as hot spots should be prioritised.

Old age and adult mortality have over the last decades enjoyed a remarkable decline throughout the western world, posing the researcher with new challenges and opening up fresh horizons in life expectancy trends. The recent drop in mortality may be largely traced to the unexpected decline in cardiovascular diseases and certain cancers. Thus it could be hoped that in the future these trends would continue and extend to include other causes where, for the moment, little change has occurred. Such a hypothesis is all the more realistic in view of the fact that recent changes are linked, not just to advances in more efficacious medical treatment, but also to a growing awareness on the part of the general public regarding questions of health and the crucial role played by life style and behaviour. These include improved dietary habits, for example, a better attitude to risk factors, particularly to smoking, alcohol abuse, dangerous driving, etc. This awareness, which prevails among more recent, well-informed and better educated cohorts, not only produces immediate results, but maybe even more so in the future, should this spare coming generations the accumulation of risks which were and continue to be the burden particularly of older cohorts.

Every time the classification of causes of death is changed, time series of deaths by cause are disrupted in more or less profound ways. When changes involve only the merging of several items or splitting a single item into several new categories, the problems caused by these ruptures are not too difficult to solve. A more or less severe imbroglio occurs, however, each time a new item results from recombining portions of different split items. Sometimes, but very rarely, some countries proceed to a bridge coding during the year of transition, which can help reconstruct coherent time series. This article first summarizes the general principles of the method developed for France by Meslé and Vallin to reconstruct complete series for France from 1925 to 1999 in the detailed list of the 9th WHO International Classification of Diseases (ICD), doing so by successively bridging a posteriori the five versions of the ICD that were in use during that period. Second, it reports on several methodological improvements that have been developed with the aim to reconstruct and analyze mortality trends by cause in sixteen industrialized countries. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s10680-017-9453-1) contains supplementary material, which is available to authorized users.

BACKGROUND: Numerous studies have addressed the problem of hazardous alcohol consumption, alcohol-related causes of death and their relationship to persisting excess male mortality in the countries of the former USSR. Yet relatively little is known about the geographical patterns of alcohol-related mortality within these countries and the cross-border continuities of such patterns. This study aims at identifying the spatial distribution and the cross-border patterns of adult male mortality from alcohol poisonings and liver cirrhosis in Belarus and Lithuania. METHODS: We use cause-specific mortality data for 2003-2007. We employ spatial econometric techniques to detect 'hot spots' of alcohol-related mortality across the combined territory of the two countries. RESULTS: Specific patterns associated with extremely high rates of mortality from alcohol poisoning can be observed in Belarus, particularly in the areas bordering Russia and Lithuania. Meanwhile, patterns of alcohol-induced liver disease dominate in Lithuania, and continue across the border from eastern Lithuania into north-western Belarus. CONCLUSIONS: The districts located along the Belarusian-Lithuanian border appear to be especially problematic, as they suffer from an enormous burden of alcohol consumption. The situation is particularly severe on the Belarusian side, where there are extremely high levels of mortality from both alcohol poisoning and liver cirrhosis. These areas should be considered primary targets for antialcohol policies. Language: en

Les populations pionnieres, beneficiant les premieres de l’augmentation de l’esperance de vie, ouvrent-elles pour les autres groupes la voie vers de meilleures chances de survie et de longevite ? Cette etude a pour but d’identifier dans quelle mesure, en Finlande, en Suede et en Norvege, la population qui n’appartient pas a cette avant-garde pourrait suivre les trajectoires de mortalite deja tracees par les pionniers aux differents groupes d’âges et pour differentes causes de deces entre 1970 et 1995. Les resultats montrent qu’il n’y a pas eu de convergence systematique des trajectoires du reste de la population vers celles de l’avant-garde. Ils confirment au contraire la theorie selon laquelle chaque changement sanitaire majeur commence par induire une divergence dans les evolutions de mortalite. En effet, au niveau infranational, loin de connaitre avec un certain delai les memes progres que le groupe precurseur, le reste de la population suit son propre chemin de reduction de la mortalite, repondant a des determinants differents. L’etude montre aussi qu’il faut un temps considerable pour que l’ensemble de la population atteigne les taux de survie dont l’avant-garde beneficiait en debut de periode d’observation. C’est le cas notamment de la prevention et du traitement des maladies cardio-vasculaires.

Apres avoir diverge au temps de la division, les esperances de vie est- et ouest-allemandes ont converge depuis la reunification. Meme si le rattrapage n’est pas tout a fait complet pour les hommes, amelioration du systeme de sante et changements de comportements individuels ont permis a l’Allemagne de l’est de combler l’essentiel de son retard.

The health situation in Russia has often been characterized as a long‐running crisis. From the 1960s until the beginning of the 2000s, the declining life expectancy trend was substantially interrupted only twice: once in the mid‐1980s as a result of Gorbachev's anti‐alcohol campaign, and again at the end of the 1990s as a result of the “rebound” effect following the dramatic rise in mortality associated with the acute socioeconomic crisis. In both cases, the progress made proved to be short‐lived. A third mortality decline in Russia began in 2003 and is still ongoing. We investigate the components and driving forces of this new development, in particular the role played by cardiovascular diseases. Using cause‐specific mortality data, we identify the main features of the recent improvements and compare these features with those observed in selected European countries, specifically France, Poland, and Estonia. Our aim is to gauge whether the features of the improvements in these countries are similar to those of the recent advancements made in Russia. Although the recent improvements in Russia have features in common with initial stages of prior mortality declines in other countries and may support optimism about the future, a return to mortality stagnation cannot be ruled out.

International audience; From 1965 to 1999, Tunisian fertility fell from 7,5 children per women to 2,1, and then kept that replacement level for more than 10 years before rising slightly. On its side, female mean age at marriage, the huge increase of which (from 21 to 29 years) was a prominent factor of fertility decrease, stabilized at the end of the 1980s. Facts are well known at the national level but to what extent national means result from contrasted changes at the regional one remains quite unclear. To analyze geographical disparities, various sources, often difficult to access, were mobilized. They allowed seeing that for both fertility and nuptiality geography changed a lot. Not only fertility fell down deeply while women age at first marriage increased a lot everywhere, but regional diversity changed dramatically. After a step of steady divergence regional fertilities converged towards the replacement level almost perfectly. Concerning the map of age at marriage, it reversed completely. As a consequence, the relations between regional diversities of fertility and nuptiality are neither simple nor well asserted; De 1965 à 1999, la fécondité tunisienne est tombée de 7,5 à 2,1 enfants par femme et s’est ensuite maintenue à ce niveau pendant plus de dix ans. De son côté, l’âge moyen au premier mariage des femmes, dont la forte augmentation a été un facteur important de la maitrise de la fécondité, s’est stabilisé dès la fin des années 1980. Passé de 21 à 29 ans, il n’a guère bougé depuis. Ces faits sont connus au niveau national, mais leur diversité géographique l’est beaucoup moins. Pour analyser cette dernière, plusieurs sources de données, souvent difficiles d’accès, ont été mobilisées. Elles nous permettent de voir que tant du côté de la fécondité que de celui de la nuptialité, la géographie a beaucoup changé. Non seulement partout la fécondité a profondément baissé tandis que l’âge moyen au premier mariage des femmes augmentait très fortement, mais les disparités régionales ont beaucoup évolué. Après une phase de forte divergence, les fécondités régionales ont convergé vers le taux de remplacement. Quant à la carte de l’âge au mariage, elle s’est complètement inversée. Il en résulte que les rapports entre la diversité régionale de la fécondité et celle de la nuptialité ne sont ni simples ni très affirmés.

Until the end of the 1990s, mortality patterns and trends in Estonia, Latvia and Lithuania were remarkably similar. However, from the year 2000 onwards, life expectancy trends in the three countries started to diverge. In particular, sustainable progress in Estonia over the period 2000–2007 contrasts with stagnation in Latvia, and even worsening trends in Lithuania. These contradictory changes seem to be mainly explained by contrasting dynamics in mortality from cardiovascular diseases, external causes of death and digestive system diseases. Whereas cardiovascular and external-cause mortality declined in Estonia and Latvia, worsening or stagnation of mortality from these causes of death was observed in Lithuania. The negative mortality changes in Lithuania were also reinforced by a striking increase in mortality from alcohol-related digestive system diseases. The findings suggest that the divergence in health trends between the three countries may be attributable to their varying degrees of success in implementing structural health care reforms and specific health policy measures. By contrast, the very recent improvement (since 2008) is parallel in the three countries and is largely because of the introduction of rather similar anti-alcohol measures.

Before the collapse of the Soviet Union, Belarus, Lithuania, and Russia were quite comparable in terms of their socioeconomic development. Despite some differences in overall mortality levels, the three former Soviet republics were also very close to each other in terms of directions of mortality trends and age- and cause-specific mortality patterns. After 1991, all the three countries experienced substantial political and social transformations, and the challenges associated with the transition from a socialist to a market economy system. The sudden changes brought numerous problems, such as rapid growth in unemployment, falling standards of living, and growing social and income inequalities. These factors contributed to the significant deterioration of the health situation in all the countries, but the size and the nature of the mortality crisis was different in Belarus than it was in Lithuania and Russia. The marked similarities in socioeconomic and mortality trends in the countries up to 1991 contrast with their notable divergence during the subsequent years. The nature and success of market reforms seems to be the most plausible explanation for these differences. Russia and Lithuania have chosen more radical forms of economic and political transformations, which have led to massive privatization campaigns. The reforms were more sustainable and systematic in Lithuania than in Russia. By contrast, Belarus has chosen a gradual and slow transition path. Recent mortality trends in Belarus are explored in detail here, and are contrasted with those observed in Lithuania and Russia. Including a cause-of-death analysis sheds more light on the plausible determinants of the variations in mortality levels between the countries. Avant la chute de l’Union Soviétique, la Biélorussie, la Lituanie et la Russie étaient tout à fait comparables en termes de développement socio-économique. En dépit de quelques différences de taux de mortalité générale, les ex-Républiques Soviétiques étaient également très proches en termes de tendances et de variations de la mortalité par cause et par âge. Après 1991, les 3 pays ont connu des bouleversements politiques et sociaux, et ont dû faire face aux défis associés au passage d’une économie socialiste à l’économie de marché. Ces changements soudains ont provoqué de nombreux problèmes, tels qu’une montée rapide du chômage, la baisse du niveau de vie et le développement d’inégalités sociales et de revenu. L’ensemble de ces facteurs a contribué à une détérioration significative de la situation sanitaire dans tous les pays, mais la crise de mortalité en Biélorussie était différente de celles de la Lituanie et de la Russie, à la fois en termes d’étendue et de nature. Les grandes similitudes des tendances socio-économiques et de mortalité dans ces pays jusqu’en 1991 contrastent avec leur divergence notable au cours des années qui ont suivi. La nature et le succès des réformes liées au passage à l’économie de marché est l’explication la plus plausible de ces différences. La Russie et la Lituanie ont choisi des formes plus radicales de transformation économique et politique, qui ont mené à des campagnes de privatisation massives. Les réformes étaient plus durables et systématiques en Lituanie qu’en Russie. La Biélorussie, en revanche, a choisi la voie d’une transformation graduelle et lente. Les tendances récentes de la mortalité en Biélorussie sont examinées en détail dans cette étude, et comparées à celles observées en Lituanie et en Russie. Une analyse des causes de décès éclaire sur les déterminants plausibles des variations de niveau de mortalité entre ces pays.

The well-known Oeppen–Vaupel straight line of maximum female life expectancies showed that the highest life expectancy observed in a given year increased linearly from 1840 to 2000. Their analysis fueled major controversy, especially when used to extrapolate future improvements in life expectancy at the same pace. We improve on the empirical analysis by enriching the dataset, expanding the period to 1750–2005, and considering both maximum life expectancy at birth and lowest age-specific survival rates. It clearly appears that the original Oeppen–Vaupel straight line must be divided into several segments characterized by different slopes and that each segment corresponds to a major advance in the health transition. There is room to push life expectancy higher, but unless some new breakthrough increases the human life span, progress will very likely decelerate as mortality reduction affects individuals at older and older ages. The main key to the future lies not in knowing whether the observed straight line can be extrapolated but in anticipating the next major health improvement that will lead to an additional increase in life expectancy.

Jusqu’à présent, dans les pays d’Europe centrale et orientale autrefois sous régime communiste, la mesure des différences sociales de mortalité s’est toujours heurtée à l’impossibilité de coupler des données de recensement à des données d’état civil pour éviter le biais classique causé par l’incohérence entre le statut individuel observé au recensement et celui déclaré au moment du décès à l’état civil. L’étude dont les résultats sont présentés ici est l’une des toutes premières jamais réalisées dans un pays issu du bloc soviétique sur la base d’un couplage des données individuelles d’état civil avec celles d’un recensement, en l’occurrence les décès de 2001-2004 avec le recensement de 2001. L’étude porte sur les différences de mortalité par cause parmi les personnes âgées de plus de 30 ans selon le niveau d’instruction, l’état matrimonial, le groupe ethnique et le milieu de résidence. De fait, les résultats obtenus sont différents de ceux qu’aurait donnés l’approche agrégée traditionnelle, mais confirment l’existence de très fortes inégalités. Les maladies infectieuses et les conséquences de l’alcoolisme s’avèrent particulièrement discriminantes.

La reconstruction de séries temporelles cohérentes de décès par cause classés selon la version la plus récente de la Classification internationale des maladies (CIM) s'avère particulièrement difficile en France depuis qu'a été adoptée, en 2000, la 10e révision de la CIM. Non seulement les changements opérés par cette dernière sont nombreux et complexes, mais la France a aussi cette année-là radicalement changé son mode de production de la statistique des causes de décès en substituant la codification automatique à la codification manuelle. Il est quasiment impossible de faire la part entre les ruptures statistiques dues au changement de nomenclature et celles qui tiennent à l'automatisation de la procédure. La réalisation très louable par l'Inserm d'une double codification (selon la CIM-9 et selon la CIM-10) sur un échantillon de décès n'est hélas que d'un secours limité en raison du trop petit nombre d'observations ainsi traitées. Peut-on s'appuyer avec plus de succès sur les résultats obtenus à plus grande échelle aux États-Unis ou en Angleterre ou sur une analyse approfondie des causes multiples de décès ? Rien n'est moins sûr.

Il ne s'agit pas ici de tenter une fois de plus d'estimer une quelconque mortalité biologique limite au-delà de laquelle aucun être humain ne pourrait vivre mais, de façon beaucoup plus modeste et pragmatique, de mesurer ce que pourrait être l'espérance de vie à la naissance d'une population qui jouirait des taux de mortalité par âge et par cause de décès les plus faibles observés de par le monde à un moment donné. En répétant le même calcul pour différentes époques, on peut voir comment cette espérance de vie évolue avec le temps. C'est ce qui a été fait ici de manière systématique pour chaque année depuis 1950. Deux conclusions majeures s'imposent. D'une part, l'espérance de vie idéale qui ressort d'un tel calcul n'a pas cessé d'augmenter depuis cinquante ans, à un rythme très soutenu, semblable à celui de la meilleure espérance de vie réellement observée. D'autre part, la suspicion d'irréalisme que l'on pouvait nourrir a priori à l'égard d'un tel indicateur s'évanouit lorsque l'on se rend compte que le niveau idéal reflétant les conditions d'une année donnée est atteint et parfois largement dépassé par presque tous les pays avancés 25 ans plus tard, au moins chez les femmes.

In the most advanced countries, child mortality and adult mortality under age 65 years have fallen so low that further improvement in life expectancy relies almost completely on the decline of mortality at older ages. This phenomenon is particularly pronounced among women, who are far ahead of men in survival rates. Thus, to project the future of life expectancy, this study focuses on trends in female life expectancy at ages 65 and older. Four countries are selected for this analysis: the United States, Netherlands, France, and Japan. It is particularly interesting to understand why American and Dutch trends in female old-age mortality have been diverging from those in France and Japan for two decades. It is shown here that most of the divergence derives from the fact that decline in cardiovascular mortality is more and more offset by increases in other causes of death in the United States and the Netherlands, while the other two countries are more successful in reducing mortality from all causes at increasingly older ages. This latter phenomenon could represent a new stage of the health transition.

Developing countries will very likely enjoy an exceptional period where the proportion of adults of working age will reach a historical maximum for a certain time and where investment for future economic and social systems will be easier than ever. But, the more favourable this event, the shorter the golden age will be, and, very likely, the more rapid and acute the successive period that will bring ageing and related problems will be. This short paper aims to highlight the demographic background of the question. Exactly what does ‘demographic window’ mean? Different countries or groups of countries are in very different situations with regard to what could be expected theoretically. Such differences can largely explain the different economic and social situations of the countries.

This paper performs a systematic analysis of all currently available Russian data on mortality by region, census year (1970, 1979, 1989, and 1994) and cause of death. It investigates what links may be found between these geographical variations in cause-specific mortality, the negative general trends observed since 1965, and the wide fluctuations of the last two decades. For that, four two-year periods of observation were selected where it was possible to calculate fairly reliable mortality indicators by geographic units using census data for 1970, 1979, 1989, and micro-census data for 1994, and used a clustering model. Behind the complexity of the studied universe, three main conclusions appeared. Firstly, in European Russia, there is a stark contrast between south-west and north-east, both in terms of total mortality and of cause-of-death patterns. Secondly, analysis of overall cause-of-death patterns for all periods combined clearly confirms that contrast at the whole country level by the prolongation of the southern part of European Russia through the continuation of the black soil ("chernoziom") belt along the Kazakhstan border, while the rest of Siberia presents a radically different picture to European Russia. Thirdly, while it is difficult to infer any permanent geographical pattern of mortality from that very fluctuating piece of history, 1988-89 appears to be a base period for at least the entire period from 1969-1994.

commentator on population health, viewing the global situation as it was in the early 1970s, could have been forgiven for concluding that the second half of the twentieth century was unfolding as an overwhelming success. Although the world had, relatively recently, experienced a global conflict that had claimed many million lives prematurely, there was much to be optimistic about. Advances in technology were changing many lives for the better. In the area of health care, new drugs, technologies, and ideas were transforming the ability to prevent and treat disease. Many of the common infectious diseases that had taken children from their families were being vanquished and one, smallpox, was on the brink of eradication. Almost everywhere, life expectancy was increasing, in some places faster than at any time in recorded history. Indeed, many commentators were predicting, with confidence, sustained improvements, with the UN Population Division assuming that countries where life expectancy at birth was still under 62 years would experience a gain of 2.5 years in each period of five calendar years, after which the gain would decrease to about two years. They had grounds for confidence as, until then, mortality trends in industrialized countries, as well as in

Abdel Omran's 1971 theory of "Epidemiologic Transition" was the first attempt to account for the extraordinary advances in health care made in industrialized countries since the 18th century. In the framework of the Demographic Transition, it implied a general convergence of life expectancies toward a limit imposed by the new epidemiological features of modern societies. However, important failures, occurred in the past decades (mainly the health crisis in Eastern Europe and AIDS in Africa), seem to have stopped that process of convergence. In fact such failures do not really contradict the theory. The latter is much more ruined by the unexpected dramatic improvement in the field of cardiovascular disease experienced since the seventies, which results in a new step of a more general process. On the basis of the broader concept of “Health Transition” initiated by Julio Frenk et al., the present paper tries to rethink the full process in term of divergence/convergence sequences inferred by successive major changes in health technologies and strategies. 1 Institut national d'etudes demographiques, 133, bd Davout 75980 Paris Cedex 20, France. Email: vallin@ined.fr 2 Institut national d'etudes demographiques, 133, bd Davout 75980 Paris Cedex 20, France. Email: mesle@ined.fr Demographic Research – Special Collection 2: Article 2 -Determinants of Diverging Trends in Mortality -12 http://www.demographic-research.org

The improvement in the positionof women and the evolution of spousal relationsare considered to be principal factors in thefertility transition. The age differentialbetween spouses is an important indicator ofthese. In Algeria, within 30 years, thespectacular increase in the mean ages at firstmarriage of women (from 18 to 28 years) and ofmen (from 24 to 31 years) has been coupled witha strong reduction in the average spousal agedifferential which has shifted from 5.6 yearsin 1966 to 3.7 years in 1998. The analysis of the dynamics of this agedifferential at the national level over aperiod of half a century (1948–1998) and ananalysis of its current regional variationsilluminate the very strong links of this trendwith the socio-economic and cultural context(education and activity of women, but alsohousing conditions, the role of agriculture,etc.). However, periodical socio-economicdifficulties (unemployment, poverty, housingshortage) weaken these long-term effects on thespousal age differential, since they force manymen to involuntarily postpone their marriage,thus slowing down the reduction in spousal agedifferentials.

Meslé France, Vallin Jacques.- Comment améliorer la précision des tables de mortalité aux grands âges ? Le cas de la France Les tables de mortalité calculées de manière classique sur la base des statistiques de décès publiées annuellement et des estimations de population par âge au 1er janvier de chaque année souffrent d'incohérences aux grands âges. Avec la baisse rapide de la mortalité aux âges élevés observée depuis quelques décennies et l'accroissement encore plus rapide de la part des nonagénaires puis des centenaires dans les populations des pays industriels, il est devenu plus important que jamais d'améliorer la précision de la mesure de la mortalité aux grands âges. Pour y parvenir en ne s 'appuyant que sur les données réelles, nous utilisons ici la méthode des générations éteintes en l'adaptant pour la rendre applicable à des générations incomplètement éteintes et reconstituer de façon assez précise la mortalité des années récentes au-delà de 90 ans. L'évolution depuis le début du siècle de l'espérance de vie à 90, 95 ou 100 ans peut ainsi être suivie avec plus de précision. La comparaison entre les résultats que donnaient jusqu'à présent les calculs plus classiques et ceux de la méthode des générations éteintes montrent que l'on surestimait les espérances de vie à ces âges pour les périodes anciennes, dissimulant ainsi leur croissance spectaculaire durant les trois dernières décennies., Meslé France, Vallin Jacques.- ^Cómo mejorar la precision de las tablas de mortalidad para las edades avanzadas? El ejemplo de Francia Las tablas de mortalidad calculadas según el método tradicional, en base a estadisticas de defunciones anuales y a estimaciones de población рог edad a 1 de enero, dan resultados incohérentes para las edades avanzadas. eon la rápida disminuciôh de Га mortalîdad a taies edades experimentada en las ultimas décadas y el aumento aun más rápido del numero de nonagenarios y de centenanos en los parses industrializados, mejorar la precision de las estimaciones de mortalidad a edades avanzadas es cada vez más importante. Para lograrlo en base a datos reaies, en este articulo utilizamos el método de las generaciones extinguidas adaptándolo, para hacerlo aplicable, a generaciones no completamente extinguidas; en base a este método reconstituimos de forma bastante précisa la mortalidad reciente más alla de los 90 aňos. Este método permite seguir la evolución de la esperanza de vida a los 90, 95 y 100 aflos con mayor precision. La comparación de los resultados obtenidos anteriormente utilizando métodos tradicionales con los obtenidos utilizando el método de las generaciones extinguidas muestra que hasta ahora se habia sobreestimado la esperanza de vida a estas edades para el pasado, minimizando de tal forma el crecimiento espectacular que esta ha sufndo en las très ultimas décadas., Meslé France, Vallin Jacques. Comment améliorer la précision des tables de mortalité aux grands âges? Le cas de la France. In: Population, 57ᵉ année, n°4-5, 2002. pp. 603-631.

Demographic transition theory might seem to imply that, after a period of exceptional population growth resulting from the time lag between mortality and fertility declines, every population, and then the whole world population will stabilize and, consequently, no more acute population problems will appear. Does the claim, recently gaining credibility, that the end of the transition is at hand actually imply a stage without major population problems? Nothing is less sure. First, it is just a claim, the realization of which still entails a period of dramatically rapid population growth in some countries, especially the poorest. But more tellingly, the end of the transition is also the end of the paradigm on which we have been relying to understand and anticipate demographic changes. Nobody knows what might ensue later: How long and low can fertility fall? How long and high can life expectancy increase? How far can population aging go? As many questions without answer and probably as many problems whose size we cannot even imagine lie ahead.

Ukraine experienced two very acute demographic crises during the Soviet era: the 1933 famine and the Second World War. While different estimates of total losses have been produced previously, we have tried here to distinguish the specific impact of the crises on mortality from their impact on fertility and migration. Taking into account all existing sources of registered data and estimates, a painstaking reconstruction of annual demographic changes has been produced and complete annual life tables have been computed for the years 1926-59. Life expectancy at birth fell to a level as low as 10 years for females and 7 for males in 1933 and plateaued around 25 for females and 15 for males in the period 1941-44.

Meslé France, Vallin Jacques.- Mortalité en Europe : la divergence Est-Ouest Après une période de convergence générale des espérances de vie, les années 1960 ont été marquées par la divergence entre les pays de l'Est, stoppés dans leur élan, et le reste de l'Europe où de nouveaux champs de progrès se sont ouverts. Une analyse hiérarchique des profils de mortalité par âge permet de voir que cette divergence va de pair avec le développement de modèles d'âges au décès très différents, les pays de l'Est, et notamment ceux de l'ex- URSS, souffrant d'une surmortalité spectaculaire aux âges adultes. L'analyse par causes de décès met en lumière le rôle décisif joué conjointement par deux types de pathologies. D'une part, la montée des maladies de société (alcoolisme, tabagisme, accidents de la circulation, etc.) s'est poursuivie à l'Est alors qu'elle a pu être enrayée à l'Ouest à partir des années 1960. D'autre part, les pays de l'Est n'ont pas réussi à entrer dans la révolution cardio-vasculaire qui a largement ouvert la voie à l'Ouest à de nouveaux gains d'espérance de vie. Cette énorme divergence entre l'Est et l'Ouest de l'Europe ne doit cependant pas faire oublier que des différences subsistent entre les pays de l'Ouest eux-mêmes dont les structures de mortalité évoluent au point de transformer radicalement les ressorts de la traditionnelle opposition nord-sud., Meslé France, Vallin Jacques.- Mortalidad en Europa: divergencias Este-Oeste Siguiendo un periodo de convergencia general de esperanzas de vida, los aňos sesenta se caracterizaron por la divergencia entre los países del Este, cuyo progreso se estancó, y el resto de Europa, donde se abrieron nuevas vias de progreso. Un análisis jerárquico de los per- files de mortalidad por edad permite observar que tal divergencia coincide con el desarrollo de estructuras de mortalidad por edad muy diferentes. Los parses del Este, especialmente los países de la ex - URSS, sufren una sobre - mortalidad espectacular en edades adultas. El análisis por causas de mortalidad révéla el papel decisivo de dos tipos de patologia. En primer lugar, el aumento de enfermedades de sociedad (alcoholismo, tabaquismo, accidentes de circulación, etc.) continuó en el Este mientras su progreso se detenia en Occidente a partir de los anos sesenta. Por otro lado, los países del Este no lograron participar en la revo- lución cardio-vascular gracias a la cual la esperanza de vida aumentó considerablemente en Occidente. Esta énorme divergencia entre Europa Occidental y Europa del Este no debe eclipsar el hecho de que entre los países occidentales también existen diferencias significativas. La evolución de la estructuras de mortalidad por edad transforma radicalmente la dinámica de la oposición tradicional norte-sur., Meslé France, Vallin Jacques. Mortalité en Europe : la divergence Est-Ouest. In: Population, 57ᵉ année, n°1, 2002. pp. 171-212.

Meslé France, Vallin Jacques.- Improving the Accuracy of Life Tables for the Oldest Old: The Case of France Life tables calculated in the classic way on the basis of annual death statistics and age- specific population estimates as of 1 January of each year become unreliable at the oldest ages. Due to the rapid decline of mortality among the oldest old observed in the past few decades and the even swifter increase in the proportion of nonagenarians and centenarians in industrialized countries, it has become more important than ever to improve the accuracy of the measurement of mortality at the oldest ages. The extinct generation method enables us to do this while using only real data. The method was adapted to be used with cohorts that are not completely extinct, thus making it possible to reconstruct recent mortality after age 90 with an acceptable degree of accuracy. The trends in life expectancy at 90, 95 or 100 can thus be studied with greater accuracy from the start of the twentieth century. The comparison between the results obtained through traditional methods and those obtained through the extinct generation method shows that life expectancy at those ages was previously overestimated, thus masking its spectacular increase during the last three decades., Meslé France, Vallin Jacques.- £Como mejorar la precision de las tablas de mortalidad para las edades avanzadas? £1 ejemplo de Francia Las tablas de mortalidad calculadas según el método tradicional, en base a estadfsticas de defunciones anuales y a estimaciones de población рог edad a 1 de enero, dan resultados incohérentes para las edades avanzadas. Con la rápida disminución de la mortalidad a taies edades experimentada en las ultimas décadas y el aumento aun más rápido del numero de nonagenarios y de centenarios en los parses industrializados, mejorar la precision de las estimaciones de mortalidad a edades avanzadas es cada vez más importante. Para lograrlo en base a datos reaies, en este articulo utilizamos el método de las generaciones extinguidas adaptándolo, para hacerlo aplicable, a generaciones no completamente extinguidas; en base a este método reconstituimos de forma bastante précisa la mortalidad reciente más alla de los 90 anos. Este método permite seguir la evolución de la esperanza de vida a los 90, 95 y 100 aňos con mayor precision. La comparación de los resultados obtenidos anteriormente utilizando métodos tradicionales con los obtenidos utilizando el método de las generaciones extinguidas muestra que hasta ahora se habia sobreestimado la esperanza de vida a estas edades para el pasado, minimizando de tal forma el crecimiento espectacular que esta ha sufrido en las très ultimas décadas., Meslé France, Vallin Jacques. Improving the Accuracy of Life Tables for the Oldest Old: The Case of France. In: Population (English edition), 57ᵉ année, n°4-5, 2002. pp. 601-629.

In recent years there has been a considerable increase in understanding of changes in mortality in Russia and some other former Soviet republics. However, the situation in the republics of the Caucasus remains poorly understood. Information on Georgia is especially fragmentary as a fifth of the country remains outside government control, there has been large scale migration since 1991, and the introduction of fees for vital registration has compromised the quality of official statistics. The aim of the study is to produce plausible estimates for life expectancy in Georgia for the period 1990-1998 and thus to assess whether Georgia has undergone changes similar to other former Soviet republics in the post-independence period. Four models were used to construct life tables. Model 1 used officially published statistics on deaths and population. Model 2 applied new estimates of population derived from household surveys to the observed deaths. Model 3 adjusted model 2 for under-registration at extremes of life, with parameter estimates derived from a survey of infant mortality and comparison of observed rates with Coale-Demeny standard life tables. Model 4 arose following inspection of death rates by cause that revealed implausible discontinuities in cancer mortality rates and involved applying the estimates of under-registration that this finding implied to model 3. The four models produce quite different estimates of life expectancy, differing by 7.8 y for men and 6.8 y for women by 1998. In any of the models, however, Georgia does not appear to have experienced the marked deterioration in life expectancy seen in Russia following the transition to independence. Importantly, Georgia had also not experienced a marked improvement in life expectancy during the 1985 Soviet anti-alcohol campaign, again unlike other Soviet republics.Official statistics substantially over-estimate life expectancy at birth in Georgia. Despite undergoing a civil war, life expectancy in Georgia has been less affected by the transition than has Russia and the overall trends in mortality since the mid 1980s suggest that this may be because alcohol has played a smaller role in these changes than it did in Russia.

This study is a first attempt to produce reliable estimates of mortality in Georgia and Armenia in the 1990s. Official statistics registered a decrease in mortality over the 1990s in spite of local wars, mass flows of refugees, and severe economic hardships faced by populations. According to official statistics, in 1999-2000 population size was about 5.4 millions in Georgia and about 3.8 millions in Armenia. Non-official estimates based on migration surveys are much lower: 4.0-4.1 millions and 3.0 millions, respectively. This huge difference is mostly due to unregistered out-migration. In addition to corrections in population, corrections are made for under-registration of deaths. Hospital statistics is used for infant deaths and the Coale-Demeny model life tables are used for ages above 70. In Georgia, the introduction of payment for the declaration of vital events resulted in a greater under-registration of deaths than in Armenia. Modified populations, mortality and life expectancy values are produced for the 1990s. In 1999 life expectancy was 68.6 and 75.6 for males and females in Georgia and 68.7 and 75.4 for males and females in Armenia. These figures are lower than the official estimates by 5.2 and 5.6 years for males and females in Georgia and by 3.8 and 1.7 years for males and females in Armenia. After corrections Caucasian male life expectancy is higher than in other post-Soviet countries.

Avec l'explosion recente du nombre des personnes tres âgees, la mesure precise de la survie aux tres grands âges est devenue un enjeu important. Une des consequences recentes de l'accroissement des nonagenaires et des centenaires est l'emergence de ce qu'il est desormais convenu d'appeler les supercentenaires : les personnes depassant l'âge de 110 ans. La difficulte en la matiere est d'abord d'authentifier l'âge. En couplant cas par cas trois sources differentes (etat civil, repertoire national, collation de listes nominatives) nous avons jusqu'a present pu identifier 46 deces de supercentenaires survenus en France depuis les annees 1960. Grâce a la methode des generations eteintes, nous avons tente de mesurer la survie au-dela de 110 ans. L'esperance de vie des femmes ainsi calculee (1,9 an pour l'ensemble des generations concernees) est cependant probablement encore surestimee car l'echantillon de supercentenaires ainsi constitue n'est pas exhaustif et ce sont les plus « jeunes » qui y sont le moins bien representes. Pour aller plus loin il faudrait pouvoir controler tous les âges au deces superieurs a 110 ans declares a l'etat civil en verifiant les actes de naissances. Ce sera l'objet de notre prochaine etape

Do it twice and you will get different results. Thats a very common law when measuring demographic indicators in developing countries where current statistics are incomplete. And it is very likely that the third time will give yet another result! It is not enough to make good demographers despair. It even presents a good opportunity to outstanding specialists like the authors of Epidemiologic transition interrupted: a reassessment of mortality trends in Thailand to try to approach the true measure of mortality in such a country. To approach not to reach absolutely of course. Indeed several questions still await answers. But the most questionable aspect of the results presented here is not to what extent reassessment fits the reality but to what extent trends reassessed justify the main title: Epidemiologic transition interrupted. The work done by the authors of the article significantly improves our knowledge about recent trends in Thai mortality. They make a very important clarification of the complex set of contradicting data produced by direct and indirect methods applied to vital statistics census data and the results of different types of surveys. They give us a clearer idea of what must be rejected what can be used and what can be improved by adequate correction. Nevertheless as usual good answers bring new questions. (excerpt)

The chapter describes diversity in life expectancy observed between and within European countries. It then proposes a possible explanatory thread and, finally, concludes with some speculation on the future of inequalities. Inequalities between countries are approached by focussing on three different perspectives: inequalities in terms of level of life expectancy, inequalities in terms of mortality patterns, and the difference between the highest life expectancy observed at a given time and the life expectancy resulting from a combination of the lowest age-specific mortality rates at the same point in time. Inequalities within countries will then be approached by selecting three criteria of difference: geographical differences, gender differences, and social differences. Trying to find a general explanation for all these different aspects of inequality is quite an impossible challenge. However, it can be helpful to follow one possible main thread to look at fundamental affinities between facts that could have been seen as quite different in nature at the outset. One possible basic idea is to consider that different histories have resulted in the current diversity. It is then useful to review changes in theoretical approaches towards health and mortality change from Omran’s epidemiologic transition theory to the more general health transition theories and, finally, to examine the historical movements of divergence and convergence that can explain the broad international diversity observed today. The next step will then be to discuss whether what seems true for inter-country inequalities can also be true for sub-national differences. Finally, some concluding remarks are made with regard to future perspectives.

In 1988 we published the results of a lengthy effort to reconstruct a cause of death series [for France] based on the ICD-8 Detailed List for the period 1925-78....The work included a redistribution of ill-defined causes and an analysis of the results in terms of etio-anatomical groups of diseases and of their impact on life expectancy. However our study did not include more recent data based on the ICD-9 series which at that time had not been extended far enough to allow us to make the connections with the previous series....The work in progress is a new opportunity (1) to present our method through specific examples of matching ICD-8 and ICD-9 (2) to summarize the specific difficulties encountered when dealing with previous revisions to obtain the 1925-78 series and (3) to show examples of changes in coding practices independent of the ICD revision itself. (EXCERPT)