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By David A. Leon

Making a difference to the health of populations, however small, is what most people in public health hope they are doing. Epidemiologists are no exception. But often caught up in the minutiae of our day-to-day work, it is easy to lose sight of the bigger picture. Is health improving, mortality declining, are things moving in a positive direction? Getting out and taking in the view (metaphorically as well as literally) can have a salutary effect. It broadens our perspectives and challenges our assumptions. Looking at recent trends in European life expectancy is a case in point.

Since 1950 estimated life expectancy at birth of the world’s population has been increasing. Initially, this was accompanied by a convergence in mortality experience across the globe—with gains in all regions. However, in the final 15 years of the 20th century, convergence was replaced with divergence, in part due to declines in life expectancy in sub-Saharan Africa. However, this global divergence was also the result of declining life expectancy in Europe. Home to 1 in 10 of the world’s population, and mainly comprised of industrialized, high-income countries, Europe has over 50 states. These include Sweden and Iceland that have consistently been ranked among the countries with the highest life expectancies in the world. But while for the past 60 years all Western European countries have shown increases in life expectancy, the countries of Central and Eastern Europe (CEE), Russia and other parts of the former Soviet Union have had a very different, and altogether more negative experience.

Trends in life expectancy between 1970 and the latest year available are shown in the Figure 1 for an illustrative selection of countries. These data were taken from one of two open sources : (i) the WHO Health for All Database or (ii) the Human Mortality Database, depending on which one had the longest time series. Differences between the sources are minimal for the purposes of this editorial. It is important to emphasize at the outset, that with one exception (discussed below), the trends shown in the Figure 1 are overwhelmingly driven by changes in mortality in adult life, not in infancy or childhood and are not the result of artefact.

Former communist countries of Eastern Europe

Between 1970 and the end of the 1980s, life expectancy at birth in the former communist countries of CEE (Czech Republic, Hungary, Poland and Slovakia), Russia and the Baltic states (Estonia, Latvia and Lithuania) stagnated or declined (Figure 1). This led to an increasing gap between them and Western European countries as the latter steadily improved. However, within a few years of the collapse of the Berlin wall in 1989, life expectancy started to steadily increase in the countries of CEE. This vividly illustrates that mortality can decline rapidly in response to political, social and economic change. Interestingly, once underway, the post-1989 increase in life expectancy in these countries has continued at a steady rate that is very similar to Western Europe. These parallel trajectories mean that the East–West gap, measured in terms of absolute differences in years of life expectancy, is proving very difficult to eliminate, despite earnest hopes to the contrary.

The trajectories of Russia and other Soviet countries, including the three Baltic States in the Figure 1, were strikingly different to those of the CEE countries. The anti-alcohol

Early today we posted an article about health care reform by Lawrence J. Schneiderman, M.D, a Professor Emeritus at UCSD Medical School and Visiting Scholar in the Program in Medicine and Human Values at the California Pacific Medical Center in San Francisco. His new book, Embracing Our Mortality: Hard Choices in an Age of Medical Miracles, looks at end of life decisions from both the medical and philosophical perspectives and advises on how to best make tough decisions. In the excerpt below Schneiderman emphasizes the importance of communicating your end-of-life preferences.

One of my patients, Earl Adams (not his real name), an African-American in his late seventies, was afflicted with severe Parkinsonism. Not only could he no longer play the organ for Sunday church services, he could barely move and relied on his devoted wife for even the most basic needs. She got him out of bed in the morning, helped him to the toilet, bathed him, fed him, kept him upright during the day, and returned him to bed at night. So successful was she at these tasks that whenever she brought him to see me he was always clean-shaven and meticulously dressed, complete with jacket and tie. (more…)

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