Irish Living Longer as Mortality Rates Decline
In the latest monthly commentary from Comhar on sustainability issues, guest commentator Professor Brendan Walsh looks at recent trends in Ireland’s mortality rates and highlights the factors that have led to Irish people living longer.
By Professor Brendan Walsh, Emeritus Professor of Economics and Senior Fellow, School of Geography, Planning and Environmental Policy, UCD
Guest Commentator for Comhar Sustainable Development Council
There has been a remarkable improvement in Irish mortality statistics in the new century. The annual average number of deaths recorded over the three-year period 2005-2007 was 3,700 or 12 per cent fewer than over the three years 1998-2000. When account is taken of population growth, we see that the overall death rate fell by almost a quarter. Among the population aged 65 and over, the rate fell by 22 per cent.
These changes are reflected in an acceleration in the improvement in Irish life expectancy at birth, which rose by 3.7 years for men and 3.0 years for women between 1995 to 1997 and 2004 to 2006, almost twice the gain recorded over the preceding 10-year period. Life expectancy has been rising at an increasing pace in many countries, but Ireland comes close to the top of this league table. In 1999, Ireland’s age-standardised death rate was 22 per cent above the EU-15 average but, by 2006, the gap had been closed.
A striking feature of the improvement in mortality statistics is that the winter peak in Irish death rates has become less pronounced. In the 1990s, the Irish “excess winter mortality” was one of the highest in Europe, but it declined markedly in the new century, especially for deaths due to respiratory diseases in the total population and deaths from all causes among the population aged 65 and over. The first-quarter death rate among the population aged 65 and over fell by almost 30 per cent between the late 1990s and 2007.
We do not yet know much about the distribution of the gains from reduced mortality, but the regional variations are instructive. The age-standardised death rate has fallen in all counties, but there was some tendency for the decrease to be highest in regions – such as Dún Laoghaire-Rathdown and Galway City – with initially relatively low rates, and lowest in regions – such as Cavan, Leitrim, North Tipperary, and Limerick – where the initial rate was relatively high. The contrast is highlighted by noting that, while in the mid-1990s the standardised death rate in Limerick City was about 25 per cent higher than in Dún Laoghaire-Rathdown, by 2003 to 2005, the differential had widened to over 30 per cent. This suggests that the socio-economic gradient in mortality rates has steepened slightly.
It is easier to describe the decline in mortality rates than to explain why the dramatic change has come about. Undoubtedly, many factors contributed to the improvement, and the phenomenon has not yet received enough scholarly attention to allow us to identify the contribution of each with any precision. What follows is a tentative synopsis of the most plausible explanations.
There are some similarities between Ireland in the new century and East Germany after 1990. East Germany benefited from the transition to an advanced medical and social system following unification with the rest of Germany, and this was reflected in an abrupt fall in mortality rates. Ireland in the second half of the 1990s suddenly caught up with world leaders in terms of living standards. This had many favourable repercussions: incomes rose steeply; the unemployment rate fell sharply, and there was a marked reduction in the level of absolute poverty. Given the correlation between poverty and unemployment and poor health outcomes within countries, it is not unreasonable to postulate that the trickling down of Ireland’s increased prosperity played an important part in improving the health of the population. It can hardly be pure coincidence that Ireland caught up with the average life expectancy of advanced countries shortly after she caught up with their living standards.
In addition to the direct benefits of higher living standards, increased prosperity also facilitated increased expenditure on public and private health services. In Ireland, non-capital public expenditure on healthcare per head of population increased by 72 per cent between 1997 and 2006, and is continuing to grow . From a policy point of view, it is important to try to identify how much this increase contributed to improved health outcomes.
A recent study classifies deaths into two categories: those due to causes that should not occur in the presence of timely and effective healthcare – so-called “amenable mortality” – and the rest. “Amenable” conditions include bacterial infections, treatable cancers, diabetes, cardiovascular and cerebrovascular disease; half of the deaths from ischaemic hearth disease, and complications of common surgical procedures. Twenty-eight per cent of deaths to Irish males aged under 75 years in 1997 to 1998 were classified as “amenable”, and 72 per cent “non-amenable”. According to this study, falling “amenable” and “non-amenable” death rates contributed about equally to the decline in Ireland’s death rate in the under-75 population between 1997 to 1998 and 2002 to 2003. The reason we did so well in terms of the overall reduction in the death rate is that, after Greece, we recorded the largest proportional decline in the “non-amenable” death rate (12 per cent). Thus, while this approach suggests that better delivery of healthcare made a significant contribution to Ireland’s recently improved health status, it also suggests that about half of the improvement has been due to other factors.
These other factors would include some important environmental and lifestyle changes that took place in Ireland during the late 1990s and in the new century.
A major component of the economic boom was an unprecedented housing boom. A consequence of this was a very rapid improvement in the housing conditions of the population. The 2006 Census of Population revealed 17 per cent of private households were living in dwelling units built within the previous five years and 28 per cent in units built within the previous 10 years. The proportion of households with central heating rose from 44 per cent in 1991 to 84 per cent in 2002 and 88 per cent in 2006 . Better heating has been shown to improve self-reported health and reduce the incidence of respiratory illnesses in New Zealand, where winter climatic conditions are similar to those in Ireland .
Since the early 1990s, there have also been some major improvements in our environment. The most important of these – from a health perspective – is the improvement in air quality. Clean air or smoke control legislation was introduced in the Greater Dublin area in 1990, in Cork in 1995, and had been extended to most other urban areas by 2003. Leaded petrol was phased out in 2000. All major population centres have enjoyed a progressive improvement in overall air quality since the early 1990s . The introduction of the coal ban in Dublin has been credited with a decline of 5.7 per cent in non-trauma deaths, and 15.5 per cent in deaths from respiratory diseases, in the city over the period 1984 to 1996 . However, the national death rate from respiratory diseases fluctuated erratically between the early 1980s and the late 1990s, and only in the new century was a clear and sustained decline apparent. If the main benefits of the clean air legislation had been reaped by the mid-1990s, it cannot account for the sustained fall in the death rate after 2000. Further research is needed to pinpoint the reasons for the continued improvement on this front.
It is also possible that climate change has been working in favour of a healthier Irish population because its main manifestation seems to be in the milder winters we have been experiencing. This would tie in with the fall in the winter peak in the death rate noted above. A reduction in the number of days of severely cold weather – and especially of those when smoggy conditions are combined with low temperatures – would be expected to lower the winter death rate from respiratory and some other conditions, and this trend would have been reinforced by the marked improvement in housing standards noted above.
But it is still somewhat unsatisfactory to attribute the abrupt fall in the Irish death rate to the trend towards milder winters, which has been occurring fairly steadily for some decades now. Moreover, the fact that the death rate in the Republic of Ireland suddenly fell to the Northern Ireland level – where similar climatic conditions prevail – is another argument against attaching much weight to the role of milder winters.
We would expect the long-run decline in tobacco consumption and the rising proportion of non-smokers to be reflected in improved community health and, particularly, lower death rates from circulatory and respiratory illnesses. By 2006, only 24.5 per cent of the population reported themselves as smokers, compared with 33 per cent in 1998 . However, while welcome, this decline does not seem large enough, or abrupt enough, to account for much of the kink in the death rate in the new century. (Any population effects of the 2006 ban on smoking in the workplace would not show in our data, although positive effects have already been found among bar staff .)
Finally, there also appears to be an increased awareness of the need for healthier diets and more active lifestyles in Ireland today, but – once again – these changes have been occurring gradually, and it is difficult to believe that the sharp breaks in death rates documented above should be attributed to them. And there have been some countervailing trends such as increased alcohol consumption – although a peak was reached early in the new century – and rising levels of obesity.
To conclude, there is indeed good news for Ireland on the health front, which has been remarkably under-reported in our media. Perhaps scare stories about crises in the health services are more newsworthy than information about increased longevity! But the evidence of an accelerated improvement in life expectancy since the turn of the century is striking. Many inter-related factors may share the credit for this – increased prosperity, more spending on healthcare, improved environmental conditions, the decline in smoking and perhaps even the trend towards milder winters – but, despite this long list, the abruptness of the change is somewhat puzzling. While there is undoubtedly much room for continued improvement, we may celebrate the fact that Irish people are now living longer and healthier lives in a greatly improved physical environment than was the case as recently as a decade ago.