0

10

20

30

40

50

60

70

80

Real yrs 1956 yrs

Lif

e e

xp

ec

tan

cy

1956 born1978 BA1982 DPhil1998 Married 2006 Gresham35th Pf Physic

Curriculum Vitae - Curriculum Mortis

35 yr

18 yr

Life and death in the new millennium

Where were the first improvements in health and longevity?

Why did life span double in Britain after 1800? What population processes? Which interventions?

Are we reaching maximum life expectancy?

Are "developing" countries actually developing?

Gresham College"The Third Universitie of England"

(1615)

1596 Matthew Gwinne, 1st Professor of Physic, Royal Physician, author of tragedy Nero

1608 "I ever have studied physic…by turning o’er authorities…" (Shakespeare, Pericles)

1647 Professors "so superbiously pettish…"1720 Lectures "should not be… intermingled with

exhortation…"1799 Lecture in Latin at 12 noon, vernacular at 1pm1904 WH Thompson (divinity) Nature and

Immortality

Terms of engagement

Health of humans in context of environment and evolution

Seeing is believing Distinguish known versus unknown Not just what happens but why Ask scientific questions for which I have

no answer Focus on populations (epidemiology)

rather than individuals (clinical)

Q1. Where were the first major

improvements in health and longevity?

20

30

40

50

60

70

80

1300 1400 1500 1600 1700 1800 1900 2000

Lif

e ex

pec

tan

cy a

t b

irth

(ye

ars) Wrigley & Schofield

Human Mortality Database

Clark

Industrial (r)evolution, health (r)evolution Life expectancy in England 1300-2000

THE SPECTRUM OF LIFE SPANS

From hunter-gatherers to…

… Japanese women

0

20

40

60

80

100

0 20 40 60 80 100

Age (years)

Pe

rce

nt

su

rviv

ing

Hunter-gatherers

Japanese women

Evolution: "Nasty, brutish..."Survival of hunter-gatherers and Japanese

Are humans more flexible than chimpanzees?

0

20

40

60

80

100

0 20 40 60 80Age (years)

Per

cen

t su

rviv

ing

Wild chimps

Captive chimps

Q2. What population

processes caused life expectancy double in 150

years?

Population = + births

change – deaths

+ immigrants

- emigrants

Fundamental equation of population biology

Elim-i-nate the

negative, accen-tuate the positive

Feedback in health & population

20

30

40

50

60

70

80

1300 1400 1500 1600 1700 1800 1900 2000

Lif

e ex

pec

tan

cy a

t b

irth

(ye

ars) Wrigley & Schofield

Human Mortality Database

Clark

Industrial (r)evolution, health (r)evolution Life expectancy in England 1300-2000

500+ years of stasis → negative feedback

Thomas Robert Malthus1766-1834

Principle of Population (1798)

population, if unchecked, increases geometrically

2, 4, 8, 16, 32, 64, 128…

but food supply grows arithmetically

1, 2, 3, 4, 5, 6, 7, 8…

so population outruns food supply

50

100

150

200

250

300

0 10 20 30 40 50 60

Households with "substantial" taxable income (%)

Infa

nt

mo

rtal

ity

per

100

0 b

irth

sMalthus in 16-17th century London?

Poorer households had more child deaths

low income, high death rate

high income, low death rate

8 London parishes 1538-1653 (Landers 1993)

PO

SIT

IVE

FEED

BA

CK

20

30

40

50

60

70

80

1300 1400 1500 1600 1700 1800 1900 2000

Life

exp

ecta

ncy

at b

irth

(yea

rs) Wrigley & Schofield

Human Mortality Database

Clark

Industrial (r)evolution, health (r)evolution Life expectancy in England 1300-2000

Rapid increase → positive

feedback

John Graunt (1620-1674)

Observations on…

the Bills of Mortality 1662

Causes of Death in the Bills of Mortality

Childbed: death of mother from infection following childbirth

Chrisomes: death of infants in the first month of life (before baptism)

Consumption: tuberculosis

Dropsie: abnormal swelling due to build up of clear, watery fluid

Drowning, Execution, Murder

Flux: dysentery

Gowt: gout, inflammation, build up of uric acid in the tissues

Kingsevil: scrofula, tuberculosis of the neck

Livergrown: enlarged liver, possibly rickets

Purples: rash due to spontaneous bleeding in to the skin; in newborns, may be insufficient vitamin K

Quinsy: acute inflammation of the tonsils

Surfeit: vomiting from over eating or gluttony

Teeth: death of a teething infant

One death, one cause?

"Malnutrition-infection complex"

Better nutritionFewer infections e.g. less diarrhoea

Q3. What in(ter)ventions

allowed life expectancy double

in 150 years?

(1) AgricultureElimination of famine in England

0

2

4

6

8

10

12

14

averagepre-17th

17th 18th 19th 20thCenturies

Nu

mb

er

of

fam

ine

s

ea

ch

ce

ntu

ry

Excess food only 20-30% pre 17th century, with same fluctuation in yield

1 Agriculture and nutritionelimination of famine in England

2 Public health "sanitation revolution"

John Snow (1813-1858) Edwin Chadwick (1800-1890) Sanitary Condition of the Labouring

Population of Great Britain (1842) On The Mode of Communication of Cholera (1855)

3 Microbiology diagnostics vaccines drugs

1890s

C17th C19th C20th

Q4. Are we reaching

maximum life expectancy?

Growth: 1 extra year in 4

40

50

60

70

80

90

100

1820 1845 1870 1895 1920 1945 1970 1995 2020 2045 2070

Life expectancy

Maxima estimated inyear given

Inexorable growth in life expectancy?women in leading countries

source: Oeppen 2002

I expect to die in 2041 aged 85 yr

60

65

70

75

80

85

90

0 10 20 30 40 50 60 70 80 90 100

My age (years)

Line of immortality

Increase in life expectancy

Ex

pe

cte

d a

ge

of

de

ath

(y

ea

rs)

Q5. Are "developing"

countries developing?

William Gibson

"The future is already here,

it's just unevenly

distributed"

Human population in round numbers (2001)

Population 6.2 billionBirths 133 millionDeaths 60 millionNet growth 73 million

1.2% per yrMax growth 85 m in 1980s

Today's least favoured countries have longevity patterns of 19th century

FrancePortugal

ArgentinaGeorgia

AlgeriaIndonesia

MyanmarTimor-Leste

CambodiaEq Guinea

TanzaniaAngola

Zimbabwe

30

40

50

60

70

80

90

100

1780 1800 1820 1840 1860 1880 1900 1920 1940 1960 1980 2000

Year in which LE reached in leading countries

Lif

e e

xp

ec

tan

cy

wo

me

n 46 countries 146 countries

Life expectancy is 70+ years in only half the world's countries

Zimbabwe

Burundi

Chad

GuineaGambia

Papua New Guinea

Guyana

RussiaUkraine

Iran

Solomon Islands

Saudi Arabia

Syria

Seychelles

Qatar

Poland

Chile

New Zealand

Spain

Japan

30

40

50

60

70

80

90

0 50 100 150 200

Countries ranked

Lif

e e

xp

ec

tan

cy

at

bir

th (

yr)

0

20

40

60

80

100

<1 5-9

15-1

9

25-2

9

35-3

9

45-4

9

55-5

9

65-6

9

75-7

9

85-8

9

95-9

9

Age class (years)

Per

cen

t su

rviv

ing

JapanUK

India

Sierra Leone

Zimbabwe

Russia

Fate of 100 boys born in different countries in 2001

Global distribution of afflictionscommunicable, non-communicable, injuries

Where 60 million people die double burden of disease in low-income countries

0

2

4

6

8

Communicable,pregnancy,

nutrition

Non-communicable

Injuries

Dea

ths

per

mill

ion

po

pu

lati

on

Low-middle income

High income

0

1

2

3

4

Neonat

al

Respira

tory

Diarrh

oea

Other

s

Mal

aria

Mea

sles

HIV/A

IDS

Inju

ries

Mill

ion

s o

f d

ea

ths

10 million children under 5 die each yearmostly of cheaply preventable conditions

3.6 million from undernutrition

Life expectancy is converging in low- and high- income countries

30

40

50

60

70

80

1960 1990 2002

Lif

e e

xp

ec

tan

cy

(y

ears

) Low-middle incomeHigh income

Thomas Jefferson

"Every generation needs a new revolution"

Life expectancy gains and losses worldwide since 1960

-4

-2

0

2

4

6

8

10

Britai

n

E Asi

a

Mid

Eas

t

S Asi

a

L Am

eric

a

SS Afri

ca

Eurasi

a

Yea

rs g

ain

ed p

er d

ecad

e 1960-1990

1990-200218

50-1

900

1900

-195

0

Chou En-lai

Q: What has been the impact of the French revolution?

A: "It's too early to tell"

69

4138

73

65

48

78

71

50

35

45

55

65

75

85

UK China Africa

Lif

e e

xp

ec

tan

cy

at

bir

th (

yr) 1952

1975

2002

China: the short march to long life

History of longevity

Human longevity - astonishingly plastic product of evolution

life span x2 in Western Europe 1800-1950 Escaping Malthus, the power of positive feedback

from environmental to genetic control Direct route to longer life

nutrition → epidemiology (public health) → microbiology (diagnosis, drugs and vaccines)

Not underestimating…

science, social institutions, capital, skilled labour

"Developing" countries Life spans range from hunter-gatherers to

industrialbut converging, with some exceptions

Cheap, effective technology to exploit +ve feedback outpaced the 1800-1950 revolutionChina and others since 1950

Lagging countries suffer old problems and new"infection-malnutrition", now with chronic

disease and AIDS; major reversals in E Europe & Africa

Technology only partly compensates for lack of science, institutions, capital, and labour

William Stewart US Surgeon General 1969

"It is time to close the book on infectious diseases…"