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The Skeptik 2013;3:97-116

Ginter E1, Simko V2, Sedláková D3

1 Slovak Medical University, emeritus, Slovakia
2 State University of New York, Downstate Medical Center at Brooklyn, USA
3 The WHO Head of Country Office, Slovakia

Life expectancy and cause-specific mortality are the most fundamental metrics of population health. From 1970 to 2010, the global life expectancy at birth increased in males from 56·4 years to 67·5 years and in females from 61·2 years to 73·3 years. Population growth resulted in an increase in the average age of the world’s population. Decreasing age-specific, sex-specific and cause-specific death rates have combined to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases, cardiovascular disorders and cancer. In Europe specifically, there has been a very significant decrease of premature (age 0-64 years) cardiovascular mortality, but only a small decrease of premature cancer mortality. Consequently, in most European countries, with exception of the post-Soviet region, cancer is the most prominent premature killer. The mortality trends in the Slovak and Czech Republic balance between values of democratic countries with good indicators and the postcommunist regions with poorer values.

Key words: life expectancy at birth, premature mortality, global world health, Europe, Slovakia, Czech Republic, communicable and non-communicable diseases, cardiovascular mortality, cancer mortality


Good health is a fundamental prereqisite for social and economic prosperity which, in turn, promotes good health. Exploring the root causes of general- and disease-specific mortality is essential for planning appropriate health interventions, to introduce measures aiming to alleviate premature and potentially preventable disease.

Here we review recent mortality trends as described in a very extensive report on global and regional mortality related to 235 causes of death between 1990 and 2010, published in December 2012 (1). The authors attempted to identify all available causes of death for 187 countries from vital registration, autopsy records, mortality surveillance, censuses, as well as from hospital and police records. In addition, we used reports of the World Health Organization (WHO), especially of its 2012 database Health for All for Europe (2).

World Health Trends

There are three main groups represented in global mortality in 2010:

  1. Non-communicable diseases, especially cardiovascular disease (CVD) and malignancy resulted in death of 34.5 millions (65.5 % of all deaths).
  2. Communicable diseases, malnutrition and neonatal disorders were to blame for death of 13.2 millions (24.9 % of all deaths).
  3. Injuries, violence, suicides etc. were responsible for the death of 5.1 million people (9.6 % of all deaths).

There was an explosive growth of the world population, (mostly China, India, Indonesia, USA, Brasil, Nigeria, Bangladesh) from 5.2 billions in 1990 to 7 billions in 2010. To correct potential bias, Table 1 indicates mortality in 1990 and 2010 for both men and women from various causes, expressed as standardized mortality per population of 100,000.

To simplify an extensive report (1) on 235 causes of death, Tab. 1 summarizes the most important groups of disease. Standardized mortality per 100 000 declined from 1990 to 2010. Disorders that increased in the period 1990 – 2010 were diabetes, neurological and mental disease, natural and man-related catastrophies.

Table 2 reflects health trends from a different perspective, as an absolute mortality from different causes in the world, in 1990 and 2010.

Decline in communicable, neonatal and nutritional disorders from 15.9 millions to 13.2 millions per year is encouraging. It atests to the impact of preventive medicine, mostly in the developing world.

Less positive are trends in non-communicable disorders, especially CVD and cancer. Catastrophic was the rise in mortality related to diabetes type 2, undoubtedly associated with the epidemic of obesity (3). Neurologic and mental disorders also increased.

Medium LE at birth in the world improved since 1970 by 3 – 4 years in every consecutive decade. After 2004 there was a substantial decline of mortality in eastern and Subsaharan Africa, mostly thanks to antiretroviral managemernt of AIDS and prevention of malaria.

The total global mortality in 2010 reached 52.8 million, 13.5 % more than in 1990. There was a higher number of deaths in people age 70 and older. These numbers have to be interpreted with regard to the absolute growth and aging of the world population. In contrast, mortality of children below age 5 decreased. Again, this is a success of preventive medicine, nutritional intervention and accessibility of modern medications.

Health trends in Europe

Most of Europe experienced substantial improvement of general health during the past decades. Medium LE prominently improved in 1990 through 2010. Exception, less favorable, is Ukraine, Belarus and the Russian Federation (Tab. 3).

It is obvious that the trend in medium LE in Europe is related to social and political situation. In countries with firmly established democratic order the LE of both men and women progressively improved. In former Soviet satellites the LE slowed down until it started to improve only after the fall of communism. This confirms that the failure of central political party planning in the Soviet union and its satellites adversely affected not only the economy and social relations but also the health of the population.

Dramatic changes in Russia after the demise of Soviet Union resulted in an extraordinary destabilization of LE that reached a minimum in 1994. Remarkably, even more than twenty years after the breakdown of the Iron Curtain there persists a gap in the general health between the democratic and the former communist regions of Europe.

Main cause of relatively high mortality in the post totalitarian Europe is the CVD. In addition, mortality is also associated with a low socioeconomic level and limited funding for health care, further an improper life style: alcoholism, smoking and inadequate intake of protective nutrients. Alcoholism, especially binge drinking is a prominent factor in Russia, Belarus, Ukraine and in the Baltic Republics (4-6). Rising infant and general mortality in the former USSR represent a major exception from the decline in worldwide mortality. The mortality trends related to the Soviet era invalidate past Soviet claims to the superiority of the communist system, even despite alleged improvements in caloric intake, clothing, housing, education and favorable ratio of doctors per capita population (7). Russian males have comparably one of the worst survival: they live shorter than males not only in Japan or Canada. but also in Chile, Mexico, China, Algeria, Brasil and Indonesia. Gorbachev’s perestroika and alcohol restriction initially affected Russian LE favorably. Subsequent political and economic instability had a catastrophic impact. Putin era stabilized the decline in LE which only recently returned to survival values in 1970s. Despite some improvement, present LE at 63 years in Russian lags almost 20 years behind Sweden or Switzerland and it is lower than in a number of developing countries. Unfavorable indicators of LE in Ukraine and in the Russian Federation are clearly also related to wide spread alcoholism (4, 5).

Premature mortality (age 0 – 64) is a more reliable index of health than the general mortality, it better reflects the overall survival and the causes of death. The diagnosis of terminal disease is more accurate at an earlier age and it is more often supported by refined diagnostic techniques and autopsy than in the very old where diagnostic criteria are less strongly enforced. Premature cardiovascular disease (CVD) and cancer prominently affect overall survival. In the well-established democratic part of Europe there has been a steady decline in premature CVD mortality. In contrast, the decline in cancer has been less prominent and in several countries cancer mortality has become the most pressing health problem. A good example is Spain (Fig. 1) where the male premature mortality for cancer is twice that of CVD mortality.

Fig. 1. Premature Spanish male cancer mortality is now twice higher than the mortality from cardiovascular disease.

Such trend, cancer mortality overcoming CVD mortality, is even more pronounced in women. In well established democratic countries in Europe, the premature female cancer mortality in 2009 was 56/100,000 while mortality for CVD was only 17/100,000. These differences in CVD and cancer-specific premature mortality in these countries in males were somewhat less striking than in females: 77/100,000 for cancer and 47/100,000 for CVD (general mortality in men is higher than in women).

These mortality trends provide a reminder for health care planners to primarily focus on prevention and management of malignant disorders.

Health trends in the Czech and Slovak Republics.

Czechs and Slovaks started their geopolitical coexistence in 1918. The following decades brought along a sequence of dramatic changes : the collaps of democracy and German dominance after 1938, Slovak uprising against Germans in 1944, Soviet control after 1948 that ended in 1989. This important date restarted democracy and new inroads into the market economy, with impressive positive influence on population health.

Trends in population health of Czechs and Slovaks convincingly document essential influence of political systems. After the fall of communism in 1989 there started a brisk correction, expressed in dramatic decline in CVD and cancer mortality (Fig. 2 and 3). Similar improvements after 1989 have been observed in the Czech population.

Fig. 2. Dramatic decline of premature cardiovascular mortaity in Slovak males after the fall of communism.

Fig. 3. Dramatic decline of premature male oncological mortaity in Slovakia after the fall of communism.

The promptness of favorable reversal in mortality is intriguing. The downturn in mortality materialized at such fast pace that it makes it improbable to attribute this to an improved health care or to a decrease in smoking and alcohol abuse. Later on, other factors contributing to further improvement in mortality exerted their beneficial influence. Credit deserves introduction of modern diagnostic techniques and equipment, access to novel medications for hypertension and lipid control. Rapid onset of improvement in Slovak and Czech mortality after the fall of communism is most plausibly explained by favorable effect of improved general well- being. The society was relieved of psychological consequences of a totalitarian oppression (8 -12).

Czechs have better LE than Slovak (Fig. 4) . Their advantage, compared with Slovaks has become more prominent in the past decade.
Different trends in LE of males in Slovakia and Czech Republic can be explained by different age-mortality structure in these two countries. Frequent explanation for this difference is a lower infant mortality in Czech Republic compared to Slovakia. Czech Republic belongs to European countries with a very low infant mortality (2,67 deaths/1,000 live births). There is also a marked difference between these two countries in the mortality of children and adolescent males (age 1–19 years). Interestingly, improvement in the male mortality at the middle age of 30–44 and 45–59, is of the same magnitude in both countries.

Fig. 4. Different trends of male LE in Czech and Slovak republics.

Less favorable LE in Slovakia compared to the Czech republic may be partly explained by a larger proportion of socially deprived Roma population in Slovakia (13). The rate of unemployment is very high in Roma males (14) who have the LE estimated at 62 years, about ten years less than is the Slovak national average. Infant mortality in Roma settlements has been repeatedly disproportionately high. This contributes to persistently higher infant mortality in Slovakia compared to the Czech republic. Roma children and teens in Roma settlements are exposed to adverse environmental hygiene, Addiction to smoking, alcohol and drugs, including toluene sniffing. has been reported, in addition to Roma adults, also in their children. The age structure of the Roma population is remarkable for a rapid decrease of males in the older age groups, reflecting high mortality after age 60. This contributes to a marked difference between Slovakia and Czech republic in male mortality at the age interval 60–74 years.

The direction to effective improvement of the health status of Slovak population (15) depends on prevention of chronic diseases (especially of oncologic and cardiovascular diseases), change in the attitude of the population to more conscientious health care and on effectiveness of attempts to resolve social disparities.

Additional factors affecting global health

There is a widely accepted consensus that the health of a population depends on the economic and social status of a society and of each individual (16-18). Poverty expressed as a subnormal gross domestic product per capita (GDP) is closely associated with low medium LE. Striking example of such association is the Russian Federation and Ukraine.

Fig. 5 clearly documents that higher GDP in different countries is accompanied by higher LE. There is an interesting exception to this positive relationship. When the country’s GDP per capita exceeds 40 000
PPP (purchasing power parity in international dollars), this health advantage disappears. A good example is the USA where health expenditures are highest in the world, while the health standard of its population is below the advanced European countries (19).

Fig. 5. Realation of gross national product per capita with LE. According to 2003-2013.

WHO ruled that the main determinants of health include not only the social and economic level but also the population’s individual characteristics and behavior (20). Subjective well-being refers to how people consider and evaluate their lives. This includes such variables as life and marital satisfaction, low level of depression, absence of anxiety and positive mood and emotions (21). It is remarkable that in the European Union the LE increases almost in a linear relation with the subjective well- being (Fig. 6).

Fig. 6. Linear relation of LE increase with the subjective well- being.

The condition of well-being is a novel factor in epidemiological research on human health. Data from long-term studies published in Finland, the USA and in several other parts of the world revealed the importance of psychological factors, especially a loss of hope, in the pathogenesis of disorders of heart and circulation (22,23).

Hope constitutes an essential experience of a human condition. It functions as a way of feeling, of thinking, of behaving, a way of relating to oneself and the world. It is a vital part of human existence- the confident belief that there is something more rather than something less, something better instead of something worse, something to live for and invest energy that gives life its necessary depth, meaning and security. Hope keeps us going. A loss of emotional motivation was partly instrumental and contributed to adverse health parameters during Soviet domination of Eastern Europe. It still exerts adverse after- effects in present Russia and Ukraine.

Loss of hope contributes to depression, associated with addiction to smoking, alcohol and drugs. Remarkable improvement in LE of Czechs, Slovaks and other post-communist nations after the fall of totalitarian oppression provides strong evidence about the power of subjective well-being.


There has been an explosive growth in world population and, fortunately the trend in global life expectancy indicates an increase in LE and also a decline in cause-specific mortality. While the decline in communicable diseases and cardiovascular mortality, especially in the developing world has been encouraging, cancer morbidity and mortality is becoming the most important objective for prevention and management. Although large world pockets of hunger still exist, nutritional deficiencies are becoming less of a factor affecting mortality. In contrast, uncontrolled consumption of high calorie food is contributing to a fateful epidemic of obesity and diabetes type 2. It is of utmost concern that despite the global spread of civilization, forces of war and violence are gaining dire prominence in world mortality.

Regional health differences provide a useful directive to uderstand the disease and to meaningfully influence population health. A remarkable lesson has to be gained from the dramatic improvement in health of countries liberated from past communist mismanagement. Czechs and Slovaks are becoming close in health to established democracies. Russia and Ukraine have health indicators equivalent or even below several countries in the developing world.

Negative impact on population health is based not only in poor economy but also in the disrespect for a newly recognized status of general well-being. Absence of positive emotional motivation results in generalized depression, accompanied by addiction to smoking, alcohol and drugs. Besides material wealth, the social order has to offer each individual hope and a confident belief in meaning and security.

Recent comprehensive data on world health provide a directive for planning and management, they remind us of enormous opportunities in the future.

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Tab. 1. Development in world standardized mortality per 100,000 population / year (1990-2010).

DISEASE 1990 2010 Change in %
All causes 999 784 - 21,5 %
Non-communicable diseases 646 520 - 19,4 %
Cardiovascular diseases 298 235 - 21,2 %
Ischaemic heart disease 131 106 - 19,5 %
Cerebrovascular disease 106 88 - 24,6 %
Hypertensive heart disease 14,9 13,1 - 11,5
Neoplasms 141 121 - 13,8 %
Trachea, and lung cancers 25,5 23,4 - 8,3 %
Stomach cancer 19,0 11,5 - 39,5 %
Communicable diseases 271 190 - 30,0 %
HIV/AIDS and tuberculosis 39,3 39,4 + 0,2 %
Injuries 82 74 - 9,3 %
Chronic respiratory diseases 98 57 - 41,9 %
Asthma 9,0 5,2 -42,1 %
Neonatal disorders 42 31 - 26,8 %
Digestive diseases 22,9 16,7 - 27,2 %
Peptic ulcer disease 7,5 3,7 - 50,9 %
Cirrhosis of the liver 18,6 15,6 - 15,8 %
Nutritional deficiencies 17,3 9,9 - 42,8 %
Self-harm and violence 21,1 19,7 - 6,9 %
Diabetes mellitus 16,3 19,5 + 19,7 %
Neurological disorders 13,7 18,8 + 37,8 %
Mental and behavioural disorders 3,2 3,5 + 9,3 %
Forces of nature, war, itervention 1,9 3,1 + 62,0 %

Tab. 2. Development in world mortality. All ages deaths, thousand per year (1990-2010).

DISEASE 1990 2010 Change in %
All causes 46511 52770 + 13,5 %
Non-communicable diseases 26560 34540 + 30,0%
Cardiovascular diseases 11904 15616 + 31,2 %
Ischaemic heart disease 5312 7029 + 34,9 %
Cerebrovascular disease 4660 5874 + 26,0 %
Hypertensive heart disease 591 873 + 47,8 %
Neoplasms 5779 7978 + 38,0 %
Trachea, and lung cancers 1036 1527 + 47,4 %
Stomach cancer 774 754 - 2,5 %
Communicable diseases 15859 13158 - 17,0 %
HIV/AIDS and tuberculosis 1770 2661 + 50,3 %
Injuries 4092 5073 + 24,0 %
Chronic respiratory diseases 3986 3776 - 5,3 %
Asthma 380 346 -9,1 %
Neonatal disorders 3081 2236 - 27,4 %
Digestive diseases 973 1112 + 14,2 %
Peptic ulcer disease 319 246 - 22,9 %
Cirrhosis of the liver 778 1031 + 32,5 %
Nutritional deficiencies 977 684 - 37,0 %
Self-harm and violence 1009 1340 + 32,9 %
Diabetes mellitus 685 1281 + 92,7 %
Neurological disorders 595 1274 + 114,3 %
Mental and behavioural disorders 138 232 + 68,0 %
Musculoskeletal disorders 70 154 + 37,8 %
Forces of nature and wars 95 214 + 125,2 %

Tab. 3. Development in life expectancy at birth (males + females) in Europe 1990-2009/2010.

Country 1990 2009-2010 Difference
Russia 69 63 - 6
Hungary 69 74 + 5
Latvia 70 73 + 3
Romania 70 74 + 4
Estonia 70 76 + 6
Ukraine 71 70 - 1
Belarus 71 71 0
Slovakia 71 75 + 4
Bulgaria 71 74 + 3
Poland 71 76 + 5
Lithuania 72 73 + 1
Czech republic 72 78 + 6
Portugal 74 80 + 6
Finland 75 80 + 5
Germany 76 81 + 5
Austria 76 81 + 5
United Kingdom 76 81 + 5
Spain 77 82 + 5
Italy 77 82 + 5
Greece 77 80 + 3
Norway 77 81 + 4
Netherlands 77 81 + 4
Switzerland 78 82 + 4
Sweden 78 82 + 4
France 78 81 + 3

Adress for correspondence:
Dr. Emil Ginter, Račianska 17, 83102 Bratislava, E-mail:

Prof. Vlado Simko MD, State University New York, Downstate Medical Center at Brooklyn, USA,

Dr. Darina Sedláková, The WHO Head of Country Office
PO Box 52 837 52 - Bratislava 37, Slovakia