Cohort effects and life expectancy and many other facts about the history of American medicine

The cohort reaching age 55 around 1982 (born around 1927) has significantly higher mortality than the cohort 10 years younger. That higher mortality continues through the cohort passing through that age range in the mid-1990s, roughly, when the cohort born in 1933 reaches age 65. That same cohort also has higher mortality when they are 65-74 and 75-84. The story is not one of selection – a handful of less healthy people who die and leave behind healthier stock. Rather, it seems that an entire generation was rendered vulnerable by being born during and just before the Great Depression (Lleras-Muney and Moreau, 2018).

That is from a new NBER history of health care paper by Maryaline Catillon, David Cutler, and Thomas Getzen.  This piece is interesting on virtually every page.  For instance, on the rise of American science:

Of the 18 Nobel Prizes in Physiology or Medicine awarded 1901-1920, none went to US researchers. Over the next two decades, four out of twenty-four did, then for the rest of the century, more than half.

Then:

…our analysis of Massachusetts data does not support a large impact of medical care supply on mortality in the pre-antibiotic era.

Using the best data I’ve seen to date, apart from RCTs, the authors conclude from their statistical work:

…there is little evidence that access to medical care plays a role in mortality over the entire 1965-2015 period, but it appears to have had an effect during recent years.

That is from p.33

Death rates from influenza/pneumonia and cancer seem most responsive to access to medical care.  And I had not known this:

The period from 1935 to 1950 saw the most…decline in infant and child mortality of any time period since 1900.  It is unclear how much of this change would have happened without antibiotics, but blood banking and advances in surgical techniques were among the host of distinct and incremental improvements that added to life expectancy while the health share of GDP increased only slightly.

Recommended.

Comments

'then for the rest of the century, more than half'

Amazing what happens when a continent goes crazy, and the place that many skilled researchers fled to considers them no longer citizens of where they came from.

'our analysis of Massachusetts data does not support a large impact of medical care supply on mortality in the pre-antibiotic era'

And this would be surprising why?

'there is little evidence that access to medical care plays a role in mortality over the entire 1965-2015 period, but it appears to have had an effect during recent years'

Guess it depends on the meaning of 'access' - certainly, anyone involved in a major car wreck is delivered to the ER and treated, and the improvements in emergency care between 1965 and 2015 are not exactly trivial.

'but blood banking and advances in surgical techniques were among the host of distinct and incremental improvements that added to life expectancy'

Oddly, though, this happened during the time antibiotics were introduced, meaning that those distinct and incremental improvements would have added to life expectancy based solely on medical care.

@clockwork_prior - I think you misunderstood this study. It's simply saying what many doctors already know, which is the body heals itself usually. How many people were saved by antibiotics who would have ordinarily simply healed themselves? Probably 99.9%, keeping in mind these days even for a common severe cold, physicians Rx antibiotics to prevent "potential" lung infections from any phlegm accumulation in the lungs.

As for the rest of the study, it's simply saying that more old people these days are obese, and less healthy, and in earlier times would have died before age 55.

Bonus trivia: one word, plastics. That's pure cancer. And unfortunately in rural Philippines where we have our house, we have to burn our trash, since no trash pickup, and it's nasty burning plastics. I took many precautions but once in a while the wind shifts and that black smoke from burning plastics goes right into your face and into your lungs.

'Probably 99.9%'

Not even close, as the massive experiment called WWII conclusively demonstrated.

I'd suggest (if you don't already do this) to increase the biomass mixed in with the trash you burn. Part of the problem is the excess chlorine present, which you can't do much about (except dilute it) but part of the problem is just the amount of energy required to fully break the C-C bonds. Added heat will help. The goal is longer exposure to heat (that's one reason smoke stacks were invented) as well as higher heat. (and more air/O2 helps as well, of course (as long as it doesn't cool the burning mass)).

@Li and @dearieme - both of you friends are right as rain...I've become an incompetent expert on burning. The key is indeed a confined space. I dug a large hole (before they used ground surface), and 'layer' trash with diesel fuel (not gasoline! flash fire, and I did get burned a few times with that) and on the bottom layer goes the batteries (had a few, early on, explode in my face and the residue went all over my face except my eyes; God is great! and strangely it made me lol it was so comical).

The biggest enemy of trash burning in east Philippines, 'typhoon alley' is the weather. Routinely it rains and routinely you have 90% humidity. The one time I got a good fire since I had dry wood (long story), and things were burning so good, incredible fire, the effing "barangay captain" came over, told my in-laws to extinguish the fire (which was so hot it took a half hour with a garden hose) because they were giving a political rally speech next door and did not like the smoke from our property. I was hopping mad. So mad. The best fire I ever had, all extinguished over some idiotic campaign speeches where the people are bribed to vote for somebody. I've though of mixing fertilizer with diesel to increase combustion but depending on the granularity of the fertilizer that's how a fuel bomb is made, and I'm not doing to do it. Already with gasoline (which I sometimes use when I run out of diesel or kerosene) it's dangerous enough (I've perfected how to ignite gasoline, but when it reaches a certain fuel/air ratio it will turn into a fireball at the tiniest spark and briefly scorch everything, but with moisture only the top layer of anything melts unless you have sustained heat). Incineration is both art and science.

The glamorous life of the 1%....

Do you burn it in an incinerator, our just in a heap?

"…there is little evidence that access to medical care plays a role in mortality over the entire 1965-2015 period"

This is kind of a big deal. The medical establishment will perhaps say that they nevertheless made things better. But that is not self evident: discomforting & invasive tests and procedures, time spent waiting in doctor's surgeries & hospitals, anxiety over diagnoses.. and then there is the cost.

"…there is little evidence that access to medical care plays a role in mortality over the entire 1965-2015 period"

I'd guess that a large part of the increase in life expectancy is caused by the decline in the rate of lethal heart attacks in males in middle age and early old age. There is no worthwhile evidence that that severe decline has had anything to do with medical treatment, dietary advice, surgery, or "working out". It looks for all the world like an infectious epidemic being overcome by a rise in the capability of immune systems.

Heart attacks are increasingly just one of the various ways by which the ancient peg out. In that sense they are no longer a big deal.

I would expect the drop in smoking rates over time to swamp most advanced medical care in terms of life expectancy statistics.

It's the correlation between wealth and health. One born in the past 40-50 years cannot fully appreciate the increase in wealth, not just for the 1% but the entire population. Sure, antibiotics had a role, but the greater role came from improvements in sanitation, hygiene, and public health in general. The term "public health" is likely considered an oxymoron at this blog, but the efforts at public health vastly improved the health of everyone. [An aside, last evening I listened to a podcast of one of my favorites, Bart Ehrman, the New Testament scholar. He was describing the difference between early Christians and pagans (it's a word of art), in particular the treatment of the sick. Christians, being Christian, gave the sick love and comfort, while pagans essentially ostracized the sick. Which was the better approach from the perspective of public health?]

Mortality is not the only objective; quality of life also is impacted. Some people who lose access to medical care can experience permanent disability from treatable diseases and injuries. For an extreme case--a face transplant or cleft-palette surgery may not have a huge impact on mortality (though it may have indirect influence through decreasing neglect of health), but it makes a huge difference in someone's life.

Is mortality the right thing to look at?

Disability is important. Doctors are also aware of it and have developed metrics beyond mortality to take disability into account when assessing health outcomes. The metrics are Disability-adjusted life years or Quality-adjusted life year.

I broke my left arm in several pieces (the radius specifically) in a stupid MTB accident. A surgery with some plates, screws and external rods and I was discharged from the hospital 36 hours later able to live a "normal" life, the normal life of sedentary people: walk, drive, eat, drink, visit friends.

The doctor told me the fracture I got would have led to a permanent disability not so long ago. I'm not disabled since 10 years ago, and perhaps I will die at the same age of my grandparents. So, this big difference in the outcome of modern medicine is not capture by the mortality statistic. Researchers should look at the Disability-adjusted life years metric.

I don't know if there is a list of low mortality high disability illness/accidents. Take polio, it's mortality rate is relatively low while the disability consequences last a lifetime.

+1

I had cataract surgery on both eyes a few years ago, at a younger than average age. The degrading lens is replaced with a highly engineered plastic one. It evolved out a WW2 efforts to address aircrew combat wounds, and is a very common procedure these days. At the same time, they can laser "sculpt" the eyeball to remove astigmatism.

The results are pretty remarkable. I can drive comfortably at night, and I don't need glasses at all for distance vision anymore. Color saturation is improved. I do wear $10 drugstore glasses to read. Absent this procedure, vision continues to decline, eventually to the point of blindness for many.

Its generally considered a once and done, lifetime fix.

I broke a bone in my foot two years. Without surgery to fasten the bone back together it would not have healed properly and I would have been with a permanent mobility impairment, which in turn would have limited my ability to exercise properly.

"The period from 1935 to 1950"

I call that the Heinlein Era: Americans seemed particularly focused then on getting things done.

I suspect there was a big increase in smoking over that period (the government gave out huge numbers of cigarettes during the War), too, which probably hurt mortality in the long run, but seemed to help people concentrate in the short run.

Cigarettes were my first thought for explaining the cohort effect as well. Also perhaps greater affordability of red meat than in past generatIons, without the health warnings deterring younger generations.

can't see where the study addresses the huge increased incidence of coronary heart disease post ww2 and much improved treatment.
isn't there is probly gonna be a 10 yr? lag between
defining a new disease and developing a good treatment
what would the mortality rate be if you gotta new very common heart disease without the new and pretty darn good treatments?

good point
if the u.s. had a new common and highly lethal disease like coronary artery disease without an effective treatment
life expectancy could very well have decreased
sorta like with the opiod clusterf***

u.s. senator mazie hirono-"I just want to say to the men in this country, just shut up ...blah,blah,blah" -

CVD deaths started rising well before WWII and peaked in the US in the late 60s. There's little sign that "improved treatment" mattered a button. A spontaneous rise was followed by a spontaneous fall. Infection might be the cause, though nobody has identified the infective agent.

It's all been a wonderful money-spinner for cardiologists though, and the manufacturers of statins.

just a humble brazilian goat rustler here
but it looks like you might be conflabulating incidence of coronary heart disease vs. deaths from
coronary heart disease.
I think the current knowledge base suggests that this was not a
"spontaneous" rise and fall of deaths.
https://www.ahajournals.org/doi/pdf/10.1161/CIRCHEARTFAILURE.116.003529
https://www.ahajournals.org/doi/pdf/10.1161/CIRCHEARTFAILURE.116.003529
and current treatment is actually pretty good as well as lucrative
even with/without out the statins

Thanks. The medical writers I've been following on this: I'll be sure to let them know that a naturalbornyogagoatrustler disagrees with them.

As for incidence vs deaths: fair point, but it's deaths that the quacks are good at diagnosing.

Bueno Puente
the natural born part is bragging
yoga goat rustling is mostly about practice

"it's deaths that the quacks are good at diagnosing"
those aren't quacks
they are pathologists
who smell like ducks
and it is called peer review

“The Great Escape”, written by Nobel economist Angus Deaton, reviews 250 years of economies of countries around the world and their impact on outcomes including life expectancy.

A side note: one hundred forty students in Mississippi entered school without all their required vaccination shots. That’s a 99.7% vaccination rate which leads the country and perhaps the world.

I've read the paper and there is really nothing at all surprising in it. I think Tyler's comments above just skim over some points that are self evident to those of us familiar with the public health literature.

Well, given that most medical care/intervention occurs in the last 6 months of life (and so will have a minor if not insignificant (statistically speaking) impact), I'm not exactly sure what this means. In the early '80s I had recurring strep infection which I'd guess would have become quite serious without antibiotic treatment. I really don't understand how they reached their conclusions: in 1930 the proportion of ag workers was enormous compared to today and their working conditions added significantly to their mortality. I've gotta dismiss this study as being, if not just plain wrong, just not addressing the right questions in the right way.

Medical application of insulin began around 1922. Declines in diabetes-related childhood mortality would be observed to decrease from around 15 years thereafter.

My HMO just sent me a notice that I should change my diet and maybe take some pills because I have a seven and a half percent chance of having a heart attack or stroke in the next 10 years.

My family and friends all laugh at this, as do I. I am already old!

No low-fat diets for me.

As any physician know, PUBLIC HEALTH is far and away the largest causal factor of improved health outcomes from the late 1800s-1950s. Public health is effective management of human/animal waste, washing hands, running water, vaccines. Antibiotics are of limited import.
However, check our the cancer survival rates of childhood leukemias...and yet these economists missed such an obvious improvement in outcomes because their sample was ‘too large.’ Lifestyle diseases hurt one part of the population and statistically is ‘coverinf up’ dramatic and real improvement in other areas.

Bueno punters +1

Onky a fraction of the population, albeit a non-trivial one, suffered actual privation in the Depression. Both of my grandfathers, for example, remained employed and were easily able to support their families. If it is the case that these ill effects are found throughout the population then we're looking at an example of non-local causality.

I will be curious to see the health of the cohort raised during The Great Recession.

Not a whole lot of people or percentage of our population needs to access healthcare requiring the highest level of medical or surgical expertise or technology. But those who do are much more likely now to enjoy more life or a better quality of life than previous. This is one major reason we carry healthcare insurance. In the past if your medical or surgical SHT hit the fan you were simply toast because little could be done. So insurance was both cheap and not very useful. Some of the payback for all our huge HC costs is in the value of that life or quality of life. And that is important but difficult to quantify in USD's.

Cool visualization of cohort effects on life expectancy in France, caused by things like the 1918 Influenza pandemic and (maybe) the French Revolution:

https://twitter.com/kjhealy/status/1069961691264401409

This makes a lot of sense when we consider the effects of early childhood stress and trauma and the adverse health effects that these factors can cause throughout the rest of our lives. https://www.sciencedirect.com/science/article/pii/S0091743503001233

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