The Mortality of Swedish and U.S. White Males: A Comparison of Experience, 1969-1971 RICHARD F. TOMASSON, PHD
Abstract: The life expectancy of males in the United States is lower than that of males in most of the developed countries and in some of the not-so-developed ones. U.S. females, by contrast, do much better in international ranking. This study compares the mortality of U.S. white males with that of Swedish males who have had the highest reported male life expectancies in the world since the early 1960s. Life expectancy at birth in 1969-71 was 67.9 for U.S. white males compared with 71.9 for Swedish males. Greater U.S. white male mortality is found at all ages from birth through ages 75-79. At the upper ages there is a rever-
sal of the differential with U.S. white males having lower mortality than their Swedish counterparts. The greatest relative differentials between the two male populations is found at ages under 1, ages 2d24, and ages 50-59. At ages under 1 the greater U.S. white male mortality is accounted for mainly by higher death rates from infectious diseases, at ages 20-24 by higher rates from the external causes of death (specifically accidents and homicide), and at ages 50-59 from most of the major organic causes of death. (Am. J. Public Health 66:968-974, 1976)
The United States is characterized by high mortality of males compared with other developed countries and some not-so-developed ones. U.S. females, on the other hand, do much better than males in international comparisons. The magnitude of the U.S. sex differential in expectation of life at birth reached 7.7 years in 1973 and again in 1974. The differential is the same for the white population-my specific concern in this paper-as for the total U.S. population. The size of this difference is extreme in the contemporary world; only Finland, France, and the U.S.S.R. have reported sex differentials as large for the most recent years.1' 2 In the early 1970s, 25 countries reported greater male expectations of life at birth than did the United States; for females seven countries reported greater expectations of life.' When the comparison is limited to U.S. white males, 19 countries reported greater male expectations of life; U.S. white females, on the other hand, were outranked by only five countries. My concern in this paper is to investigate the components of the differentials in mortality that exist between Swedish and U.S. white males. Sweden was chosen as the standard of comparison because it has been the country with the lowest overall male mortality and the highest male expectations of life in the world since the early 1960s. (For females
Norway has had slightly higher life expectancies than Sweden). A perusal of the age-specific death rates in the 1973 Demographic Yearbook (especially devoted to mortality) shows that Swedish male rates in the early 1970s were the lowest in the world at ages under 10.1 At ages 10-44 Sweden was only one of a number of countries with or near the lowest recorded levels of male mortality. At ages 45-74 Swedish males had the lowest overall mortality in the world, but their Dutch and Icelandic coUnterparts had rates for an occasitnal five-year age category a hair-breadth below them. At ages 75 and over a number of countries reported lower mortality for males than did Sweden, but reliability here is less than at other ages and relative variability in rates from year-to-year is greater. Because of the relatively small population of Sweden, 8.1 million in 1970, 1 have everywhere combined the Swedish data for the three years 1969, 1970, and 1971. I have also combined the U.S. age-adjusted rates for these three years for the specific causes of death, although there are only slight differences between the U.S. white male rates for 1969-71 and for 1970 alone. U.S. white male rates rather than total male rates are used in this study for two reasons. First, there are marked differences in the specific-cause patterns of mortality between whites and nonwhites in the United States.3 4 Second, the quality of the nonwhite data is known to be of poor quality because of the large underenumeration of blacks.5 No further attention will be paid to female mortality in this study because the mortality patterns of Swedish and U.S. white females are not very different and the differentials are of much smaller magnitude than among their male counter-
Address reprint requests to Dr. Richard F. Tomasson, Department of Sociology, The University of New Mexico, Albuquerque, NM 87131. This paper, based on a presentation at the annual meeting of the American Sociological Association, New York, August 1976, was submitted to the Journal March 15, 1976, revised, and ac-
cepted for publication May 25, 1976. 968
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MORTALITY OF SWEDISH AND U.S. WHITE MALES
parts. As can be seen in Table 1, the 1969-71 life expectations of Swedish males was 4.0 years greater at birth than among U.S. white males, by age 50 the excess was still 2.5 years. For females Swedish life expectation at birth was only 1.5 years greater and by age 50 only 0.4 years greater than among U.S. white females. What particularly needs to be delineated are the components of the large male mortality differentials that exist between Sweden and the United States, two of the highest standard of living industrial societies in the world. TABLE 1 -Expectations of Life at Various Ages for Both Sexes, Sweden and the U.S. White Population, 1969-71 Males
Age
(1) 0 15 50 65
Females
Sweden
U.S.
(3)
(4) (2)-(3)
Sweden
U.S.
(6)
(7) (5)-(6)
71.9 58.3 25.8 14.1
67.9 54.8 23.3 13.0
4.0 years 3.5 years 2.5 years 1.1 years
77.0 63.0 29.5 16.7
75.5 52.1
1.5 years 0.9 years 0.4 years -0.2years
(2)
(5)
29.1 16.9
Sources: References 6, 7.
The Data The assumption underlying both the Swedish and the U.S. mortality data is that they are based on virtually complete registration. There may, however, still be a few pockets in the hinterland of the United States, though not in Sweden, where some deaths are not registered. There is also some underenumeration of U.S. whites, an estimated 2.4 per cent compared with 9.9 per cent among nonwhites.5 Again, this is not a problem in Sweden. These two sources of error in the U.S. data are slight and counteract each other to some degree. One problem in specific-cause-of-death analysis is the proportion of deaths classified under the unsatisfactory rubric "symptoms and ill-defined conditions." Only 0.5 per cent of Swedish male deaths in 1969-71 and 1.2 per cent of U.S. white male deaths in the same period were so classified. More problematic for comparative analysis are fads and fashions and even genuine improvements in the classification of deaths. This is an important factor both in comparing countries and sometimes in studying one country from year to year. For example, the absolute number of Swedish male deaths classified under "all other forms of heart disease" declined from 1,029 in 1969 to 595 in 1971 while the total number of deaths from "diseases of heart" increased from 17,200 to 18,910.8 This represents a changed pattern, and probably an improvement, in the classification of heart disease deaths and not any real change. Because of changes such as these, general categories like "diseases of heart" are sometimes safer indicators of differences than are more specific classifications. For most causes of death, though, problems like this do not arise. Causes of death in both Sweden and the U.S. are classiAJPH October, 1976, Vol. 66, No. 10
fied according to the Eighth Revision of the International Classification of Diseases as adopted by the World Health Organization in 1965.9 This Revision was put into use by both countries in 1968.
Age-Specific Mortality The magnitude of the mortality differentials that exist between Swedish and U.S. white males appears even greater when age-specific death rates are looked at rather than expectations of life. At all ages from under one through ages 75-79, U.S. white males have appreciably higher mortality than do Swedish males. From Table 2 we see that during the first year of life U.S. white males have mortality 56 per cent higher than do their Swedish counterparts. The excess decreases to 40 per cent at ages 1-4 and reaches a low point of 6 per cent at ages 5-9. Then at ages 10-14-along with ages 59 the years of lowest mortality in modem societies-excess U.S. white male mortality rapidly increases, reaching the high point in relative difference at ages 20-24. U.S. white male mortality then decreases through ages 30-34, after which it increases to ages 50-59 declining to virtual unity at ages 80-84. At ages 85 and over the differential is reversed, with U.S. white males having mortality lower than Swedish males. But, as noted earlier, we should be suspicious of the reliability of the data at these advanced ages. TABLE 2-Age-Specific Death Rates for Swedish Males and U.S. White Males, 1969-71 (Rates per 100,000 population)
(1)
(2)
Age
Swedish Males
U.S. White males
Under 1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 and over
1,314.9 58.7 44.0
2,053.0 81.9 46.6 47.9
34.4
95.7 109.7 113.2 140.1 183.4 280.9 428.2 659.5 1,067.6
1,804.6 2,971.2 4,926.2 7,858.1 12,441.7 22,154.8
150.0 197.1 168.9 183.8 260.5 417.6 675.9 1,092.9 1,755.5 2,715.8
3,988.7 5,929.9 8,658.5 12,188.4 19,727.3
2
(1)
10
156 140 106 139 157 180 149 131 142 149 159 166 164 150 134 120 110 98 89
Sources: References 8,10.
When we compare age-specific rates for Swedish males with those for selected U.S. states with particularly low white male mortality, we see that the Swedish male rates remain appreciably lower at all ages up to ages 80-84. Table 3 shows the 1969-71 age-specific death rates for Swedish 969
TOMASSON
males together with the corresponding rates for white males in Utah and Minnesota. Utah has the lowest or among the lowest white male mortality of all the U.S. states."' Minnesota has white male mortality well below the U.S. rates and a white population closer in ethnic background (Northwestern European) to Sweden than any other U.S. state. It also resembles Sweden as much as any state in terms of economy, geography, and population distribution. TABLE 3-Age-Specific Death Rates for Swedish Males, and White Males In States of Utah and Minnesota, 19691971. (Rates per 100,000 population)
(1)
Age
Swedish Males
(2)
Utah White Males
480.1 0-4 294.8 44.0 47.9 5-9 34.4 50.2 10-14 144.6 95.7 15-19 181.6 109.7 20-24 155.1 113.2 25-29 163.8 140.1 30-34 183.4 215.9 35-39 40-44 280.9 359.6 428.2 581.1 45-49 953.1 659.5 50-54 55-59 1,067.6 1,465.5 60-64 1,804.6 2,342.1 65-69 2,971.2 3,462.8 70-74 4,926.2 5,050.1 75-79 7,858.1 8,274.4 80-84 12,441.7 11,608.5 85 and over 22,154.8 16,065.3
(3)
(2) X (1)
163 109 146 151 166 137 117 118 128
136 145 137 130 117 103 105 93 73
(4)
(5)
456.6 46.6 46.8 146.0 213.1 134.1 144.5 192.1 331.2 577.2 925.6 1,576.9 2,291.6 3,588.8 5,174.5 8,043.8 11,507.0 18,742.4
155 106 136 153 194 118 103 105 118 135 140 148 127 121 105 102 92 85
Minnesota (4) Xl00 White Males (1)
Sources: Same as Table 2.
Table 3 shows that Swedish males have appreciably lower mortality than white males in Utah and Minnesota from ages 0-4 through ages 75-79. At ages 80-84, however, the differential is reversed with Utah and Minnesota white males having slightly lower mortality than their Swedish agemates. At ages 85 and over Swedish mortality is appreciably greater. Note that at nearly all ages the rates and ratios for these two states fall between the rates for Swedish males and all U.S. white males (Table 2).
Specific Causes of Death For the great majority of the causes of death, U.S. white males have higher age-adjusted rates and higher age-specific rates up to ages 75-79 and above than do Swedish males. Cause-specific rates, like crude death rates, are, however, particularly poor indicators of the differences between these two populations because Swedish males are so much older than their U.S. white male counterparts. The median age in 1970 of Swedish males was 35.0 and of U.S. white males 26.1; the percentages over age 65 were, respectively, 12.2 and 7.7 per cent. When the age-specific rates are age-ad970
justed to the conventional standard of the age distribution of the total U.S. population as enumerated in 1940, as is done in Table 4, the Swedish male rate is seen to be 689.9 and the U.S. white male rate 896.9, 30 per cent higher. This table also gives the age-adjusted rates for the major causes of death in the two populations.
Discussion and Speculation Discussion of the three orders of peak relative differential mortality-at ages under 1, ages 20-24, and ages 5054-could (and perhaps should) lead us into the comparative ethnography of the two societies. The following are various factors that might enter into an explanation of the three sorts of differential mortality of our two male populations. 1. Sweden's system of compulsory national health insurance dates only from 1955, but the institution of the statesupported hospital, including physicians' services, goes back to the second half of the eighteenth century. 13 Throughout the nineteenth century, but particularly after legislation passed in 1862, the communally administered health system became increasingly developed. The common people were more likely to use the community hospitals than were the upper classes who used physicians in private practice, but there was nothing of the "charity" stigma attached to them. The point is that medical care, like education, has been regarded as both a communal responsibility and an individual right in Sweden long before the advent of the modern welfare state. It is suggestive that Sweden, along with Norway, recorded the lowest infant and child death rates in Europe as early as the middle of the nineteenth century.14 Prenatal care, delivery, and postnatal care have been free and readily available throughout Sweden for many decades. Sustained professional care of pregnant women and later of their babies is universal. Such established and routinized care has not come this far in the United States, and it is free only for the indigent. 13 Infant death rates in the United States are known to be related to socioeconomic and educational level,'5 and we should be cautious about overestimating the role of the health system here at the expense of class and cultural factors. Yet with reference to mortality during the first year of life, unlike mortality later in the life cycle, scholars like Victor Fuchs go too far in saying that "differences in health levels between the United States and other developed countries or among populations within the United States are not primarily related to differences in the quantity or quality of medical care. Rather, they are attributable to genetic and environmental factors and to personal behavior."" This is least true of differential mortality in the first year of life. The "quantity and quality" of medical care is a more crucial variable at this age than at any other in the developed societies. West Germany is a better case in point than even the United States. Here "a developed system of prenatal care is missing" and the lack has commonly been justified in terms of the "naturalness" of childbirth.'6 The infant death rate in West Germany, however, has been the highest of all developed societies (23.3 per 1,000 live births in 1971), substantially highAJPH October, 1976, Vol. 66, No. 10
MORTALITY OF SWEDISH AND U.S. WHITE MALES TABLE 4-Age-Adjusted Death Rates for the Major Causes of Death for Swedish Males and U.S. White Males, 1969-1971 (Based on age-specific death rates per 100,000 estimated midyear population in each age category. Direct method used In computation. The standard population used is the age distribution of the total U.S. population as enumerated In 1940. Causes of death are classified according to the Eighth Revision, International Classification of Diseases, In effect from 1968.)
All causes Major cardiovascular diseases (390-448) Diseases of heart (390-98,402,404,410-29) Hypertension (400,401,403) Cerebrovascular diseases (430-38) Arteriosclerosis (440) Malignant neoplasms (140-209) of digestive organs and peritoneum (150-59) of respiratory system (160-63) Influenza and pneumonia (470-74,480-86) Bronchitis, emphysema, and asthma (490-93) Diabetes mellitus (250)
Cirrhosis of liver (571) Tuberculosis, all forms (01 0-1 9) Certain causes of mortality in early infancy (760-78) Accidents (E800-949) Motor Vehicle accidents (E810-23) All other accidents (E800-07, E825-49) Suicide (E950-59) Homicide (E960-69)
Swedish Males
U.S. White Males
Ratio
689.9 320.7 252.5 2.0 55.8 8.3 134.2 51.0 22.0 24.1 9.9 8.3 8.2 3.6 12.2 47.9 21.7 26.2 27.9 1.1
896.9 442.9 348.5 2.7 69.9 9.8 154.4 41.9 49.7 25.7 20.9 12.7 18.7 2.5 18.7 76.1 40.2 35.8 17.9 7.3
130 138 138 135 125 118 115 82 226 107 211 153 228 69 153 159 185 137 64 664
Sources: Swedish rates calculated from Reference 8. U.S. rates are averages for 1969, 1970, and 1971 from Reference 11 or calculated by me. A few of the U.S. rates calculated by me have been changed slightiy to agree with the unpublished computations of the National Center for Health Statisfics.
er than that of the United States, and more than twice as high as that of Sweden (11.1 in 1971, 9.2 in 1974). Yet there is an otherwise well-developed system of medical care in West
Germany. The share of the health budget going to the care of pregnant women and their babies is greater in Sweden than in the United States where a greater share goes for the care of the old.13 The conventional stay in the hospital after the birth of a baby in Sweden is eight or nine days compared with three days in the United States, and nearly all mothers become successful breast feeders.17 This is probably part of the explanation for the extremely low infant mortality in Sweden during the first week of life; for 1970 this rate was 14.1 for U.S. white males and 9.2 for Swedish males8' 10 (declining to 7.8 in 19735). 2. Of less importance than the foregoing in explaining the extremely low infant mortality that prevails in Sweden is the smaller percentage of births to women under age 20 and at ages 35 and over and the lower rate of births at the third and higher orders of parity that have occurred there. Studies of infant mortality show higher rates for infants born to mothers under 20 and over 35 and increasingly greater mortality from the third parity.18' 19 Only 8.4 per cent of births were to teenage mothers in Sweden compared with 15.0 per cent among U.S. white mothers in 1969-71. Components of Differential Mortality at Different
Ages
From Tables 2 and 4, it becomes clear that accounting for the pervasively higher U.S. white male rates lies with a AJPH October, 1976, Vol. 66, No. 10
number of diseases and external causes of death. Study of the age-specific rates for the specific causes of death in the two populations (not presented here) shows that the U.S. white male rates are generally higher from the first year of life into old age. The 30 per cent U.S. white male excess in the age-adjusted death rate for all causes can be accounted for by higher mortality (in rank order) from heart disease, accidents, lung cancer, cerebrovascular diseases, emphysema, cirrhosis of the liver, certain causes of mortality in early infancy, homicide, and diabetes. As can be seen in Table 2 the periods of greatest relative differential are the first year of life, ages 20-24, and ages 50-54. However, the components that can account for the variation at these different periods in the life cycle are totally different. During the first year of life, the U.S. white male rate is 56 per cent higher than the comparable Swedish rate. Most of the variation can be explained by the greater U.S. white male mortality from infant pneumonia, certain causes of mortality in early infancy, and symptoms and ill-defined conditions. (At no age is the classification of the causes of death so vague as during the first year of life.) Note from Table 5 that less than 5 per cent of the greater mortality of U.S. white male infants can be attributed to accidents even though mortality from this cause is three times the Swedish rate. At ages 20-24, when mortality is low, the relative differential between the two populations is at a relative maximum with a U.S. white male excess of 80 per cent. Note in Table 6 that 93 per cent of the differential can be explained by the external causes of death and that diseases are quite unimportant. There would be only negligible differential mortality be971
TOMASSON TABLE 5-Components of the Death Rate Differential of Ages Under 1, Swedish Males for 196971 and U.S. White Males for 1970 (Per 100,000 population)
All causes Diseases Major cardiovascular diseases Influenza and pneumonia Hernia and intestinal i obstruction Certain causes of mortality in early infancy Symptoms and ill-defined conditions External causes Motor vehicle accidents All other accidents
Differentfals
Swedish Males
U.S. White Males
1,314.9
2,113.2
8.3 31.4 7.1
17.8 154.8 19.7
9.3 123.4 12.6
794.2
1,262.7
468.5
15.4
85.7
70.3
2.4 17.2
9.1 48.1
6.7 30.9 1
798.3
684.17 1 I J 721.7 37.6
Sources: Same as Table 2.
tween the two populations at these young ages if it were not for accidents, mostly motor vehicle, and homicide. At ages 20-24, however, several countries in the world-e.g., Denmark and Japan-have slightly lower rates than does Sweden, largely attributable to lower mortality from motor vehicle accidents. ' From the 20s into old age the relative importance of external causes of death in accounting for the differential mortality of the two populations declines sharply. By ages 50-54 only 7 per cent of the differential can be attributed to external causes. (Suicide is excepted here because Swedish male mortality is higher.) From ages 35-39 the increasingly greater toll of most diseases among U.S. white males can be observed from the age-specific rates. Table 7 shows the components that make up the variation at ages 50-54 when the relative differential is greater than at any period other than ages 20-24; the U.S. white male excess is 66 per cent at these ages and almost as high (64 per cent) at ages 55-59. After ages 55-59 the relative differential declines. However, at ages 65-69 the absolute differential peaks reaching 1,017.5 with rates of 2,971.2 and 3,988.7 per 100,000 population.
3. Sweden has progressed further than the United States in absorbing its lower classes (as distinct from the working class) into the conventional living standards of the greater society. There is less personal and social disorganization and their sequelae in Swedish society, much of which is known to be related to greater mortality. Among the common factors in lower class life associated with higher mortality are violence, drugs, alcohol, accidents, obesity, poor diet, irregular living habits, and unstable family life.20 All of these characterize the lowest socioeconomic levels of American society to a greater extent than of Swedish society.'17 21 4. Sweden has a highly structured and "tight" social structure in which internal constraints are strong. Constraint has been suggested by Kitagawa and Hauser22 and by Retherford23 as a factor in explaining mortality differentials. Elsewhere and in another context I have discussed constraint in interpersonal relations and a cautionary attitude toward life as pervasive Swedish modes of behavior.'7 A tight social structure with well-defined limits and controls on behavior, both internal and external, makes for greater personal secu-
TABLE 6-Components of the Death Rate Differential at Ages 20-24, Swedish Males for 1969-71 and U.S. White Males for 1970
(Per 100,000 population)
All causes
Diseases Major cardiovascular diseases Malignant neoplasms Influenza and pneumonia External causes Motor vehicle accidents All other accidents Homicide Other external causes
Swedish Males
U.S. White Males
109.9
199.0
4.3 9.4 1.2
6.4 12.5 2.9
32.8 18.3 1.3 1.8
84.9 36.1 11.1 4.7
Differentials
89.1 2.1 1 3.1 .
6.9
1.7 J
]
89.5 52.1 17.8 9.8
8
26 J
2.9
Sources: Same as Table 2.
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AJPH October, 1976, Vol. 66, No. 10
MORTALITY OF SWEDISH AND U.S. WHITE MALES TABLE 7-Components of the Death Rate Differential at ages 50-54, Swedish Males for 1969-71 and U.S. White Males for 1970. (Per 100,000 population) Swedish Males
U.S. White Males
659.5
1,098.6
216.7 25.0
474.2 90.2
117.4 19.7 9.2 2.1 11.5
135.2 55.3 18.5 14.7 21.5
I 17.8 35.6 9.3 12.6 J 10.0
20.1 33.0 0.6
34.3 41.9 8.5
14.2 1 8.9 7.9 J
All causes Diseases Diseases of heart Malignant neoplasms of the respiratory system Malignant neoplasms of other sites Cirrhosis of liver Bronchitis, emphysema, and asthma Symptoms and ill-defined conditions Influenza and pneumonia External causes Motor vehicle accidents All other accidents Homicide
Differentials
439.1 257.5 65.2
407.6 438.6 31.0
Sources: Same as Table 2.
rity and lower levels of internal stress. These, in turn, probably contribute to lower mortality from homicide, accidents, and some organic conditions. A large scale survey research study of welfare values and their realization in the four Scandinavian countries found that the constrained Swedes claim to suffer somewhat less stress and anxiety than the Norwegians and Danes and much less than the Finns, among whom male mortality is by far the highest in Scandinavia.24 A striking example of the possibilities of constraint and its consequences as a factor in the explanation of modern differential mortality is offered by the contiguous states of Utah and Nevada." Utah, largely Mormon, has white male mortality at the lowest U.S. levels. Nevada, with a similar climate and a much higher per capita income, has the least favorable white male mortality of all the U.S. states.'7' 25 Death rates run 40-50 per cent higher at most ages for both Nevada males and females compared with their Utah age mates. Nevada also had the highest proportion of in-migrants of any U.S. state in 1970, and probably also has the "loosest" social structure. Utah and Nevada, then, might be taken as representing the geographical extremes in constraint in the United States. One more suggestive example: the Japanese-Americans, with the lowest mortality of any identifiable component of the U.S. population, can be viewed as the most constrained of all American subcultures.22' 26
5. There is an activist approach toward lessening the dangers of existence in Sweden, part of the enormous emphasis in this society on rectifying social problems. The Swedish government's 1975 proposal to turn Sweden into a nation of nonsmokers through most methods short of outright prohibition is an example of this orientation. So, too, is the national concern with industrial safety and hygiene and with preventing childhood accidents. White male death rates are two to three times higher in the United States for both industrial and childhood accidents. The early attack on the problem of industrial pollution is another example of Swedish activism toward social problems. The prison sentences that Swedes AJPH October, 1976, Vol. 66, No. 10
undergo for driving with alcohol above a certain level in the blood is also an example of the aggressive pursuit of public safety. (The enormous reticence that Swedes have to driving after drinking is an example of the foregoing factor, the internalization of clear external constraints. The norms in U.S. society on this matter, as in so many other areas of life, are vague, conflicting, and, consequently, less constraining.) 6. Consumption of cigarettes and alcohol are both much lower in Sweden than in the United States. Cigarette smoking, in particular, is known to be associated with higher levels of mortality for many organic conditions, most notably lung cancer, emphysema, and the cardiovascular diseases. Per capita consumption of cigarettes in Sweden has increased sharply over the past half century, but between 1925 and 1966 it increased only from 25 to 37 per cent of the comparable consumption in the United States.27 Between 1966 and 1973 there has been a 12 per cent decline in per capita tobacco consumption.7 Swedish per capita consumption of alcohol is less than one-third of what it is in the United States.7' 28, 29 7. Diet, exercise, and weight are factors known to be associated with mortality. Dietary differences between these two populations are greater than might be expected in the two most affluent societies in the world. Meat and sugar consumption, for example, is lower in Sweden than in the United States, and the consumption of fish much higher. Average daily caloric consumption in Sweden was 2,850 for 1970-71, low for a modern society.7 The comparable caloric consumption in the United States for 1970 was reckoned to have been 3,300.29 My personal observation is that obesity is almost nonexistent in Sweden and that Swedes get more exercise than Americans, at the very least they walk more.
REFERENCES 1. United Nations. Demographic Yearbook 1973. New York, 1974. 2. Metropolitan Life Insurance Company. Stat. Bul. 55:October, 1974. 3. U.S. National Center for Health Statistics. Vital and Health Sta-
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TOMASSON
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tistics. Mortality Trends: Age, Color, and Sex, 1950-1969. 20:15. U.S. Government Printing Office, Washington, DC, 1973. Tomasson, R. F. Patterns in Negro-White differential mortality, 1930-1957. Milbank Mem. Fund Quart. 38:362-386, 1960. U.S. Bureau of the Census. Current Population Reports: Coverage of Population in the 1970 Census and Some Implications for Public Programs. Series P-23, No. 56. U.S. Government Printing Office, Washington, DC, 1975. U.S. National Center for Health Statistics. U.S. Decennial Life Tables for 1969-71. Volume 1, Number 1. U.S. Department of Health, Education, and Welfare publication No. (HRA) 751150. U.S. Government Printing Office, Washington, DC, 1975. Nordic Council. Yearbook of Nordic Statistics 1974. P. A. Norstedt, Stockholm, 1975. National Central Bureau of Statistics. Dodsorsaker 1969 and 1970, 1971. Stockholm, 1972, 1974. World Health Organization. International Classification of Diseases: Eighth Revision, 1965. Geneva, 1967. U.S. National Center for Health Statistics. Vital Statistics of the United States 1969-1971. Vol. 1I-Mortality, Part A. U.S. Government Printing Office, Washington, DC, 1973-75. Fuchs, V. R. Who Shall Live? Health, Economics, and Social Choice. New York: Basic Books, 1975. U.S. National Center for Health Statistics. Monthly Vital Statistics Reports-Final Mortality Statistics, 1969-1971. U.S. Government Printing Office, Washington, DC, 1972-1974. Anderson, 0. W. Health Care: Can There Be Equity? The United States, Sweden, and England. New York: John Wiley, 1972. Farr, W. Mortality of children in the principal states of Europe. J. Stat. Soc. 29: 1-35, 1866. U.S. National Center for Health Statistics. Vital and Health Statistics, Infant Mortality Rates: Socioeconomic Factors. 22:14. U.S. Government Printing Office, Washington, DC, 1972. Dahrendorf, R. Society and Democracy in Germany. Garden City, NY: Doubleday, 1967. Tomasson, R. F. Sweden: Prototype of Modern Society. New York: Random House, 1970.
I
18. U.S. National Center for Health Statistics. Vital and Health Statistics Infant Mortality Rates: Relationships with Mother's Reproductive History. 22:15. U.S. Government Printing Office, Washington, DC, 1973. 19. U.S. National Center for Health Statistics. Vital and Health Statistics. Age of Mother, Total-Birth Order, and Other Variables. 20:14. U.S. Government Printing Office, Washington, DC, 1973. 20. Benjamin, B. Social and Economic Factors Affecting Mortality. Mouton, The Hague, 1965. 21. Banfield, E. C. The Heavenly City Revisited. Boston: Little Brown, 1974. 22. Kitagawa, E. M., and Hauser, P. M. Differential Mortality in the United States: A Study of Socioeconomic Epidemiology. Cambridge: Harvard University Press, 1973. 23. Retherford, R. D. The Changing Sex Differential in Mortality. Westport, CT: Greenwood Press, 1975. 24. Allardt, E. About Dimensions of Welfare: An Exploratory Analysis of a Comparative Scandinavian Survey. Research Group for Comparative Sociology, University of Helsinki, 1973. 25. Sauer, H. I. Geograhic Variation in Mortality and Morbidity. pp. 105-129 in Mortality and Morbidity in the United States. Erhardt, C. L., and Berlin, J. E. Eds. Cambridge: Harvard University Press, 1974. 26. Kitano, H. Japanese-Americans (rev. ed.) Englewood Cliffs, NJ: Prentice-Hall, 1976. 27. Socialstyrelsen. Fakta om rokning och hiilsa. Supplement. P. A. Norstedt, Stockholm, 1968. 28. Bruun, K. Alkohol i Norden. Aldus/Bonniers, Stockholm, 1973. 29. U.S. Bureau of Census. Statistical Abstract of the United States, 1974. U.S. Government Printing Office, Washington, DC, 1974.
ACKNOWLEDGMENTS Robert W. Buechley, PhD of the Cancer Research and Treatment Center of the University of New Mexico Medical School made numerous suggestions which have been incorporated in the final version of this paper.
I
Paying the Price O
ur civilization has long since decided that technological progress is worth the price. We accept the stresses of industrialization and urbanization, the carnage on the highways, the threat of radioactive fallout and the hazards of exposure to the noxious chemicals that are so freely discharged into our environment.... These by-products of man's pursuit of technical and medical advancement are social as well as professional problems. " R. Keith Cannan in Rene Dubos and Maya Pines, Health and Disease, New York: Time Incorporated, 1965, p. 7.
974
AJPH October, 1976, Vol. 66, No. 10
Abstract: The life expectancy of males in the United States is lower than that of males in most of the developed countries and in some of the not-so-developed ones. U.S. females, by contrast, do much better in international ranking. This study compares the mortality of U.S. white males with that of Swedish males who have had the highest reported male life expectancies in the world since the early 1960s. Life expectancy at birth in 1969-71 was 67.9 for U.S. white males compared with 71.9 for Swedish males. Greater U.S. white male mortality is found at all ages from birth through ages 75-79. At the upper ages there is a rever-
sal of the differential with U.S. white males having lower mortality than their Swedish counterparts. The greatest relative differentials between the two male populations is found at ages under 1, ages 2d24, and ages 50-59. At ages under 1 the greater U.S. white male mortality is accounted for mainly by higher death rates from infectious diseases, at ages 20-24 by higher rates from the external causes of death (specifically accidents and homicide), and at ages 50-59 from most of the major organic causes of death. (Am. J. Public Health 66:968-974, 1976)
The United States is characterized by high mortality of males compared with other developed countries and some not-so-developed ones. U.S. females, on the other hand, do much better than males in international comparisons. The magnitude of the U.S. sex differential in expectation of life at birth reached 7.7 years in 1973 and again in 1974. The differential is the same for the white population-my specific concern in this paper-as for the total U.S. population. The size of this difference is extreme in the contemporary world; only Finland, France, and the U.S.S.R. have reported sex differentials as large for the most recent years.1' 2 In the early 1970s, 25 countries reported greater male expectations of life at birth than did the United States; for females seven countries reported greater expectations of life.' When the comparison is limited to U.S. white males, 19 countries reported greater male expectations of life; U.S. white females, on the other hand, were outranked by only five countries. My concern in this paper is to investigate the components of the differentials in mortality that exist between Swedish and U.S. white males. Sweden was chosen as the standard of comparison because it has been the country with the lowest overall male mortality and the highest male expectations of life in the world since the early 1960s. (For females
Norway has had slightly higher life expectancies than Sweden). A perusal of the age-specific death rates in the 1973 Demographic Yearbook (especially devoted to mortality) shows that Swedish male rates in the early 1970s were the lowest in the world at ages under 10.1 At ages 10-44 Sweden was only one of a number of countries with or near the lowest recorded levels of male mortality. At ages 45-74 Swedish males had the lowest overall mortality in the world, but their Dutch and Icelandic coUnterparts had rates for an occasitnal five-year age category a hair-breadth below them. At ages 75 and over a number of countries reported lower mortality for males than did Sweden, but reliability here is less than at other ages and relative variability in rates from year-to-year is greater. Because of the relatively small population of Sweden, 8.1 million in 1970, 1 have everywhere combined the Swedish data for the three years 1969, 1970, and 1971. I have also combined the U.S. age-adjusted rates for these three years for the specific causes of death, although there are only slight differences between the U.S. white male rates for 1969-71 and for 1970 alone. U.S. white male rates rather than total male rates are used in this study for two reasons. First, there are marked differences in the specific-cause patterns of mortality between whites and nonwhites in the United States.3 4 Second, the quality of the nonwhite data is known to be of poor quality because of the large underenumeration of blacks.5 No further attention will be paid to female mortality in this study because the mortality patterns of Swedish and U.S. white females are not very different and the differentials are of much smaller magnitude than among their male counter-
Address reprint requests to Dr. Richard F. Tomasson, Department of Sociology, The University of New Mexico, Albuquerque, NM 87131. This paper, based on a presentation at the annual meeting of the American Sociological Association, New York, August 1976, was submitted to the Journal March 15, 1976, revised, and ac-
cepted for publication May 25, 1976. 968
AJPH October, 1976, Vol. 66, No. 10
MORTALITY OF SWEDISH AND U.S. WHITE MALES
parts. As can be seen in Table 1, the 1969-71 life expectations of Swedish males was 4.0 years greater at birth than among U.S. white males, by age 50 the excess was still 2.5 years. For females Swedish life expectation at birth was only 1.5 years greater and by age 50 only 0.4 years greater than among U.S. white females. What particularly needs to be delineated are the components of the large male mortality differentials that exist between Sweden and the United States, two of the highest standard of living industrial societies in the world. TABLE 1 -Expectations of Life at Various Ages for Both Sexes, Sweden and the U.S. White Population, 1969-71 Males
Age
(1) 0 15 50 65
Females
Sweden
U.S.
(3)
(4) (2)-(3)
Sweden
U.S.
(6)
(7) (5)-(6)
71.9 58.3 25.8 14.1
67.9 54.8 23.3 13.0
4.0 years 3.5 years 2.5 years 1.1 years
77.0 63.0 29.5 16.7
75.5 52.1
1.5 years 0.9 years 0.4 years -0.2years
(2)
(5)
29.1 16.9
Sources: References 6, 7.
The Data The assumption underlying both the Swedish and the U.S. mortality data is that they are based on virtually complete registration. There may, however, still be a few pockets in the hinterland of the United States, though not in Sweden, where some deaths are not registered. There is also some underenumeration of U.S. whites, an estimated 2.4 per cent compared with 9.9 per cent among nonwhites.5 Again, this is not a problem in Sweden. These two sources of error in the U.S. data are slight and counteract each other to some degree. One problem in specific-cause-of-death analysis is the proportion of deaths classified under the unsatisfactory rubric "symptoms and ill-defined conditions." Only 0.5 per cent of Swedish male deaths in 1969-71 and 1.2 per cent of U.S. white male deaths in the same period were so classified. More problematic for comparative analysis are fads and fashions and even genuine improvements in the classification of deaths. This is an important factor both in comparing countries and sometimes in studying one country from year to year. For example, the absolute number of Swedish male deaths classified under "all other forms of heart disease" declined from 1,029 in 1969 to 595 in 1971 while the total number of deaths from "diseases of heart" increased from 17,200 to 18,910.8 This represents a changed pattern, and probably an improvement, in the classification of heart disease deaths and not any real change. Because of changes such as these, general categories like "diseases of heart" are sometimes safer indicators of differences than are more specific classifications. For most causes of death, though, problems like this do not arise. Causes of death in both Sweden and the U.S. are classiAJPH October, 1976, Vol. 66, No. 10
fied according to the Eighth Revision of the International Classification of Diseases as adopted by the World Health Organization in 1965.9 This Revision was put into use by both countries in 1968.
Age-Specific Mortality The magnitude of the mortality differentials that exist between Swedish and U.S. white males appears even greater when age-specific death rates are looked at rather than expectations of life. At all ages from under one through ages 75-79, U.S. white males have appreciably higher mortality than do Swedish males. From Table 2 we see that during the first year of life U.S. white males have mortality 56 per cent higher than do their Swedish counterparts. The excess decreases to 40 per cent at ages 1-4 and reaches a low point of 6 per cent at ages 5-9. Then at ages 10-14-along with ages 59 the years of lowest mortality in modem societies-excess U.S. white male mortality rapidly increases, reaching the high point in relative difference at ages 20-24. U.S. white male mortality then decreases through ages 30-34, after which it increases to ages 50-59 declining to virtual unity at ages 80-84. At ages 85 and over the differential is reversed, with U.S. white males having mortality lower than Swedish males. But, as noted earlier, we should be suspicious of the reliability of the data at these advanced ages. TABLE 2-Age-Specific Death Rates for Swedish Males and U.S. White Males, 1969-71 (Rates per 100,000 population)
(1)
(2)
Age
Swedish Males
U.S. White males
Under 1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 and over
1,314.9 58.7 44.0
2,053.0 81.9 46.6 47.9
34.4
95.7 109.7 113.2 140.1 183.4 280.9 428.2 659.5 1,067.6
1,804.6 2,971.2 4,926.2 7,858.1 12,441.7 22,154.8
150.0 197.1 168.9 183.8 260.5 417.6 675.9 1,092.9 1,755.5 2,715.8
3,988.7 5,929.9 8,658.5 12,188.4 19,727.3
2
(1)
10
156 140 106 139 157 180 149 131 142 149 159 166 164 150 134 120 110 98 89
Sources: References 8,10.
When we compare age-specific rates for Swedish males with those for selected U.S. states with particularly low white male mortality, we see that the Swedish male rates remain appreciably lower at all ages up to ages 80-84. Table 3 shows the 1969-71 age-specific death rates for Swedish 969
TOMASSON
males together with the corresponding rates for white males in Utah and Minnesota. Utah has the lowest or among the lowest white male mortality of all the U.S. states."' Minnesota has white male mortality well below the U.S. rates and a white population closer in ethnic background (Northwestern European) to Sweden than any other U.S. state. It also resembles Sweden as much as any state in terms of economy, geography, and population distribution. TABLE 3-Age-Specific Death Rates for Swedish Males, and White Males In States of Utah and Minnesota, 19691971. (Rates per 100,000 population)
(1)
Age
Swedish Males
(2)
Utah White Males
480.1 0-4 294.8 44.0 47.9 5-9 34.4 50.2 10-14 144.6 95.7 15-19 181.6 109.7 20-24 155.1 113.2 25-29 163.8 140.1 30-34 183.4 215.9 35-39 40-44 280.9 359.6 428.2 581.1 45-49 953.1 659.5 50-54 55-59 1,067.6 1,465.5 60-64 1,804.6 2,342.1 65-69 2,971.2 3,462.8 70-74 4,926.2 5,050.1 75-79 7,858.1 8,274.4 80-84 12,441.7 11,608.5 85 and over 22,154.8 16,065.3
(3)
(2) X (1)
163 109 146 151 166 137 117 118 128
136 145 137 130 117 103 105 93 73
(4)
(5)
456.6 46.6 46.8 146.0 213.1 134.1 144.5 192.1 331.2 577.2 925.6 1,576.9 2,291.6 3,588.8 5,174.5 8,043.8 11,507.0 18,742.4
155 106 136 153 194 118 103 105 118 135 140 148 127 121 105 102 92 85
Minnesota (4) Xl00 White Males (1)
Sources: Same as Table 2.
Table 3 shows that Swedish males have appreciably lower mortality than white males in Utah and Minnesota from ages 0-4 through ages 75-79. At ages 80-84, however, the differential is reversed with Utah and Minnesota white males having slightly lower mortality than their Swedish agemates. At ages 85 and over Swedish mortality is appreciably greater. Note that at nearly all ages the rates and ratios for these two states fall between the rates for Swedish males and all U.S. white males (Table 2).
Specific Causes of Death For the great majority of the causes of death, U.S. white males have higher age-adjusted rates and higher age-specific rates up to ages 75-79 and above than do Swedish males. Cause-specific rates, like crude death rates, are, however, particularly poor indicators of the differences between these two populations because Swedish males are so much older than their U.S. white male counterparts. The median age in 1970 of Swedish males was 35.0 and of U.S. white males 26.1; the percentages over age 65 were, respectively, 12.2 and 7.7 per cent. When the age-specific rates are age-ad970
justed to the conventional standard of the age distribution of the total U.S. population as enumerated in 1940, as is done in Table 4, the Swedish male rate is seen to be 689.9 and the U.S. white male rate 896.9, 30 per cent higher. This table also gives the age-adjusted rates for the major causes of death in the two populations.
Discussion and Speculation Discussion of the three orders of peak relative differential mortality-at ages under 1, ages 20-24, and ages 5054-could (and perhaps should) lead us into the comparative ethnography of the two societies. The following are various factors that might enter into an explanation of the three sorts of differential mortality of our two male populations. 1. Sweden's system of compulsory national health insurance dates only from 1955, but the institution of the statesupported hospital, including physicians' services, goes back to the second half of the eighteenth century. 13 Throughout the nineteenth century, but particularly after legislation passed in 1862, the communally administered health system became increasingly developed. The common people were more likely to use the community hospitals than were the upper classes who used physicians in private practice, but there was nothing of the "charity" stigma attached to them. The point is that medical care, like education, has been regarded as both a communal responsibility and an individual right in Sweden long before the advent of the modern welfare state. It is suggestive that Sweden, along with Norway, recorded the lowest infant and child death rates in Europe as early as the middle of the nineteenth century.14 Prenatal care, delivery, and postnatal care have been free and readily available throughout Sweden for many decades. Sustained professional care of pregnant women and later of their babies is universal. Such established and routinized care has not come this far in the United States, and it is free only for the indigent. 13 Infant death rates in the United States are known to be related to socioeconomic and educational level,'5 and we should be cautious about overestimating the role of the health system here at the expense of class and cultural factors. Yet with reference to mortality during the first year of life, unlike mortality later in the life cycle, scholars like Victor Fuchs go too far in saying that "differences in health levels between the United States and other developed countries or among populations within the United States are not primarily related to differences in the quantity or quality of medical care. Rather, they are attributable to genetic and environmental factors and to personal behavior."" This is least true of differential mortality in the first year of life. The "quantity and quality" of medical care is a more crucial variable at this age than at any other in the developed societies. West Germany is a better case in point than even the United States. Here "a developed system of prenatal care is missing" and the lack has commonly been justified in terms of the "naturalness" of childbirth.'6 The infant death rate in West Germany, however, has been the highest of all developed societies (23.3 per 1,000 live births in 1971), substantially highAJPH October, 1976, Vol. 66, No. 10
MORTALITY OF SWEDISH AND U.S. WHITE MALES TABLE 4-Age-Adjusted Death Rates for the Major Causes of Death for Swedish Males and U.S. White Males, 1969-1971 (Based on age-specific death rates per 100,000 estimated midyear population in each age category. Direct method used In computation. The standard population used is the age distribution of the total U.S. population as enumerated In 1940. Causes of death are classified according to the Eighth Revision, International Classification of Diseases, In effect from 1968.)
All causes Major cardiovascular diseases (390-448) Diseases of heart (390-98,402,404,410-29) Hypertension (400,401,403) Cerebrovascular diseases (430-38) Arteriosclerosis (440) Malignant neoplasms (140-209) of digestive organs and peritoneum (150-59) of respiratory system (160-63) Influenza and pneumonia (470-74,480-86) Bronchitis, emphysema, and asthma (490-93) Diabetes mellitus (250)
Cirrhosis of liver (571) Tuberculosis, all forms (01 0-1 9) Certain causes of mortality in early infancy (760-78) Accidents (E800-949) Motor Vehicle accidents (E810-23) All other accidents (E800-07, E825-49) Suicide (E950-59) Homicide (E960-69)
Swedish Males
U.S. White Males
Ratio
689.9 320.7 252.5 2.0 55.8 8.3 134.2 51.0 22.0 24.1 9.9 8.3 8.2 3.6 12.2 47.9 21.7 26.2 27.9 1.1
896.9 442.9 348.5 2.7 69.9 9.8 154.4 41.9 49.7 25.7 20.9 12.7 18.7 2.5 18.7 76.1 40.2 35.8 17.9 7.3
130 138 138 135 125 118 115 82 226 107 211 153 228 69 153 159 185 137 64 664
Sources: Swedish rates calculated from Reference 8. U.S. rates are averages for 1969, 1970, and 1971 from Reference 11 or calculated by me. A few of the U.S. rates calculated by me have been changed slightiy to agree with the unpublished computations of the National Center for Health Statisfics.
er than that of the United States, and more than twice as high as that of Sweden (11.1 in 1971, 9.2 in 1974). Yet there is an otherwise well-developed system of medical care in West
Germany. The share of the health budget going to the care of pregnant women and their babies is greater in Sweden than in the United States where a greater share goes for the care of the old.13 The conventional stay in the hospital after the birth of a baby in Sweden is eight or nine days compared with three days in the United States, and nearly all mothers become successful breast feeders.17 This is probably part of the explanation for the extremely low infant mortality in Sweden during the first week of life; for 1970 this rate was 14.1 for U.S. white males and 9.2 for Swedish males8' 10 (declining to 7.8 in 19735). 2. Of less importance than the foregoing in explaining the extremely low infant mortality that prevails in Sweden is the smaller percentage of births to women under age 20 and at ages 35 and over and the lower rate of births at the third and higher orders of parity that have occurred there. Studies of infant mortality show higher rates for infants born to mothers under 20 and over 35 and increasingly greater mortality from the third parity.18' 19 Only 8.4 per cent of births were to teenage mothers in Sweden compared with 15.0 per cent among U.S. white mothers in 1969-71. Components of Differential Mortality at Different
Ages
From Tables 2 and 4, it becomes clear that accounting for the pervasively higher U.S. white male rates lies with a AJPH October, 1976, Vol. 66, No. 10
number of diseases and external causes of death. Study of the age-specific rates for the specific causes of death in the two populations (not presented here) shows that the U.S. white male rates are generally higher from the first year of life into old age. The 30 per cent U.S. white male excess in the age-adjusted death rate for all causes can be accounted for by higher mortality (in rank order) from heart disease, accidents, lung cancer, cerebrovascular diseases, emphysema, cirrhosis of the liver, certain causes of mortality in early infancy, homicide, and diabetes. As can be seen in Table 2 the periods of greatest relative differential are the first year of life, ages 20-24, and ages 50-54. However, the components that can account for the variation at these different periods in the life cycle are totally different. During the first year of life, the U.S. white male rate is 56 per cent higher than the comparable Swedish rate. Most of the variation can be explained by the greater U.S. white male mortality from infant pneumonia, certain causes of mortality in early infancy, and symptoms and ill-defined conditions. (At no age is the classification of the causes of death so vague as during the first year of life.) Note from Table 5 that less than 5 per cent of the greater mortality of U.S. white male infants can be attributed to accidents even though mortality from this cause is three times the Swedish rate. At ages 20-24, when mortality is low, the relative differential between the two populations is at a relative maximum with a U.S. white male excess of 80 per cent. Note in Table 6 that 93 per cent of the differential can be explained by the external causes of death and that diseases are quite unimportant. There would be only negligible differential mortality be971
TOMASSON TABLE 5-Components of the Death Rate Differential of Ages Under 1, Swedish Males for 196971 and U.S. White Males for 1970 (Per 100,000 population)
All causes Diseases Major cardiovascular diseases Influenza and pneumonia Hernia and intestinal i obstruction Certain causes of mortality in early infancy Symptoms and ill-defined conditions External causes Motor vehicle accidents All other accidents
Differentfals
Swedish Males
U.S. White Males
1,314.9
2,113.2
8.3 31.4 7.1
17.8 154.8 19.7
9.3 123.4 12.6
794.2
1,262.7
468.5
15.4
85.7
70.3
2.4 17.2
9.1 48.1
6.7 30.9 1
798.3
684.17 1 I J 721.7 37.6
Sources: Same as Table 2.
tween the two populations at these young ages if it were not for accidents, mostly motor vehicle, and homicide. At ages 20-24, however, several countries in the world-e.g., Denmark and Japan-have slightly lower rates than does Sweden, largely attributable to lower mortality from motor vehicle accidents. ' From the 20s into old age the relative importance of external causes of death in accounting for the differential mortality of the two populations declines sharply. By ages 50-54 only 7 per cent of the differential can be attributed to external causes. (Suicide is excepted here because Swedish male mortality is higher.) From ages 35-39 the increasingly greater toll of most diseases among U.S. white males can be observed from the age-specific rates. Table 7 shows the components that make up the variation at ages 50-54 when the relative differential is greater than at any period other than ages 20-24; the U.S. white male excess is 66 per cent at these ages and almost as high (64 per cent) at ages 55-59. After ages 55-59 the relative differential declines. However, at ages 65-69 the absolute differential peaks reaching 1,017.5 with rates of 2,971.2 and 3,988.7 per 100,000 population.
3. Sweden has progressed further than the United States in absorbing its lower classes (as distinct from the working class) into the conventional living standards of the greater society. There is less personal and social disorganization and their sequelae in Swedish society, much of which is known to be related to greater mortality. Among the common factors in lower class life associated with higher mortality are violence, drugs, alcohol, accidents, obesity, poor diet, irregular living habits, and unstable family life.20 All of these characterize the lowest socioeconomic levels of American society to a greater extent than of Swedish society.'17 21 4. Sweden has a highly structured and "tight" social structure in which internal constraints are strong. Constraint has been suggested by Kitagawa and Hauser22 and by Retherford23 as a factor in explaining mortality differentials. Elsewhere and in another context I have discussed constraint in interpersonal relations and a cautionary attitude toward life as pervasive Swedish modes of behavior.'7 A tight social structure with well-defined limits and controls on behavior, both internal and external, makes for greater personal secu-
TABLE 6-Components of the Death Rate Differential at Ages 20-24, Swedish Males for 1969-71 and U.S. White Males for 1970
(Per 100,000 population)
All causes
Diseases Major cardiovascular diseases Malignant neoplasms Influenza and pneumonia External causes Motor vehicle accidents All other accidents Homicide Other external causes
Swedish Males
U.S. White Males
109.9
199.0
4.3 9.4 1.2
6.4 12.5 2.9
32.8 18.3 1.3 1.8
84.9 36.1 11.1 4.7
Differentials
89.1 2.1 1 3.1 .
6.9
1.7 J
]
89.5 52.1 17.8 9.8
8
26 J
2.9
Sources: Same as Table 2.
972
AJPH October, 1976, Vol. 66, No. 10
MORTALITY OF SWEDISH AND U.S. WHITE MALES TABLE 7-Components of the Death Rate Differential at ages 50-54, Swedish Males for 1969-71 and U.S. White Males for 1970. (Per 100,000 population) Swedish Males
U.S. White Males
659.5
1,098.6
216.7 25.0
474.2 90.2
117.4 19.7 9.2 2.1 11.5
135.2 55.3 18.5 14.7 21.5
I 17.8 35.6 9.3 12.6 J 10.0
20.1 33.0 0.6
34.3 41.9 8.5
14.2 1 8.9 7.9 J
All causes Diseases Diseases of heart Malignant neoplasms of the respiratory system Malignant neoplasms of other sites Cirrhosis of liver Bronchitis, emphysema, and asthma Symptoms and ill-defined conditions Influenza and pneumonia External causes Motor vehicle accidents All other accidents Homicide
Differentials
439.1 257.5 65.2
407.6 438.6 31.0
Sources: Same as Table 2.
rity and lower levels of internal stress. These, in turn, probably contribute to lower mortality from homicide, accidents, and some organic conditions. A large scale survey research study of welfare values and their realization in the four Scandinavian countries found that the constrained Swedes claim to suffer somewhat less stress and anxiety than the Norwegians and Danes and much less than the Finns, among whom male mortality is by far the highest in Scandinavia.24 A striking example of the possibilities of constraint and its consequences as a factor in the explanation of modern differential mortality is offered by the contiguous states of Utah and Nevada." Utah, largely Mormon, has white male mortality at the lowest U.S. levels. Nevada, with a similar climate and a much higher per capita income, has the least favorable white male mortality of all the U.S. states.'7' 25 Death rates run 40-50 per cent higher at most ages for both Nevada males and females compared with their Utah age mates. Nevada also had the highest proportion of in-migrants of any U.S. state in 1970, and probably also has the "loosest" social structure. Utah and Nevada, then, might be taken as representing the geographical extremes in constraint in the United States. One more suggestive example: the Japanese-Americans, with the lowest mortality of any identifiable component of the U.S. population, can be viewed as the most constrained of all American subcultures.22' 26
5. There is an activist approach toward lessening the dangers of existence in Sweden, part of the enormous emphasis in this society on rectifying social problems. The Swedish government's 1975 proposal to turn Sweden into a nation of nonsmokers through most methods short of outright prohibition is an example of this orientation. So, too, is the national concern with industrial safety and hygiene and with preventing childhood accidents. White male death rates are two to three times higher in the United States for both industrial and childhood accidents. The early attack on the problem of industrial pollution is another example of Swedish activism toward social problems. The prison sentences that Swedes AJPH October, 1976, Vol. 66, No. 10
undergo for driving with alcohol above a certain level in the blood is also an example of the aggressive pursuit of public safety. (The enormous reticence that Swedes have to driving after drinking is an example of the foregoing factor, the internalization of clear external constraints. The norms in U.S. society on this matter, as in so many other areas of life, are vague, conflicting, and, consequently, less constraining.) 6. Consumption of cigarettes and alcohol are both much lower in Sweden than in the United States. Cigarette smoking, in particular, is known to be associated with higher levels of mortality for many organic conditions, most notably lung cancer, emphysema, and the cardiovascular diseases. Per capita consumption of cigarettes in Sweden has increased sharply over the past half century, but between 1925 and 1966 it increased only from 25 to 37 per cent of the comparable consumption in the United States.27 Between 1966 and 1973 there has been a 12 per cent decline in per capita tobacco consumption.7 Swedish per capita consumption of alcohol is less than one-third of what it is in the United States.7' 28, 29 7. Diet, exercise, and weight are factors known to be associated with mortality. Dietary differences between these two populations are greater than might be expected in the two most affluent societies in the world. Meat and sugar consumption, for example, is lower in Sweden than in the United States, and the consumption of fish much higher. Average daily caloric consumption in Sweden was 2,850 for 1970-71, low for a modern society.7 The comparable caloric consumption in the United States for 1970 was reckoned to have been 3,300.29 My personal observation is that obesity is almost nonexistent in Sweden and that Swedes get more exercise than Americans, at the very least they walk more.
REFERENCES 1. United Nations. Demographic Yearbook 1973. New York, 1974. 2. Metropolitan Life Insurance Company. Stat. Bul. 55:October, 1974. 3. U.S. National Center for Health Statistics. Vital and Health Sta-
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tistics. Mortality Trends: Age, Color, and Sex, 1950-1969. 20:15. U.S. Government Printing Office, Washington, DC, 1973. Tomasson, R. F. Patterns in Negro-White differential mortality, 1930-1957. Milbank Mem. Fund Quart. 38:362-386, 1960. U.S. Bureau of the Census. Current Population Reports: Coverage of Population in the 1970 Census and Some Implications for Public Programs. Series P-23, No. 56. U.S. Government Printing Office, Washington, DC, 1975. U.S. National Center for Health Statistics. U.S. Decennial Life Tables for 1969-71. Volume 1, Number 1. U.S. Department of Health, Education, and Welfare publication No. (HRA) 751150. U.S. Government Printing Office, Washington, DC, 1975. Nordic Council. Yearbook of Nordic Statistics 1974. P. A. Norstedt, Stockholm, 1975. National Central Bureau of Statistics. Dodsorsaker 1969 and 1970, 1971. Stockholm, 1972, 1974. World Health Organization. International Classification of Diseases: Eighth Revision, 1965. Geneva, 1967. U.S. National Center for Health Statistics. Vital Statistics of the United States 1969-1971. Vol. 1I-Mortality, Part A. U.S. Government Printing Office, Washington, DC, 1973-75. Fuchs, V. R. Who Shall Live? Health, Economics, and Social Choice. New York: Basic Books, 1975. U.S. National Center for Health Statistics. Monthly Vital Statistics Reports-Final Mortality Statistics, 1969-1971. U.S. Government Printing Office, Washington, DC, 1972-1974. Anderson, 0. W. Health Care: Can There Be Equity? The United States, Sweden, and England. New York: John Wiley, 1972. Farr, W. Mortality of children in the principal states of Europe. J. Stat. Soc. 29: 1-35, 1866. U.S. National Center for Health Statistics. Vital and Health Statistics, Infant Mortality Rates: Socioeconomic Factors. 22:14. U.S. Government Printing Office, Washington, DC, 1972. Dahrendorf, R. Society and Democracy in Germany. Garden City, NY: Doubleday, 1967. Tomasson, R. F. Sweden: Prototype of Modern Society. New York: Random House, 1970.
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18. U.S. National Center for Health Statistics. Vital and Health Statistics Infant Mortality Rates: Relationships with Mother's Reproductive History. 22:15. U.S. Government Printing Office, Washington, DC, 1973. 19. U.S. National Center for Health Statistics. Vital and Health Statistics. Age of Mother, Total-Birth Order, and Other Variables. 20:14. U.S. Government Printing Office, Washington, DC, 1973. 20. Benjamin, B. Social and Economic Factors Affecting Mortality. Mouton, The Hague, 1965. 21. Banfield, E. C. The Heavenly City Revisited. Boston: Little Brown, 1974. 22. Kitagawa, E. M., and Hauser, P. M. Differential Mortality in the United States: A Study of Socioeconomic Epidemiology. Cambridge: Harvard University Press, 1973. 23. Retherford, R. D. The Changing Sex Differential in Mortality. Westport, CT: Greenwood Press, 1975. 24. Allardt, E. About Dimensions of Welfare: An Exploratory Analysis of a Comparative Scandinavian Survey. Research Group for Comparative Sociology, University of Helsinki, 1973. 25. Sauer, H. I. Geograhic Variation in Mortality and Morbidity. pp. 105-129 in Mortality and Morbidity in the United States. Erhardt, C. L., and Berlin, J. E. Eds. Cambridge: Harvard University Press, 1974. 26. Kitano, H. Japanese-Americans (rev. ed.) Englewood Cliffs, NJ: Prentice-Hall, 1976. 27. Socialstyrelsen. Fakta om rokning och hiilsa. Supplement. P. A. Norstedt, Stockholm, 1968. 28. Bruun, K. Alkohol i Norden. Aldus/Bonniers, Stockholm, 1973. 29. U.S. Bureau of Census. Statistical Abstract of the United States, 1974. U.S. Government Printing Office, Washington, DC, 1974.
ACKNOWLEDGMENTS Robert W. Buechley, PhD of the Cancer Research and Treatment Center of the University of New Mexico Medical School made numerous suggestions which have been incorporated in the final version of this paper.
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Paying the Price O
ur civilization has long since decided that technological progress is worth the price. We accept the stresses of industrialization and urbanization, the carnage on the highways, the threat of radioactive fallout and the hazards of exposure to the noxious chemicals that are so freely discharged into our environment.... These by-products of man's pursuit of technical and medical advancement are social as well as professional problems. " R. Keith Cannan in Rene Dubos and Maya Pines, Health and Disease, New York: Time Incorporated, 1965, p. 7.
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