|5 Development since 1880
We have placed the beginning of the great secular decline in mortality in Finland at 1880. Since this date, life expectancy has increased until the present day in a sustained manner with only temporary setbacks caused by wars. In certain age groups, nevertheless, some more persistent adverse developments have been observed at times.
The annual decline in age-specific mortality is illustrated in Figure 3 for each stage of transition. In sharp contrast with the sluggish and uncertain changes before it, the long and deep-going second stage (1880-1945) resulted in a thorough transformation of the mortality regime while still leaving some serious problems. Death rates in infancy and childhood were reduced to a third or less of their former levels but for young adults the improvement was much smaller due mainly to the stubborn presence of tuberculosis. For middle-aged women the death rate declined by almost one half but less for the elderly. For men, the decline was altogether more modest and at ages 55-69 suffered an actual setback. Valkonen has found that the mortality of middle-aged and elderly men in Finland rose in the beginning of this century, at least partly because of smoking  while an increase in the consumption of fats and milk products may also have contributed . An analysis by cause of death made at the end of the second stage indicated that middle-aged men, but not women, had in Finland a much higher death rate from heart diseases than in Sweden .Figure 3. Annual percentage change in mortality by age and sex at different stages of transition.
Throughout the second and later stages of transition until today, infant and child mortality have followed their own path, not always in line with what happened at other ages. The propaganda for better child care which had borne fruit in the preceding centuries, continued after 1900 and a nation-wide system of maternal and child health was founded in the interwar years, a logical continuation, with better means, leading to a substantial decline in infant mortality . The system was developed further after the last war, and by the 1970s virtually all expectant mothers and 97 percent of new-born children were registered at MCH centres where they had an average of 15 and 12 examinations respectively .
An average annual decline of 1-2 percent in childhood mortality translated into a drop of more than 60 percent over the second stage. After that, the decline accelerated and each of the two successive stages, much shorter than the second, also recorded gains of about 60 percent each. Antibiotics obviously played a part but were by no means the prime mover in the development.
The infant mortality rate (IMR) stood in 1881-90 at 151 per 1000, with only minor regional differences. When the great decline set in, the more prosperous areas gained an initial advantage and cities overtook rural areas but eventually this development came fill circle, and regional as well as social differences have by now virtually disappeared.(Note 3) IMR was in mid-century close to 50, still high by European standards but progress has continued until the present when Finland has moved to the forefront in this area with IMR as low as 3.9 in 1995. Improvement in living standards as well as other progress have in Finland as elsewhere been important factors in the reduction of infant mortality but do not explain the above-average success in Finland. We ascribe this achievement to a very successful program of maternal and child health.
The third stage (1945-1970) began with a sudden acceleration of mortality decline. Most remarkable in the Finnish situation was that the mortality of young adults fell rapidly as tuberculosis, until then a very persistent public health problem, was virtually eliminated as cause of death of the young. Unprecedented survival benefits were experienced at all ages though they were smaller for the oldest. This wave of improvement soon ran its course and was followed by a slowdown in the 1960s. Middle-aged men had recorded at first a much more substantial mortality decline than ever before but by 1960 this had come to a halt and even reversed. This adverse turn has been analysed by Valkonen and ascribed in the first place to changes in health-related behaviour [40, 41].
The same did not happen to women for whom additional, though smaller, gains were recorded throughout the third stage. It has to be emphasized that the benefits of the third stage of transition, bestowed largely by antibiotics, were strongly age selective: greatest in childhood and youth after which they took a gradually diminishing form towards old age. While the annual decline of mortality reached 6-8 percent below age 25, at age 40 it was 2.5 percent for men, 4.5 for women and after age 90 less than one-half percent for both.
The fourth stage of transition was as unexpected as the third. Around 1970, mortality of the elderly began to decline in most Western countries, including Finland, as never before in recorded history and gains in survival were observed even at the highest ages. In Finland the profile of the fourth stage is one in which mortality continues to fall rapidly in infancy and early childhood, is meeting resistance among young adults but declines very substantially in middle age reaching the most rapid rates of decline at about age 60 for men, 70 for women where it has averaged 2.5 percent a year over the last 25 years. Though the decline gradually tapers off towards the oldest ages, it still remains on an entirely unprecedented level even at ages 95 and over where the annual decline amounts to one percent a year.
The gains in survival in old age have been somewhat larger for women than men and their life expectancy at age 65 has increased during the fourth stage by 4.0 years as compared with 2.9 years for men. Yet, at the same time, the very considerable - if belated - improvement in the mortality of middle-aged men has contributed to increase the life expectancy of new-born boys by 6.2 years vs. 6.0 for girls.
Shown in Figure 3, the difference between the third and fourth stage is very striking for both sexes: the rising curve of the third stage is intercepted in middle age by the declining curve of the fourth as it is heading towards the lowest levels ever observed in old age. We consider this crossover of the decline patterns a distinctive mark of the passage from the third to the fourth stage of mortality transition.
Extensive research on mortality differentials has been carried out in Finland by dividing the entire population into groups according to socio-economic, educational and other classifications and following them up through record-linkage. The general thrust of such studies has been that while death rates have been declining in all groups, the differences between groups have persisted or even increased [16, 18, 19, 42]. The decline in the mortality from ischemic heart disease is almost fully explained by changes in risk factors . The conclusion is that ample room for further improvement still exists.
|Finnish Life Tables since 1751
Väinö Kannisto, Oiva Turpeinen, and Mauri Nieminen
© 1999 - 2000 Max-Planck-Gesellschaft ISSN 1435-9871