Getting a life:limits to health in the 21st century

CH

RIS

TO

PH

ER

DY

EMaximizing what?

Controlling environment

Controlling genes & behaviour

Losing control?

Maximizing what?

20

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80

1600 1700 1800 1900 2000

Lif

e ex

pec

tan

cy a

t b

irth

(ye

ars)

Wrigley & Schofield

Human Mortality Database

Industrial (r)evolution, health (r)evolution Life expectancy in England 1600-2000

Long life, quality life?

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1.0

Cardi

ovas

cula

r

Mal

igna

nt ca

ncer

Neuro

psych

iatri

c

Respira

tory

infe

ct

Respira

tory

dis

Diges

tive

Unint

l inju

ries

Diabe

tes

Genito

urinar

y

Infe

ctio

us-p

aras

itic

De

ath

s (

mill

ion

s)

W Europe: causes of death 2002

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7

Neuro

psych

iatri

c

Sense

org

an

Musc

ulosk

elet

al

Respira

tory

dis

Cardio

vasc

ular

Diges

tive

Mal

ignan

t can

cers

Unintl

inju

ries

Diabet

es

Endocrin

e

Yea

rs o

f d

isab

ility

(m

illio

ns

)W Europe: causes of disability 2002

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8

Neuro

psych

iatri

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Mal

igna

nt ca

ncers

Cardi

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Respira

tory

dis

Mus

culo

skel

etal

Sense

org

an

Diges

tive

Unint

l inju

ries

Diabe

tes

Infe

ctio

us-p

aras

itic

DA

LY

s (

mill

ion

s)

W Europe: years of health lost

HALE and hearty?

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Countries ranked

Lif

e e

xp

ec

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cy

(y

r)

or

% li

fe h

ea

lth

y

Healthy lifeexpectancyLife expectancyfrom birth% life healthy

Life expectancy ranges from 34-86 yrabout 80-90% life healthy everywhere

Four qualities of life?Ruut Veenhoven

  Outer quality Inner quality

 Livability of environment

Life-ability of person

Life chances Biotope Fitness

  Market Capital

  Utility of lifeAppreciation of

life

Life resultsAdaptation:

species persistence

Adaptation: long & happy

life

  Public wealth Private profit

HAPPY LIFE YEARS IN 1995-2005

Top Middle range Bottom

     

> 60 years ± 40 years <25 years

Switzerland 63,9

Philippines 44,1

Moldova 23,7

Denmark 62,7

South Korea

43,8

Uganda 23,3

Iceland 62,2

Iran 41,4

Angola 17,6

Austria 61,0

Hungary 40,0

Tanzania 15,2

Australia 60,7

Morocco 37,9

Zimbabwe 11,5

Reclaiming our health"Diagnosis – the most common disease" (K Kraus)

• Sisi syndromeDepressed, but pretending to be active and

positive about life (GSK)• Female menopause

Hormones needed• Ageing male syndrome

Cuts down men in their prime (Jenapharm)• Attention deficit syndrome

Hippihop and the small white tablet (Novartis)

Controlling the

environment

What limits good health?

THE SPECTRUM OF LIFE SPANS

From hunter-gatherers to…

… Japanese women

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100

0 20 40 60 80 100

Age (years)

Pe

rce

nt

su

rviv

ing

Hunter-gatherers

Japanese women

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

Survival in England & Wales, 1840-2000

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Age class (years)

Su

rviv

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rop

ort

ion

1840

2000

Longevity in England & Wales Survival improved first in children then

in adults

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1840 1860 1880 1900 1920 1940 1960 1980 2000

Fiv

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0-15 yr

15-60 yr

60-80 yr

England: Increase in lifespan slowed after 1950

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- M

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)

Women

Men

Women - Men

Causes of death, England & Wales, 1911-2003

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1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

De

ath

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r

Circulatory

Respiratory

Cancer

Infections

(1) AgricultureElimination of famine in England

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averagepre-17th

17th 18th 19th 20thCenturies

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s

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ch

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ntu

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

1 Agriculture and nutritionelimination of famine in England

2 Public health "sanitation revolution"

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

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

3 Microbiology diagnostics vaccines drugs

1890s

C17th C19th C20th

"Malnutrition-infection complex"

Better nutritionFewer infections e.g. less diarrhoea

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1820 1840 1860 1880 1900 1920 1940 1960 1980 2000

TB

dea

ths/

100,

000/

yrBritain beat TB in the 19th and 20th centuries?

TB deaths England & Wales 1840-1991

Keats1821

E Bronte1848

C Bronte1855

Mansfield1923

Lawrence1930

Orwell1953

Leigh1967

but mostly not with drugs or vaccines

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Low resp

irato

ry

HIV/A

IDS

Diarrh

oea

Tubercu

losi

s

Mal

aria

Mea

sles

Pertu

ssis

Tetan

us

STDs ex

c HIV

Men

ingiti

s*

Tropic

al d

isea

ses

Hepat

itis

B

Mill

ion

s o

f d

eath

s in

200

2Infectious causes of death in ICD-10

13/60m deaths in 2002 from infections 86% caused by top 5

0

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Wat

er &

sanit

ation

Choler

a or

rota

vacc

Oral r

ehyd

ratio

n

Breas

tfeed

ing p

rom

o

Wat

er p

ump

Latri

nes

Co

st/y

ear

hea

lth

y li

fe (

$/D

AL

Y)

Cure

Prevention

DIARRHEA: 1.8 MILLION DEATHS/YEARmethods for prevention and cure

-0.9 -0.8 -0.7 -0.6 -0.5 -0.4 -0.3 -0.2 -0.1 0

Pro-redistribution

Voter turnout

Active population (labour)

Women in workforce

Male employment

Health expenditure

Health care coverage

Income redistribution

GDP

Correlation infant mortality vs measures of democracy

More social equality = better overall healthNavarro et al, Lancet 2006

"Common consensus to invest in the future"

Controlling genes and behaviour

"…I have set before you life and death, the blessing and the curse; therefore choose life…"

Deuteronomy 30:19

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Body mass index (kg/m2)

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lati

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ris

k d

ea

th

Union Army Veterans, 1900, 25-yr risk

Modern Norwegians, 7-yr risk

Relative risk of death among 50-year old men

Causes of obesity:the burden of personal choice

Evidence strength

Decreases risk of obesity Increases obesity

Very strong Increased physical activity Sedentary lifestyle, high intake of high calorie fast foods

Strong Breast feeding, parental support of healthy food choices

Intense advertising of snack foods. High intake of sweetened soft drinks

Possible Foods that are lower in simple sugars and contain more complex starches

Larger portion sizes, more food taken outside the home

Source: Parliamentary Office of Technology (postnote) Sept. 2003

FTO: gene predisposes to diabetes by increasing body mass

McCarthy, Science 2007

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Overweight (BMI > 25) Obese (BMI > 30)

Od

ds

of b

ein

g o

verw

eig

ht/o

bes

e w

ith 1

co

py

of g

ene

16% of adults with 2 copies of gene weighed 3 kg more, with 2/3 increased risk

of obesity

THE (UNLIMITED?) POWER OF TECHNOLOGY

Growth: 1 extra year in 4

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1820 1845 1870 1895 1920 1945 1970 1995 2020 2045 2070

Life expectancy

Maxima estimated inyear given

Inexorable growth in life expectancy?women in leading countries

source: Oeppen 2002

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1950 2000 2050 2100

Lif

e ex

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JapanUSASwedenUKUK projected

When will life expectancy reach 100?

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10

100

1000

1 10 100 1000 10000 100000 1000000 10000000

Body mass (kg)

Lif

esp

an (

yr)

Life in 1/4 powers: can humans ever live to be 1000?

Lifespan mammals = 0.85 × mass1/4

Humans

1

10

100

1000

10000

1 100 10000 1000000

Body mass (g)

Bea

ts/m

inu

teHeart beat = 3.1 × mass-1/4

1.5 billion beats/lifetime

Fixing the faults of old age?"in the end costs exceed benefits"

Doug Wallace U California

"…as each life-limiting process is countered, some other process will become limiting"

Losing control?

Thomas Robert Malthus1766-1834

Principle of Population (1798)

population, if unchecked, increases geometrically

2, 4, 8, 16, 32, 64, 128…

but food supply grows arithmetically

1, 2, 3, 4, 5, 6, 7, 8…

so population outruns food supply

Teenage mothers 2000

Human population will stabilize in 21st century?

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5

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15

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25

2000 2020 2040 2060 2080 2100 2120 2140

Bil

lion

s o

f p

eo

ple

lower fertility - lower life expectancy

higher fertility - higher life expectancy

Brucellosis

E Coli O157

Multidrug resistant Salmonella

Plague

Ebola and CCHF

Influenza H5N1

Hantavirus

Lassa fever

Monkeypox

Nipah Hendra

NV-CJD

Rift Valley Fever

SARS CoV

VEE

Yellow fever

West Nile

Emerging and re-emerging zoonoses, 1996–2004

Cryptospporidiosis

Leptospirossis

Lyme Borreliosis

Apocalypse soon?

• Unavoidable transmission route

• Highly infectious

• High proportion of people exposed

• Transmission rapid compared with response time (everyone gets infected before knowing)

• Fatal

25 years of AIDS25 years of AIDS

9 In 1991-1993, HIV prevalence in young pregnant women in Uganda and in young men in Thailand begins to decrease

10 Highly Active Antiretroviral Treatment launched

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45

Mil

lio

n

1980 1985 1990 1995 2000 2005

1 2 3 45 6

8

9

11

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13

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1516

7

10

1 Immune deficiency in gay men in USA

2 Acquired Immune Deficiency Syndrome (AIDS) is defined

3 The Human Immune Deficiency Virus (HIV) is identified as the cause of AIDS

4 In Africa, a heterosexual AIDS epidemic is revealed

8 The first therapy for AIDS – zidovudine, or AZT -- is approved for use in the USA

People People living living with with HIVHIV

Children Children orphaned orphaned by AIDS in by AIDS in sub-sub-Saharan Saharan AfricaAfrica

1.1

HIV infected in 2005: 40 million

Died in 2005: 3 million

Total deaths: 25 million

"…limit temperature increases from global warming to 2-2.5°C above the 1750 pre-industrial level…" Scientific Expert Group Report on Climate Change, Feb 2007

Bobak, M. et al. BMJ 2004;329:767

PERILS OF SOCIAL COLLAPSESurvival from age 45 to 70 in Sweden and Russia

Getting a life

"We suffer from the asymmetry between our knowledge of

nature and our knowledge of man, between

outside awareness and self-ignorance"

How to live to 100... and enjoy itNew Sci 3 June 2006

1. Go for the burn2. Don't be a loner 3. Consider relocation4. Make a virtue out of a vice 5. Exercise the grey cells6. Smile! 7. Nurture your inner hypochondriac 8. Watch what you eat 9. Take a few risks

“If I had known I was going to live this long I would have taken better care of myself"H Doernemann, aged 110

Getting a life • Achievement of C18-C20 England was to control

environment, preventing a few major causes of illness through nutrition and removing sources of infection- technology and its organized application

• Challenge of C21 is to control genes (technology) and behaviour (burden of choice)- while maintaining gains of C18-C20

• Development needs "a common consensus to invest in the future""….balance individual and market freedoms with

public leadership…"