Journal of Gerontology
1970, Vol. 25, No. 2, 83—86
Age and Geographic Differences in Death Rates
Herbert I. Sauer, MSPH, and H. Denny Donnell, Jr., MD, MPH1
T^HE risk of dying in middle age (age 45-64) the Census (1963a). For areas with substan-*- has already been shown to vary sub- tial populations in resident institutions (U. S.
stantially from one country to another and Bureau of the Census, 1963b), adjustments
also within the United States (American have been made in the estimated population at
Heart Association & National Heart Institute, risk; the basic method has been described in a
1965; Enterline, Rikli, Sauer, & Hyman, 1960; prior study (Sauer, Payne, Council, & Terrell,
Linder & Grove, 1943; Sauer & Brand, 1968). 1966).
Our present study focuses upon patterns of
death rates for white males age 65-74, which ALL-CAUSES DEATH RATES
may be thought of as either late middle age or
All-causes death rates have been presented
early old age, along with several factors which for white males age 45-64 (Sauer & Brand,
are associated with areas having either high or 1968, Fig. 1). They show the highest octile of
low death rates.
death rates, the 64 areas with the highest
While states are useful as geographic units rates, to be predominantly near the East Coast,
(Enterline & Stewart, 1956) many states are but also including Nevada and Hawaii. The
quite large and heterogeneous. On the other areas with the lowest rates are concentrated
hand, many counties have populations so small in the West Central and mountain areas.
as to limit their usefulness. For these reasons
A major finding of the present study is that
we have settled on state economic areas, as the patterns for late middle age (65-74) are
defined by the U. S. Bureau of the Census similar to those for age 45-64 (Fig. 1), with a
(1963a), a total of 509 areas, as reasonably coefficient of correlation (r) of + .75. Howhomogeneous units with respect to socio-eco- ever, more low-rate areas for age 65-74 are
nomic characteristics, while having populations located in the Mid-South and in Florida than
of moderate size.
for age 45-64. It has already been shown that
Average annual death rates per 100,000 for age 65-74 those born in Florida have
population at risk by place of usual residence roughly average death rates, while those movfor 1959 to 1961 are from the National Center ing to Florida from the North have low rates;
for Health Statistics.
Age-sex-race-specific this may be due to self-selection of migrants
rates by 10-year age groups, such as to Florida who have a higher potential for
age 65-74, are used. For states, rates age-ad- longevity (Sauer, 1967). Another difference
justed by the direct method by 5-year age is the greater number of high-rate areas in the
groups, age 65-69 and 70-74, are essentially North and fewer in the Southeast for late
the same as the ordinary age-specific rates, the middle age, as compared with middle age.
difference being consistently 1% or less; usu- This trend continues for age 75 and over, with
ally states with low rates are nominally lower many of the highest rate areas in the Northand states with high rates nominally higher east, and many of the lowest rate areas in the
when age-adjusted. Ordinary 10-year age- Southwest.
specific rates thus seem adequate for present
The difference in rates between geographic
purposes.
areas increases with age; for example among
Population data are from the U. S. Bureau of the 509 state economic areas, for age 35-44 the
rate of the 95th percentile is 218 points higher
1
than the 5th percentile rate, while for age 75
U. S. Public Health Service, Heart Disease Control Program
and Department of Community Health and Medical Practice, Uniand over, the corresponding difference in rates
versity of Missouri, Columbia, Missouri 65201.
83
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r
84
SAUER AND DONNELL
is almost 3000 points (Table 1). These rates
also serve as a reminder of the drastic increase
in the risk of dying with increasing age. For
natural causes, that is, all causes except accidents and violence, there is roughly a 10% increase in risk each year, as one grows older,
from early adulthood to age 95. As a result
it is possible for the pattern of percentage dif-
Age 45-64: 17 countries had lower rates
than did the U. S.
Age 65-74: 10 countries had lower rates,
and
Fig. 1. All-causes death rates, white males 65-74,
1959-1961.
Age 75-84: 6 countries had lower rates.
Thus, in middle age white males have high
rates compared with those for other countries,
while for older age (75-84), the U. S. rate is
lower than that for most countries. As presented by the National Center for Health
Statistics (1969), U. S. nonwhites have still
higher rates for age 45-64 and lower rates for
age 75-84 than do U. S. whites.
CAUSE-SPECIFIC DEATH RATES
Fig. 2. CVR death rates, white males 65-74, 19591961.
Death rates for the cardiovascular-renal
diseases (CVR) (International list causes 330334, 400-468, and 592-594) for late middleaged white males are generally lowest west of
the Mississippi River, with a few low-rate
areas in the Mid-South and southern Florida
(Fig. 2 ) .
We have been asked: Are the low rates in
the West Central U. S. due to the fact that
they contain few cities? Metropolitan areas
Table 1. All-Causes Death Rates of the
5th and 95th Percentiles, by Age,
White Males, 509 State Economic Areas
of the U. S., 1959-1961
(Average Annual Death Rates per
100,000 Population).
ctile
1009-1478
Fig. 3. Malignant neoplasms death rates, white males
65-74, 1959-1961.
Age Group
35 to 44
45 to 54
55 to 64
65 to
65
to 7474
75 and over
United
States
Rate
329.1
917.6
2200.0
4764.7
11896.6
5th
Percentile
Rate
254.0
701.8
1694.3
3823.9
10321.5
95th
Percentile
Rate
471.6
1140.5
2624.4
5477.2
13267.5
Excess of 95th
Percentile above
5th Percentile
217.6 (85.7%)
438.7 (62.5%)
930.1 (54.9%)
1653.3 (43.2%,)
2946.0 (28.5%)
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ferences between geographic areas by age to
be the opposite of the absolute amount of differences; that is, the percentage difference may
be most marked for age 35-44 and least marked
for age 75 and over. This is true for all causes,
as may be observed in the last column of Table
1. Although white female rates are consistently lower than are the white male rates,
the patterns are similar in that the percentage
differences are greatest for age 35-44 and least
for older age.
For 20 countries, European, British Commonwealth, and Japan, with data available
from World Health Organization reports
(1962, 1963, 1964), the all-causes death rates
for males may be compared with U. S. white
males as follows:
GEOGRAPHIC DIFFERENCES IN DEATH
Table 2. Correlation of Selected Variables
and Death Rates for White Males
Age 65-74, 1959-1961.
Variable
Comlation8 of 881 areas
Of total population,
% rural farm
Of females, % employed
Of men age 65 and over,
% working
Malignant
Coronary NeoHeart plasms
CVR Disease (140All
Causes Diseases (420)
205)
Malignant
Neoplasms
Except
Lung
-.65
+ .61
-.56
+.53
-.57
+ .56
-.57
+ .60
-.45
+.51
-.31
-.34
-.22
-.13
-.08
+.39
-.31
+.51 +.38
-.34
-.40
+ .33
-.46
+.24
-.52
-.43
-.55
-.53
-.43
-.33
Correlations of 1S6
metropolitan areas
Annual precipitation
Average daily temperature
change in January
Elevation above sea level
85
CORRELATION OF VARIABLES
About 30 socio-economic variables have
been correlated with various death rates. The
socio-economic data presented by the Bureau
of the Census (1963a) are for the total population of each state economic area. Since the
death rates are for whites only, areas with
more than 5% nonwhites were excluded from
the analysis. Also, to guard against possible
confounding effects, areas with large military
populations were excluded, leaving 231 areas
for the correlations.
Some of the highest correlations of socioeconomic variables with death rates for white
males age 65-74 are presented in Table 2.
Areas with a high proportion of the population classified as "rural farm" tend to have
lower death rates for all causes ( r = —.65) and
also for major cause categories. The proportion of females employed shows a correlation,
which is positive: the lower the proportion of
women employed, the lower the death rate.
On the other hand, of older men (age 65 and
over) the higher the percentage working, the
lower the death rate, particularly for the CVR
diseases ( r = - . 3 4 ) .
In farming areas there is a slight tendency
for a higher proportion of older men to be
working; the cross-correlation of "percent rural
farm" and "of men age 65 and over, percent
working" is + .37. This may be in part, a cultural phenomenon—that farmers often continue working, but at a slower pace, because
they are not faced with compulsory retirement. If so, then the "percent rural farm"
may be held constant by means of partial correlation; when this is done, the correlation between "of men age 65 and over, per cent working" and the CVR death rate drops to —.18.
In the areas with low death rates in middle
age, a higher proportion survive into the usual
age of retirement. Since there is a tendency
for a higher proportion of older men to be
working, it suggests that there is not a higher
rate of invalidism in old age in the low-death
rate areas.
Cross-correlation of variables also shows
that the proportion of older men working is independent of the proportion of females employed (r=—.01) but that in farming areas,
the percentage of women formally employed
tends to be lower ( r = - . 5 7 ) . Obviously much
further study is needed regarding the intercorrelation of many variables.
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generally do have higher rates than rural areas
(Enterline et al., 1960), but our data show
that several metropolitan areas in the western
half of the country are included in the lowrate group. The highest-rate areas are nearly
all along the East Coast and include a substantial number of non-metropolitan areas,
but Chicago, New Orleans, and Reno are also
included in the high-rate group.
Malignant neoplasms death rates are lower
in non-metropolitan areas to an even greater
extent than are CVR rates (Fig. 3). In addition to areas west of the Mississippi, there are
a substantial number of low-rate areas in the
Mid-South. The highest-rate areas are chiefly
metropolitan, in the eastern half of the U. S.,
particularly in the Northeast.
Geographically, there is a moderate degree
of association between the rates for CVR
diseases and malignant neoplasms—(i.e., where
CVR is lowest, malignant neoplasms are generally below average). For white males 35-74,
the coefficient of correlation is +.56 and is
almost as high for the metropolitan areas correlated separately. Thus, the association is not
due, to any appreciable extent, to the tendency for metropolitan areas to have higher
rates for both categories than do non-metropolitan areas. For 21 countries, European,
British Commonwealth, Japan, and the U. S.,
the correlation is very slight, only +.20, and
is about the same for age 45-64 as for age
65-74. Thus, if there are common factors affecting the risk of dying for both CVR diseases
and malignant neoplasms with the U. S., they
do not appear to be affecting the international
mortality patterns appreciably.
RATES
86
SAUER AND DONNELL
SUMMARY
The distribution of white male death rates
for late middle age (age 65-74) is to a substantial extent similar to that for middle age,
lowest west of the Mississippi River and highest along the East Coast.
The percentage difference in death rates
between geographic areas decreases with increasing age. However, with the tremendous
increase in rates with increasing age, the
amount of the difference in rates between geographic areas is substantially greater.
There are a number of moderately substantial correlations between factors in the environment and the risk of dying, but more work is
needed before definite conclusions may be
drawn.
REFERENCES
American Heart Association & National Heart Institute. Cardiovascular diseases in the U. S., facts
and figures. New York: American Heart Association, 1965.
Enterline, P. E., & Stewart, W. H. Geographic patterns
in deaths from coronary heart disease. Public Health
Reports, 1956, 71, 849-855.
Enterline, P. E., Rikli, A. E., Sauer, H. I., & Hyman,
M. Death rates for coronary heart disease in metropolitan and other areas. Public Health Reports,
I960, 75, 759-766.
Linder, F. E., & Grove, R. D. Vital statistics rates in
the United States, 1900-1940. Washington, D. C.:
Government Printing Office, 1943.
National Center for Health Statistics, Vital statistics
of the U. S., 1967, Vol. II, Pt. A, USDHEW, Washington, D. C : Government Printing Office, 1969.
Sauer H. I. Migration and the risk of dying. Proceedings of the Social Statistics Section, 1967, Paper presented at the annual meeting of the American
Statistical Association, Dec. 27-30, 1967.
Sauer, H. I., Payne, G. H., Council, C. R., & Terrell,
J. C. Cardiovascular disease mortality patterns in
Georgia and North Carolina, Public Health Reports,
1966, 81, 455-465.
Sauer, H. I., & Brand, F. R. Geographic patterns in
the risk of dying. Paper presented at Environmental
Geochemistry Session, American Association for the
Advancement of Science, Dec. 30, 1968.
U. S. Bureau of the Census. U. S. Census of population: 1960 subject reports. State economic areas,
PC(3)-1A, Washington, D. C : U. S. Government
Printing Office, 1963. (a)
U. S. Bureau of the Census. 17. S. Census of population: 1960 subject reports. Inmates of institutions,
PC(2)-8A, Washington, D. C: U. S. Government
Printing Office, 1963. (b)
U. S. Weather Bureau. Local climatological data—annual summary, U. S. Department of Commerce,
Washington, D. C : Government Printing Office,
1967.
World Health Organization. Annual epidemiological
and vital statistics, 1959, 1960, and 1961. Geneva:
World Health Organization, 1962, 1963, 1964.
Downloaded from http://geronj.oxfordjournals.org/ at Penn State University (Paterno Lib) on May 12, 2016
Forty measures of weather, based on annual data and on January and July data, were
correlated with death rates, for 126 metropolitan state economic areas for which such
weather data were readily available (U. S.
Weather Bureau, 1967). There is a moderate
tendency for measures of precipitation and
CVR death rates to be associated: the less
the precipitation, the lower the death rate
(r=+.51).
"Average daily temperature
changes in January" show an opposite association, the highest negative correlation (r=
— .52) being for malignant neoplasms other
than lung cancer; that is, the greater the January daily temperature fluctuation, the lower
the death rate (Table 2).
Elevation above sea level is also associated
with lower death rates, particularly for the
cardiovascular-renal diseases: the higher the
elevation, the lower the risk. Obviously, when
one recalls the extremely low rates for the
Netherlands one hesitates about assuming that
a high elevation is necessary to provide protection against the CVR diseases.
In the various correlation matrices thus far
prepared of weather, socio-economic, and other
variables with death rates, a rather substantial proportion of the correlations meet usual
standards for being considered "statistically
significant," either positive or negative. This
observation is presented in more detail as follows: Of the various cause-specific death rates,
five independent categories were chosen, CVR,
malignant neoplasms, accidental and violent
causes, chronic respiratory diseases, and all
other causes combined. When any two environmental variables had a correlation of .8
or more, they were assumed to have measured
the same thing and one was arbitrarily excluded. Of 142 remaining correlations that
are more or less independent, 98 are "significant at the .05 level" and 80 are "significant
at the .01 level." This is a sufficiently large
number as to make it necessary to focus attention upon such questions as: Which correlations are merely coincidental? Which are produced by common causes? And which are
causal? It seems reasonable also to continue
to explore the relation of many other variables,
including the chemical content of the drinking
water, with appropriate analytic methods. In
other words, we are not attempting, at present,
to assess the meaning of these various associations.