Small Pain, Big Gains.

Smallpox vaccines and other medical advances have led to longer, healthier

lives.

Advances in medicine, economics and technology over the past 100 years have improved mortality rates. Since 1900, the average life span of Americans has increased nearly 30 years, from 47 at the turn of the century to 76.7 in 1998. The number of Americans at least 65 years old jumped from 3 million in 1900 to 34 million in 1997, according to the U.S. Census Bureau.

Vaccines for smallpox and diphtheria, the increased availability of infant prenatal care and the discovery of antibiotics and insulin all contribute to longer lives. Death rates were cut in half from 1,719 deaths per 100,000 people at the beginning of the century to 865 per 100,000 in 1997. Leading causes of death in 1900 were influenza and pneumonia, which were responsible for killing 202 Americans out of every 100,000. Today, those illnesses kill 35 per 100,000.

"At the early part of the century there was a 50% probability that patients would leave the hospital alive," said Dr. Pete Bell of the Mortality Research Center. The center, established by ING Reinsurance Co., Denver, has a team of actuaries, physicians, epidemiologists and biostatisticians that study mortality statistics and projections to help clients structure reinsurance pricing and create risk-management programs.

Bell, a former president of the Academy of Insurance Medicine, has read minutes from meetings the academy held in the early 1900s. "Medical directors were talking about how high blood pressure was linked to illness and were interested in the mortality implications on the insurance industry even before physicians were starting to deal with how to handle chronic illness instead of just trauma," he said.

The leading causes of death in the first 20 years of the century were pneumonia, tuberculosis, heart disease, head trauma and kidney disease, according to the National Center for Health Statistics.

Spanish Flu

The worst health epidemic of the century, the Spanish flu, hit the United States during World War I. The flu killed 500,000 Americans in 1917 and 1918. By comparison, 116,516 Americans died in World War I, and more than 405,399 were killed in World War II, according to the U.S. Department of Defense.

The flu was largely responsible for a 35% increase over the normal rate of mortality experienced by 27 life insurance companies based in Connecticut, according to a report by the state's insurance department that was published in Best's Life Insurance News in September 1919.

Influenza and related illnesses represented almost 48% of the $252.2 million that Connecticut-based life insurers paid in death claims in the six-month period between Oct. 1, 1918, and March 31, 1919. One of the largest life insurance companies paid about $27 million in death claims vs. an anticipated $3.4 million between October 1918 and April 1919.

At the same time, the flu contributed to a large jump in life insurance sales. New business written by Connecticut-based companies increased 79% to $3.34 billion in 1919, according to the report.

Decade by Decade

In the 1920s, heart disease took its place as the No. 1 killer of Americans--a position it continues to hold--followed by pneumonia, head trauma, cancer and tuberculosis. Cancer moved to among the top five diseases for the first time.

The value of the discovery of penicillin was evident in the 1940s, as it helped to control pneumonia, which dropped from second to fifth place as a leading cause of death during the decade.

Over the succeeding decades, heart disease and cancer remained the top two killers of Americans. In 1912, an American physician, Dr. James B. Herrick, linked heart disease with hardening of the arteries. Cardiovascular disease encompasses high blood pressure, coronary heart disease, chest pain and stroke. If all forms of major cardiovascular disease were eliminated, life expectancy would increase by almost 10 years, according to the American Heart Association. Currently, one in five Americans has some form of cardiovascular disease. The four main contributors to heart disease are high cholesterol, high blood pressure, smoking and diabetes.

There has been a steady rise in the cancer mortality rate in the United States over the past 50 years, led by lung cancer, according to the American Cancer Society. In 1930, 143 Americans per 100,000 died of cancer. That rate rose to 157 in 1950, 163 in 1970 and 172 in 1992. Death rates for many other types of cancer have leveled off or declined over the past 60 years. When lung cancer deaths were excluded, cancer mortality declined 15% between 1950 and 1991.

The American Cancer Society research attributes about 400,000 deaths each year to smoking. Cigarette smoking has declined in the past 25 years, but the numbers have stalled in the last four years. About 27% of U.S. men and 23% of women smoke. In 1960, researchers found a link between lung cancer and smoking, and in 1964 the U.S. Surgeon General's report said smoking increased the risk of disease. "A culmination of things came together of what doctors saw before when it came to the effects of smoking," Bell said.

Testing

As mortality improved and medical tests proliferated, life insurance underwriting became more sophisticated. Medical testing by insurers determines what diseases a person has, what the implications are or what the indications are of an individual developing the disease vs. the general population. The advent of separate classes for smokers and nonsmokers had an impact on underwriting in the late 1960s and early 1970s. "Before the smoker categories and more sophisticated blood and urine tests, underwriters were limited to asking a lot of, 'Did you ever have this or that?'" Bell said.

A new health threat appeared in the 1980s--AIDS. For a brief period in 1996, acquired immune deficiency syndrome was the eighth leading cause of death in the United States. By 1998, however, it did not appear among the top 15, although it still ranks fifth for the 25 to 44 age group. The improvement is attributed to advances in pharmaceuticals that treat people infected with the human immunodeficiency virus, which causes AIDS. In 1998, 13,210 people died from AIDS, down from 16,516 in 1997, according to the Centers for Disease Control. In October, the centers reported a 21% drop in the age-adjusted death rate from HIV infection in the United States in 1998 to 4.6 deaths per 100,000, the lowest rate since 1987.

After the spread of AIDS in the early 1980s, life insurers began to use a battery of screening tests to enhance their underwriting. They could use blood tests to screen for diabetes, kidney disease, liver functions, cholesterol and HIV. Urine tests reveal the presence of blood cells or protein, which help detect kidney disease. Electrocardiograms are used to screen for heart disease.

Drivers of Change

Along with medical discoveries, researchers are linking the economic growth of the past 100 years to improved mortality and better health for U.S. citizens. Researchers Robert W. Fogel, the 1993 recipient of the Nobel Prize in Economics, and Dora L. Costa of the Massachusetts Institute of Technology's National Bureau of Economic Research, have found that advances in technology have produced larger people who are stronger and live longer.

They report that as humans have gained control of their environment over the last 300 years, particularly during the last century, body size has increased by more than 50% and longevity has doubled. Advances in manufacturing, communications and energy production have led to a healthier lifestyle.

The study suggests that the numbers of people affected by chronic conditions is dropping because Americans are growing larger and healthier due to better nutrition, better health care and fewer risks--including a declining number of smokers and less exposure to infectious diseases. The study cites predictions that chronic disease will decline 6% per decade in the future.

Other studies point out that if mortality rates continue to decline 2% annually, by 2050, there will be 36 million more senior citizens than previously forecasted by the U.S. Census Bureau. This would impact health costs, life insurance rates and pensions.

Another study by Costa compared the health statistics of Civil War veterans in the Union Army pension program with random samples from information gathered by the National Health Nutrition Examination Survey for 1959 to 1994. Costa reports a link between the shift from manual labor to white-collar occupations and lowered exposure to infectious disease and chronic conditions in older men. She reports that between the first and last decades of the 20th century; respiratory problems dropped by 70%; heart-valve disease, by 90%; artherosclerosis (blockage of the arteries), by 60%; and joint and back problems, by 30%. She attributed the 10% to 15% decline in chronic conditions to reduced exposure to infectious disease.

A look into the next 100 years begins with supercomputers that can unravel the mysteries of disease, mapping of human chromosomes and predictions of extending mortality limits to 130 years.

In December 1999, IBM said it would build the world's fastest supercomputer. The computer, dubbed "Blue Gene," will be used to decipher how proteins, which control all cellular functions in the body, are folded and how changes in the folds can turn proteins into disease. Also in December, a team of international scientists decoded chromosome 22. Some 35 diseases and syndromes such as cancer, deafness and heart disease have a genetic component linked to chromosome 22. Identification of the chromosome allows scientists to better understand the genetic influences of disease.

Researchers at Duke University have determined that humans could live to be 130 years old within the next 90 years. Eric Stallard, research professor and associate director of the Center for Demographic Studies at the university, and his colleague Kenneth Manton used data from the U.S. vital-statistics system from the years 1960 to 1990.

Stallard said, "The current record of 121 years old is not the limit for humans

                          Leading Causes of Death
                                                                 Death
Rank                                                    Number    Rate [1]
1900
  1        Pneumonia (all forms) and influenza          40,362   202.2
  2        Tuberculosis (all forms)                     38,820   194.4
  3        Diarrhea, enteritis and ulceration
           of the intestines                            28,491   142.7
  4        Heart disease                                27,427   137.4
  5        Stroke                                       21,353   106.9
  6        Kidney disease (all forms)                   17,699    88.6
  7        All accidents                                14,429    72.3
  8        Cancer                                       12,769    64.0
  9        Senility                                     10,015    50.2
 10        Diphtheria                                    8,056    40.3
All Causes                                             343,217 1,719.1
1998
  1        Heart disease                               724,269   268.0
  2        Cancer                                      538,947   199.4
  3        Stroke                                      158,060    58.5
  4        Chronic obstructive pulmonary diseases      114,381    42.3
  5        Pneumonia and influenza                      94,828    35.1
  6        Accident and adverse effects                 93,207    34.5
             Motor vehicle accidents                    41,826    15.5
             All other accidents and adverse effects    51,382    19.0
  7        Deiabetes mellitus                           64,574    23.9
  8        Suicide                                      29,264    10.8
  9        Kidney disease                               26,295     9.7
 10        Chronic liver disease and cirrhosis          24,936     9.2
All Causes                                           2,338,075   865.0
(1.)Rate per 100,000 people and not age-adjusted.
Source: National Vital Statistics Reports.