Philippe AusselThe drivers of future mortality: an underwriter’s perspective

The drivers of future mortality

Over time: mortality improvements

Looking back: historical determinants

Peaking ahead: future drivers

Last but not least

Main literature reviewed

A. Case, C. Paxson, 2010. "Causes and consequences of early-life health," Demography, Springer, vol. 47(1), pages S65-S85, March. http://www.nber.org/papers/w15637.pdf

D. M.Cutler, A. Deaton and A. Lleras-Muney. "The Determinants Of Mortality," Journal of Economic Perspectives, 2006, v20 (3, Summer), 97-120. Available from: http://www.nber.org/papers/w11963

D. M. Cutler, E. L. Glaeser, A. B. Rosen, 2009. "Is the U.S. Population Behaving Healthier?," NBER Chapters, in: Social Security Policy in a Changing Environment National Bureau of Economic Research, Inc. Available from: http://www.nber.org/papers/w13013.pdf

S.S. Morse. “Factors in the emergence of infectious diseases”. Available from: http://wwwnc.cdc.gov/eid/article/1/1/pdfs/95-0102.pdf

National Institutes of Health (US); Biological Sciences Curriculum Study. NIH Curriculum Supplement Series [Internet]. Bethesda (MD): National Institutes of Health (US); 2007-. Understanding Emerging and Re-emerging Infectious Diseases. Available from: http://www.ncbi.nlm.nih.gov/books/NBK20370/

J. Olshansky, B.A. Carnes and A. Désesquelles. “Prospects for Human longevity”, Science, Vol 291, Issue 5508, 1491-1492, 23 February 2001. Available from: http://sjayolshansky.com/sjo/Manuscripts_files/Science2001.pdf

R.J. Pokorsky, MD, MBA. “Pricing implications of trends in population mortality and underwriting effectiveness”, J Insur Med 2004;36:54-59. Available from: http://aaimedicine.org/journal-of-insurance-medicine/jim/2004/036-01-0054.pdf

M.C. Purushotham. “Mortality improvements”, The Actuary Magazine, August/September 2011 – Volume 8 Issue 4. Available from: http://www.soa.org/library/newsletters/the-actuary-magazine/2011/august/act-2011-vol8-iss4-purushotham.pdf

J. Vaupel. “The advancing frontier of human survival” presented at the Living to 100 symposium of the SOA – January 8-10, 2014. Available from: https://www.soa.org/Library/Monographs/Life/Living-To-100/2014/mono-li14-1-soa-informal-discussant.pdf

Before we really start

• Impact on socio-demographic population needs.

• Macro-economic planning.

• Micro-economic challenges for insurance and pension institutions.

• Longer living viewed as positive trend and substantial social achievement.

Mortality

Longevity

Every day, there is news …

Mortality improvements over time

Mortality improvements over time

Age at death over time

Life expectancies over time

Causes of death over time

Leading causes of death

Age at death over time increased…

England & Waleshttp://www.princeton.edu/~deaton/downloads/cutler_deaton_lleras-muney_determinants_mortality_jep_2006.pdf

UShttp://www.ssa.gov/OACT/NOTES/as116/as116_V.html#wp999267

…and similarly Life expectancies increased, …

…as causes of death evolved.

Life expectancy over time

0

20

40

60

80

100

120

140

1,000,000 BC10,000 BCRoman Empire1700's1820's1870‐1900'sTodayOldest ever

Maximum life span?

Looking back: historical determinants

Historical determinants

Nutrition

Public health

Urbanization

Socioeconomic factors

Behavioural and lifestyle changes

Nutrition

• Improved agricultural machinery.

• Improved farmland yields.

• Improved quantities and qualities of available food.

• Improved food handling and conservation.

• Resulted in improved overall health status.

Public health

• Overall improved sanitation and hygiene.

• Population-wide vaccinations and public health education.

• Antibiotics and antimicrobial treatments.

• Serologic testing.• Viral isolation and

tissue culture.• Molecular

techniques.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4829a1.htm#fig1

50% gain

Urbanization

• Initially, adverse effect on mortality and survival rates.

• Then, improved sanitary and housing conditions reduced waterborne diseases.

• Closer access to hospitals.

Socioeconomic factors

• Economic inequality in terms of level of education, income, wealth and social status have discriminating factors on life expectancy.

• Major focus of public policies to lessen gaps.

http://inequality.org/inequality‐health/http://www.decisionsonevidence.com/wp‐content/uploads/2012/11/Life‐Expectancy‐and‐Mean‐Years‐of‐Schooling.png

Behavioural and lifestyle changes

Smoking

Excessive alcohol

Driving safety

Disease prevention

Exercising

Worksite safety

Let’s pause … and reflect!

• Will the (linear) trend of mortality improvement continue and if so, at what rate?

• Is it feasible to eliminate all possible risk factors for an entire population?

• How will the new discoveries be implemented at a population-level, and how cost-effective will they be?

• Past medical breakthroughs haven’t been programmed or planned … they “just” happened! So, will the future be like the past, or just different as it has been?

• What does it take to push the current average life expectancy of 80-85 to the magical 100, or the maximum global life span from 122 years to 150?

Is it flattening?

Peaking ahead: future drivers

Peaking ahead: future drivers

Medical advances

Behavioural and lifestyle changes

Infectious diseases

What if …

Medical advances

• Improved prevention and surveillance?

• Improved diagnostic tools and algorithms?

• Improved intervention techniques, and reduction of the operation risk?

• Improved (bio)medical treatments based on genotype specific therapies, rejuvenation of human tissues, replacement of malfunctioning genes, nanoand quantum technologies, molecular genetics allowing genes to be repaired?

Behavioural and lifestyle changes

• Resolving socioeconomic inequality?

• Access to health care, health prevention and education? Will it be remotely performed?

• Continued prevention for smoking, obesity, hypertension, dyslipidemia, diabetes, environmental and occupational diseases, drug and distracted driving, excessive alcohol use, processed foods, motivation to exercise, safety standards for avocations and occupations, prevention of suicide and other violent deaths (homicides).

• Increased compliance to medical recommendations and screenings.

Infectious diseases• 6 major types of infectious agents:

– Bacteria– Viruses– Fungi– Protozoa– Helminthes (parasites)– Prions (e.g. Creutzfeldt-Jakob disease)

• To survive, infectious agents need “reservoirs”.

• Recent infections included: – AIDS and HBC virus (untested blood)– Legionnaire disease (ventilation systems)– Hantavirus (rodent)– Lyme disease (reforestation)– Avian influenza

• Dormant pathogens can be activated at any time any where when there is a disturbance in their ecological environment (agricultural, economic, climate, population movements, human behaviors, etc.).

• Treatment resistance (malaria, tuberculosis), globalization, public health deficiencies are the new concerns.

http://trialx.com/curebyte/2011/08/27/clinical‐trials‐and‐images‐of‐emerging‐infectious‐diseases/

What if …

75

80

85

90

95

100

105

Today Tomorrow

Life expectancy at birth … all 3 major causes of death would be

completely eliminated whereby, already today, many people are living longer (or dying less)

because of pacemakers, statins,

beta-blockers, tamoxifen, artificial

limbs, etc.

15‐year gain

Is there any room for future improvements left?

Projected mortality rates Ages 0-1 and 1-14

http://www.data.unicef.org/maternal‐health/maternal‐mortality

Infant m

ortality

Maternal mortality

Projected mortality rates Ages 15-54 and 55-64

Middle ages: Risk factors  prevention

Young adults: Accidental deaths

Projected mortality rates Ages 65-74 and 75-84

Young seniors: Keeping active

Young retirees: Disease‐free living

Projected mortality rates Ages 85-89 and 90+

Seniors: Disability‐free living

Older seniors: Quality of life

Last, but not least!

Let’s pause again, and think more!

The Preston curve

Health care spending

Squaring of the mortality curve

Population pyramids

Economic recession and population health

The Preston curve

http://www.princeton.edu/~deaton/downloads/cutler_deaton_lleras‐muney_determinants_mortality_jep_2006.pdf

Health care spending vs. life expectancy

http://square.umin.ac.jp/massie‐tmd/druglagwarui.html

Squaring of the mortality curve

“Overall, probabilities of surviving to older ages have increased over the last century, and this trend is expected to continue in the future but at a slower pace”. 

Age pyramids: today

http://populationpyramid.net

Age pyramids: tomorrow

http://populationpyramid.net

Effect of economic recession on population health

Stephen Bezruchka CMAJ 2009;181:281-285

• Mortality (except from suicide) is increasing in times of economic expansion, and decreasing in economic downturn in “richer countries” (it is the opposite in poorer countries). 

• In richer countries, greater national wealth doesn’t lead to improved population welfare (“Affluenza” syndrome?).

• Multiple mechanisms are at play: increased leisure time, more time with friends and family, slower lifestyle, less work stress, less smoking and drinking … 

• Some governments (UK) are shifting from just length of life, to improving quality of life. 

The drivers of mortality …

… from yesterday to tomorrow! NutritionNutrition

Sanitation and vaccinationsSanitation and vaccinations

UrbanizationUrbanization

EducationEducation

Medical advancesMedical advances

Diseases preventionDiseases prevention

SmokingSmoking

Alcohol and drivingAlcohol and drivingWorksite safetyWorksite safety

ExercisingExercising

Obesity, Diabetes, drug resisting infectious 

diseases, processed foods, globalization

Obesity, Diabetes, drug resisting infectious 

diseases, processed foods, globalization

Quality of lifeQuality of life

Medical breakthroughs?Medical breakthroughs?

Health care funding?Health care funding?

UnknownsUnknowns

Will the trend continue?

If so, at what rate?Is it slowing down?Length of life or quality of life?What are the unknowns?

Today

Thank you!

Philippe AusselThe drivers of future mortality: an underwriter’s perspective