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Mortality Rates As An Expression Of Differences María Elena AstraínI, María del Carmen PríaII, and Norberto RamosIII ABSTRACT : A descriptive study of mortality rates was conducted in the municipalities of Camagüey Province. The municipalities were divided into three groups, according to living conditions. A synthetic indicator was used, based on the Human Development Index, and data was obtained from various provincial sources. For each group, triennial data was evaluated, including cause of death, sex, age group, years of life potentially lost, and other data typified by direct methods. Results over the three-year period showed that the municipalities with the best and the worst living conditions registered the highest infant mortality rates. However, neonatal mortality and low birth weight were more prevalent in the municipalities with the best living conditions (Group A) while there was a comparatively higher prevalence of the post-neonatal component in mortality rates for the municipalities with the poorest living conditions (Group C). Higher mortality risk from endogenous causes was found in Group A municipalities, while Group C municipalities showed the greatest incidence of premature mortality, as well as the highest rates of violent deaths, including a significant number of suicides.Subject Headings: DIFFERENTIAL MORTALITY RATE; HEALTH SITUATION ASSESSMENT; QUALITY OF LIFE INDICATORS. A population's health situation is directly related
to the society's historical moment. However, within a particular society, living conditions vary for different sectors of the population, which is reflected in different health profiles. These
differential profiles express the ways a given group of people is involved in the general functioning of the society, including their insertion into the life of the territory where they live, and their access to goods and
services.1 Therefore, we can infer that health problems manifest themselves differently in different groups within the same population; and that these inequalities reveal the existence of dissimilar living
conditions. Such differences should be taken into account if society is to effectively address inequities in health. 2 Important changes have taken place in Cuban society over the last three decade,
including consideration of health care as a constitutional right and responsibility of all citizens; higher educational levels in general; more active participation of women in society; increased life expectancy;
decreased infant mortality; and reduced morbidity and mortality rates in general. However, these and other changes have not eliminated regional differences in living conditions,3
which may have become more acute in the 1990s, due to "the special period" (term used to describe the current Cuban economic crisis). In this
study, we classified Camagüey Province's municipalities by their living conditions—Groups A, B and C-- to determine if there are differences among them in mortality rates by age, sex, cause of death, and incidence of premature
death. Methods An indicator based on the Human Development Index was used4-6
to classify the province's municipalities according to their living conditions. D. Victorio and G. Bergonzoli were the first to use this indicator for the study and classification of living conditions. The Human Development Index involves four aspects:
1. Environmental processes 2. Biological processes 3. Processes related to consciousness and behavior 4. Economic processes
We used different variables to evaluate each of these dimensions. Data was obtained from secondary sources in the province for the year 1996. 1. Environmental processes
1.1. Housing conditions
- Architectural features, building/construction materials used, including walls and roofing Dwelling types: house, apartment, tenement, rooming house, hut or shanty
1.2. Water supply
- Number of inhabitants with access to the water supply system - Cubic meters of water per inhabitant
1.3 Sewage and liquid waste management
- Number of inhabitants benefiting from the sewerage system
1.4 Solid waste disposal and management
- Frequency of garbage collection in each area
2. Biological processes
- Percent of inhabitants aged 60 and over - Low birth-weight rate
- Percent of pregnant women with second-degree malnutrition at the time of conception - Percent of pregnant women in the third trimester with hemoglobin levels at less than 11.0 g/L - Percent of pregnant women with less than 8 kg. weight gain during pregnancy
3. Economic processes
- Migration (immigrant/emigrant ratio) - Doctor-patient ratio - Nurse-patient ratio - Hospital beds per inhabitant
The Deprivation Index for each variable was obtained. The Average Relative Deprivation Index and the General Average Relative Deprivation Index were calculated for each of the four aspects. The Human Development
Index for each municipality was also calculated. For the analysis of the mortality rate, we used the number of deaths reported in the province from 1991 to 1993, and the population for the same period. The mortality rate over the three-year period was calculated by cause of death, age and sex.. For the analysis of premature deaths, we calculated the rate of years of life potentially lost (YLPL), according to
cause of death, typified mortality rates and YLPL by direct methods. The results obtained for each municipality were compared. Results Based on the values of the Human Development Indices shown in Table 1, a scale with
three equal intervals was designed for final classification of municipalities by living conditions, as follows: - Municipalities with good living conditions (Group A):
- Municipalities with fair living conditions (Group B)
- Municipalities with poor living conditions (Group C)
Table 1. Average Relative Deprivation Index (RP), General Average Relative Deprivation Index (GRP), and Human Development Index (HD) by municipality
Our study shows that the municipalities with better living conditions (Group A) had better housing, hygiene and sanitary conditions. However, with regards to biological processes, Nuevitas Municipality had the highest Deprivation Indices for most variables studied, while Camagüey had good results. With regards to economic processes, both municipalities showed good indicators. Among the municipalities with fair living conditions (Group B), Céspedes and Guáimaro Municipalities had fair housing conditions and poor hygienic and sanitary conditions; while Sierra Cubitas and Florida showed fair hygienic and sanitary conditions. Most municipalities in this group had good results in for the majority of biological variables studied. Regarding economic processes, results for variables were irregular within each municipality. Most of the municipalities with poor living conditions (Group C) had poor housing, hygienic and sanitary conditions; however, with regard to biological processes, most municipalities in this group showed good results for many variables studied. Concerning economic processes, most of the municipalities in this group had poor outcomes for the indicators studied. Analysis of mortality showed that Groups A and C had the highest infant mortality rates, with very similar results for each of the municipalities (Table 2). Nevertheless, a component analysis showed neonatal mortality to be relatively higher in Group A (67.8%), followed by Groups B and C (62.5% and 60.9%, respectively); while the post-neonatal component was more prevalent for Groups C and B (31.1% and 37.5%, respectively). Table 2. Mortality rate by selected age groups, sex and strata (Camagüey Province, 1991-93)
* Rates per 1,000 live births and children under one year of age
Group C showed higher infant mortality rates from sepsis, anoxia and other perinatal disorders. In Group A, most infant mortality was due to iso-immunization and hyaline membrane disorder.
A high mortality rate for the 15-24 and 35-44 age groups (both sexes) was observed in the municipalities included in Groups C and B. The mortality rate for women 25-34 was higher
in the municipalities with poorer living conditions (Group C). For the other age groups (45 and over), the higher mortality rates were found in the municipalities included in Group A.
Analysis of mortality rates by cause of death (Table 3) showed carcinomas, vascular diseases in general, congenital anomalies and perinatal disorders to be more common
causes of death in municipalities with poorer living conditions (Groups B and C). Table 3. Mortality rates by cause of death for different strata. Camagüey, 1991-1993
Note: MR = Mortality Rate per 10,000 inhabitants Table 4 . Years of life potentially lost (YLPL) for different strata. Camagüey, 1991-1993.
Note: * Rate per 1,000 inhabitants Table 5. Mortality from malignant tumors by localization and group. Camagüey, 1991-1993
* Rate per 10, 000 inhabitants Analyzing premature deaths (Table 4), we find that—with the exception of heart disease, bronchitis, pulmonary emphysema and asthma--premature death rates were higher in
municipalities with poorer living conditions. This was true even for causes of death which represented higher risks in the municipalities with better living conditions (Group A) (Table 3).
Since municipalities with poorer living conditions presented the highest mortality rate from malignant tumors, we included more detail on this aspect (Table 5).
The highest mortality from lung, cervical, uterine and oral cancers was found in the municipalities with the poorest living conditions (Group C). The highest mortality rate for
prostate cancer was found in municipalities with fair living conditions (Group B); and the highest for breast cancer in municipalities with good living conditions.
Regarding premature deaths, we found the highest rates for cervical, uterine, oral and prostate cancer were found in the municipalities with the poorest living conditions (Group
C); while lung and breast cancer appeared more frequently as causes of premature death in Group A municipalities. Table 6. Mortality from violent deaths by cause and group. Camagüey, 1991-1993
* Rate per 10,000 inhabitants Due to the fact that violent death is an exogenous cause of death, and because of it is
closely tied to the conditions in which the individual grows and develops, several categories of violent death were studied.
Suicide in Group C was the sum of suicide rates in Group A and B municipalities. The risk of death from traffic accidents, accidental falls and homicide was higher for Group A,
though the difference with the remaining groups was minimal (Table 6). Mortality rates from premature death due to suicide and accidental falls were higher in
Group C, while Group A had the highest rates due to traffic accidents and homicide. Discussion Different approaches, variables and data sources may be used to classify communities according to their living conditions. For our study, municipalities were classified using
municipal records (secondary sources)—a methodology that could also be applied at other levels. This classification showed that the greatest differences involved environmental factors,
followed by economic factors, where the difference were not as accentuated. Contradictory results were obtained with biological factors which, apart from aging, included indicators
measuring nutritional status of pregnant women and newborns. Better results for these indicators were found in municipalities classified as having poorer environmental and economic conditions.
A possible explanation may be that Groups B and C are rural and semi-rural municipalities, where people have more access to produce from agricultural cooperatives, private farmers
and home gardens; while urban residents in Group A depend almost exclusively on produce sold through government-run stores. Higher infant mortality rates in municipalities belonging to Groups A and C may be due to
different causes. In municipalities with better living conditions, it may be due to higher low birth-weight indices—an important risk factor. These municipalities also showed a more
prevalent neonatal mortality rate, including hyaline membrane disease, intra-uterine growth retardation (IUGR) and fetal immaturity, which are closely related to newborn birth weight.
These were the causes of death most frequent in infants from these municipalities. In the municipalities with poor living conditions (Group C), poor housing, hygiene and
sanitary conditions—not low birth weight—were the problem. In this case, post-neonatal deaths were the primary component of infant mortality, and sepsis the prevailing cause of death.
An analysis of the main causes of death for the whole population showed that Group A had the highest risk of death from heart disease, cerebrovascular disease and diabetes, which
was to be expected since these are endogenous causes, and are typical of more developed and aged communities. However, premature death from these causes—with the exception of heart disease—was more frequent in Group C.
Influenza and pneumonia, exogenous causes of death more likely associated with poor living conditions (Group C), were however found more frequently in municipalities with better
living conditions (Group A). At the same time, premature deaths from these causes were more prevalent in Group C: the explanation lies in the fact that mortality in Group A was
more frequent among the elderly, whereas Group C mortality was more frequent among the younger population, where death from such causes may be more easily prevented.
Both premature deaths and general mortality rates from malignant tumors were higher in municipalities with poor living conditions (Group C), due to the high rates of cervical, uterine
and oral cancers. National prevention programs are in place for each of these cancers, which leads us to believe that their implementation was deficient in these municipalities.
Municipalities with poor living conditions also showed higher mortality rates from lung cancer. This may be due to important risk factors, such as smoking, in these municipalities.
In the case of prostate cancer, the lowest mortality rate was found in municipalities with the poorest living conditions. However, premature death from this same cause was twice as
high as that of Group A municipalities. This may be due to resource-distribution in the health sector in these communities, and with the failure to perform rectal examination in patients over 40.
As to breast cancer, mortality rates and premature death rates were higher in Group A. This may support the idea that there may be factors in municipalities with poorer living
conditions that tend to protect their female population from this disorder: mothers breastfeed their babies for a longer period of time, and women give birth younger.
Mortality rates and premature deaths from violence were higher for Group C, due to the higher rates of suicide. Similar outcomes were obtained in the country as a whole by
Donate and Macías. Suicide was the number one cause of death in mountainous areas between 1986 and 1989. Higher rates from traffic accidents were found in Group A
municipalities; which is understandable since our province's capital is included in this group—an urban industrial center with heavy traffic, including bicycles, which have been
responsible for a higher number of accidents and lethalities in the entire country. Homicides had greater impact in Group A municipalities, since violence is more frequent in urban areas than in rural or semi-rural ones. These results show that mortality rate varies from one municipality to the other depending on their living conditions.
These results would not have been obtainable by using the traditional method of considering the province as a homogenous population, which tends to blur differences in living conditions.
Our approach allows us to pinpoint particular health problems in particular communities, and to direct the country's scarce resources into prioritized actions for their solution. References 1. Castellanos P. Perfiles de salud y condiciones de vida: una propuesta operativa para el estudio de las inequidades en salud en América Latina. España: 1992,1-2. 2. Proyecto de Sistemas Nacionales de Vigilancia de la Situación de Salud según condiciones de vida y del Impacto de las Acciones de Salud y Bienestar. Washington, DC: PAHO, 1992:16-7. 3. Macías Z, Donate M. Condiciones de vida y situación de salud. Havana: Instituto Cubano de Investigaciones y Orientación de la Demanda Interna (ICIODI). 1979;8-9. 4. López C. Índice de desarrollo humano: el caso Cuba. Bol Ateneo Juan César García, 1994;2(1):17-8. 5. Victoria D, Bergonzoli G. Métodos técnicos de instrumento para el análisis de la situación de salud, Costa Rica: PAHO, 1994:60-1. 6. Cuellar I. Indicadores sintéticos: el índice de desarrollo humano y una medición integrada de salud comunitaria. Trabajo para optar por el título de Especialista de Primer Grado en Bioestadística. Havana. Facultad de Salud Pública, 1994. This article originally appeared in Spanish in the Revista Cubana de Salud Pública, vol. 24, No. 1, (pp. 23-31), January-June, 1998.
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