If the relative risks of mortality in Figure 2.4 are standardized on the French crude death rate of c. 1785, one obtains the time series of crude death rates (per thousand) shown in Table A1.

Table IV in Waaler (1984) contains relative mortality rates for Norwegian males aged 50 to 64, averaged over height intervals of 10 cm and weight intervals of 10 kg. Attempts to fit iso-risk curves to these averages produced unsatisfactory results. Because at that time we did not have access to the data from which these averages were derived, it seemed reasonable to “fill in” the table by polynomial interpolation and use the generated data to estimate the risk–height–weight relationship.

The interpolation was done in two steps. The first step consisted of taking the relative mortality rates given in the table and using standard least-squares regressions to fit polynomials in weight to each column of risk values (corresponding to given levels of height) and polynomials in height to each row (corresponding to given levels of weight). These polynomials, which were each of the maximum order permitted by the number of entries in the corresponding row or column, were then used to generate values across each row and down each column of the table in intervals of whole centimeters and kilograms. This step generated 700 data points.

To further increase the available data, the rows and columns generated in the first step were used as the data for the second round of polynomial interpolations.

The debate over the extent of chronic malnutrition in developing countries, which began after World War II, has been conducted largely between investigators associated with the Food and Agriculture Organization (FAO), the World Health Organization (WHO), and the World Bank, on the one hand, and critics who believe that their estimates of the extent of malnutrition are too high. I will use the acronym FAWOB to designate the investigators associated with these three organizations.

Few investigators have suggested that the FAWOB estimates are too low. One reason for the neglect of this possibility is the tendency of investigators to assume explicitly or implicitly that affluent persons in affluent countries reached their genetic potential during the middle decades of the twentieth century and that no further improvements in physiology were possible without some major genetic breakthrough. In Chapter 2, I outlined a theory of technophysio evolution that disputes that assumption. Next, I want to apply the theory of technophysio evolution to a number of problems related to health and mortality in the Third World.

Changing Views of Chronic Malnutrition and of the Methods of Measuring it

Nutritional science was still in its infancy during the early twentieth century. It was not until the turn of the century that Wilbur O. Atwater and his collaborators estimated the energy requirements of basal metabolism.

Research during the past two decades has produced significant advances in the description and explanation of the secular decline in mortality. Although many of these findings are still tentative, they suggest a new theory of evolution that Dora Costa (an economist and biodemographer at MIT) and I call “technophysio evolution.” Studies of the causes of the reduction in mortality point to the existence of a synergism between technological and physiological improvements that has produced a form of human evolution that is biological but not genetic, rapid, culturally transmitted, and not necessarily stable. This process is still ongoing in both rich and developing countries. In the course of elaborating this theory, thermodynamic and physiological aspects of economic growth will be defined, and their impact on economic growth rates will be discussed.

Unlike the genetic theory of evolution through natural selection, which applies to the whole history of life on earth, technophysio evolution applies only to the past 300 years of human history and particularly to the past century. Despite its limited scope, technophysio evolution appears to be relevant to forecasting likely trends over the next century or so in longevity, the age of onset of chronic diseases, body size, and the efficiency and durability of vital organ systems. It also has a bearing on such pressing issues of public policy as the growth in population, in pension costs, and in health care costs.

The twentieth century saw major improvements in the human condition, not only in the rich countries of the world but also in developing nations. Nothing has been more remarkable, however, than the extension of life expectancy, which has increased by about 30 years since 1900 in England, France, and the United States and in equal or larger amounts in such countries as India, China, and Japan. Among the nations of the Third World, the rate of improvement has been nearly twice as fast as among the nations in the Organization for Economic Cooperation and Development (OECD) (see Table 1.1).

What is responsible for this unanticipated extension of human life? That question has occupied some of the best minds of the past century in both the social sciences and the biomedical sciences, and it is also the central question of these chapters. The drive to explain the secular decline in mortality did not begin until about World War I because it was uncertain before that time whether such a decline was in progress. There was little evidence in the first four official English life tables covering the years 1831–80 of a downward trend in mortality. Although the signs of improvement in life expectancy became more marked when the fifth and sixth tables were constructed, covering the 1880s and 1890s, few epidemiologists or demographers recognized that England was in the midst of a secular decline in mortality that had begun about the second quarter of the eighteenth century and that would more than double life expectancy at birth before the end of the twentieth century.

The frontispiece to this volume is a mathematical representation of the relationship between human physiology and longevity. It is emblematic of the enormous advances in the health and wealth of people over the past 300 years. It is also emblematic of the vast increase in humankind's control over the environment and of the scientific, industrial, biomedical, and cultural revolutions that are the foundations for that control.

These advances are aptly described by the term “technophysio evolution,” which was coined to describe the unique nature of human progress since 1700. During these three centuries there has been a fifty-fold increase in the average incomes of the peoples of the United States and Japan and comparable increases in the leading countries of Western Europe. The peoples of these countries have greatly improved their health and more than doubled their longevity.

Technophysio evolution and its implications are the central themes of this volume. The term describes the complex interaction between advances in the technology of production and improvements in human physiology. The interaction is synergistic, which means that the total effect is greater than the sum of its parts. This interaction between technological and physiological improvements has produced a form of evolution that is not only unique to humankind but unique among the 7,000 or so generations of human beings who have inhabited the earth. Although the process has been experienced only by the last ten generations of humankind, it is still ongoing.

Will the twenty-first century witness as large an increase in the average life expectancy of the rich countries–thirty to forty years–as occurred during the twentieth century? Most experts believe it will not. The middle estimate of the U.S. Census Bureau, for example, is that the increase in life expectancy between 2000 and 2050 will be only about 7 years, and the estimated increase for the entire twenty-first century is just 13 years. This is less than half the increase that occurred during the twentieth century. The same conservatism is evident in the projections of the UN, OECD, and other national and international agencies.

These pessimistic projections rest on several propositions. Perhaps the most widely accepted is the proposition that opportunities for large reductions in mortality rates are possible only when death rates under age 5 are very high. Proponents of this view argue, for example, that the sharp decline in U.S. mortality rates during the twentieth century was the result of a unique opportunity that cannot be replicated by those nations that have already experienced it: the opportunity to wipe out the majority of deaths due to acute infectious diseases, which were concentrated in infancy and early childhood. Whereas more than a third of all deaths at the turn of the twentieth century were of children under 5, today infant and childhood deaths are less than 2 percent of the annual total.

In the United States and around the world, concern is growing about who gets health care. Individuals from different socioeconomic backgrounds face distressingly different prospects of living a healthy life. As numerous studies confirm, the disparities in various measures of health between the privileged and the deprived still remain wide, even in rich countries, despite the long-term tendency toward a healthier society.

Some investigators believe that the disparities are actually increasing. They suggest that the shift in the health care system in advanced industrial countries from the principle of universal access to a more market-oriented system may be one cause of the growing disparities they observe; rising income inequality is another potential culprit.

Policy makers worldwide meanwhile speak of more efficiently delivering “essential” health care, but nobody is certain what this means in practice.

What counts as essential in health care? What is the optimal mix of private and government components of health care services? To answer these questions, it is necessary to confront the question of how to define essential health care and then explore the policy implications of the analysis.

Standards for Rationing

International organizations such as WHO and the OECD have called on all countries to guarantee delivery of “high-quality essential care to all persons, defined mostly by criteria of effectiveness, cost and social acceptability.” Cost has become a controlling issue since the health care systems established in most OECD countries after World War II, which sought to guarantee complete health care for all through government-run health or insurance systems, have become so expensive that they now threaten the fiscal stability of governments.