Published by EH.Net (April 2016)

Suchit Arora, The Transitions of Aging.  Berlin: Springer International Publishing, 2015.  xvi + 226 pp.  $129 (hardcover), ISBN: 978-3-319-14402-3.

Reviewed for EH.Net by Bernard Harris, School of Social Work and Social Policy, University of Strathclyde.

Over the course of the last three decades, a considerable number of economists, demographers, historians and epidemiologists have drawn attention to the importance of the role played by cohort-specific factors in shaping the patterns and processes of mortality change.  Many of these studies have taken advantage of the opportunity presented by the existence of long-run demographic data for countries such as England and Wales and Sweden.  In this book, Suchit Arora, a Senior International Economist at the State Teachers Retirement System of Ohio, focuses his attention on the British data.  He uses the data not only to understand the nature and impact of the transition in mortality, but also to evaluate its implications for changes in health spending.

As the author explains, the book has a “quantitative bent.”  It includes forty-seven figures, fifty tables and more than one hundred separately-numbered equations.  Its key elements can be summarized as follows: (1) an analysis of period-specific mortality rates; (2) their translation into cohort-specific rates; (3) a historical account of relevant policy changes; and (4) an examination of their implications for our understanding of the nature of human aging and its relationship to health expenditure.

Over the last fifty years, the proportion of older people in the populations of OECD countries has increased substantially.  It is also well-known that the demand for health care rises with age and that the cost of care has also increased.  However, one of the central arguments of the book is to challenge the assumption that an increase in the proportion of older people leads necessarily to an increase in health costs.  This is because of the extent to which the age-related demand for health care is also changing.

For Arora, an understanding of the importance of cohort factors to the pattern of mortality decline is crucial to this argument.  He uses anthropometric data to show how the quality of children’s lives fluctuated over the course of the nineteenth century.  Drawing on the work of Floud, Wachter and Gregory (1990), he argues that the average heights of successive birth cohorts of British men rose during the late-eighteenth and early-nineteenth centuries, fell during the second quarter of the nineteenth century, and then increased.  These improvements in childhood health cast a protective shadow over the subsequent health of these generations as they grew older.

A second key feature of the book is its emphasis on the role of economic and especially political factors in explaining the health transition.  Over the last forty years, historians and demographers have engaged in a sustained and vigorous debate over the relative importance of improvements in diet and public health provision in explaining the decline of mortality in England and Wales and other countries during the latter part of the nineteenth century (see e.g. Szreter 1988; Harris 2004).  Within this context, Arora pays particular attention to the development of a better understanding of the causes of infection and the introduction of a battery of public health measures to explain the reduction in the number of deaths from infectious diseases and the associated improvement in childhood health.

The emphasis on political choices also informs the book’s account of the increase in health service expenditure.  If the association between sickness and age is dynamic rather than static, “population aging” cannot be held solely responsible for increasing expenditure.  The other factors which need to be taken into account include “the high value an electorate places on health care spending,” “policy and budget allocations,” and “medical technology” (p. 178).

This is an optimistic book, both in tone and content.  It challenges the assumption that aging is a “burden” and encourages readers to focus instead on the positive changes which have enabled successive generations of children and adults to survive to higher ages.  It also highlights the positive contribution which health service provision, and social intervention more generally, have made to this achievement and the extent to which they can continue to play a beneficial role in the future.

However, it also contains some surprising omissions.  Although it devotes quite a lot of attention to the determinants of health in the nineteenth century, it says very little about the impact of smoking on health in the twentieth century (Rogers et al. 2005), and although it celebrates the improvements in stature during the second half of the nineteenth century, it also says very little about the increase in obesity during the second half of the twentieth century (Offer, Pechey and Ulijaszek 2012).  Each of these factors is likely to have had a substantial effect on the demand for health care in the recent past and may continue to do so for some time to come.


Floud, R., Wachter, K. and Gregory, A. (1990), Height, Health and History: Nutritional Status in the United Kingdom, 1750-1980, Cambridge: Cambridge University Press.

Harris, B. (2004), “Public Health, Nutrition and the Decline of Mortality: The McKeown Thesis Revisited,” Social History of Medicine, 17 (3), 379-407.

Offer, A., Pechey, R. and Ulijaszek, S., eds. (2012), Insecurity, Inequality and Obesity in Affluent Societies, Oxford: Oxford University Press.

Rogers, R., Hummer, R., Krueger, P.M. and Pampel, F. (2005), “Mortality Attributable to Cigarette Smoking in the United States,” Population and Development Review, 31 (2), 259-292.

Szreter, S. (1988), ‘”The Importance of Social Intervention in Britain’s Mortality Decline, c. 1850-1914: A Reinterpretation of the Role of Public Health,” Social History of Medicine, 1 (1), 1-37.

Bernard Harris ( is Professor of Social Policy and Head of the School of Social Work and Social Policy at the University of Strathclyde.  He is the coauthor (together with Roderick Floud and Sok Chul Hong) of “How Many Calories?  Food Availability in England and Wales in the 18th and 19th Centuries,” Research in Economic History, 31 (2015), 111-91.

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