Death is not a democracy that equals all people. Death is, quite the contrary, the worst of inequalities. And the new National Atlas of Mortality in Spain, which explores almost 10 million deaths between 1989 and 2014, reveals “very important geographical differences”, according to the statistician Miguel Angel Martinez Beneito, main author of the work, the most detailed to date.
The map, to which EL PAÍS has had access, represents the risk of death in each municipality from 74 causes. Burgos, for example, has a risk of dying from stomach cancer that is 105% higher than what would be expected according to the Spanish average, while that of Córdoba is 26% lower than the national reference. The figures are an estimate based on the deaths registered in each locality and its surroundings, adjusting the calculation as if all the towns had citizens of similar ages. Information displayed indicates relative, not absolute, risks. The risk of dying from an unusual disease can be four times higher in one town than another and still be a low risk.
“We see mortality in the south higher than that observed in the north of Spain. This reflects, in part, socioeconomic inequality, ”explains Martínez Beneito, who has carried out the work under the command of a team from the Fisabio Foundation and the General Directorate of Public Health of the Generalitat Valenciana. An example of these disparities is diabetes, a disease associated with junk food whose risk is scandalously climbing from north to south. The provinces with the highest risk are Tenerife, Seville, Cádiz and the rest of Andalusia. The Canary Islands is the community with the largest obese population.
“With the atlas we can also visualize phenomena of a more occupational nature, such as excess mortality due to certain respiratory diseases in the areas surrounding the mining regions of Spain”, emphasizes Martínez Beneito, recently joined the University of Valencia. In the Asturian mining basin there are several municipalities where there is a high risk of death in men from respiratory tract diseases and from cancer of the esophagus and larynx, as well as from cirrhosis or suicide. In the municipalities of Jaén and El Bierzo (León), historically mining, some of the same causes stand out.
Towns with up to a thousand inhabitants have, in general terms, a significantly lower mortality than urban areas. In larger cities other factors weigh. Madrid and Barcelona, for example, have lower than average risk figures, possibly due to their better health infrastructures. The latest mortality atlas in Spain was published in 2013 with data from the 1984-2004 period. So the authors, led by Joan Benach, from the Pompeu Fabra University of Barcelona, warned that it is possible to achieve optimal health “only if you live in a community with a healthy environment, in a city with a cheap means of transport and with the appropriate social and environmental conditions , in a neighborhood with access to adequate social and health services and equipment ”.
The data from the new atlas show better than ever known phenomena, such as the increased risk of dying from stomach cancer in some regions of Castilla y León, such as Burgos and Palencia. Previous studies have linked this uniqueness to a diet poor in vegetables and rich in cured foods. Zip code influences your chances of dying from a certain cause, but don’t panic and move. 40% of cancers, for example, are you can prevent with healthy habits, how to avoid tobacco, alcohol, sugary drinks, junk food, sedentary lifestyle and exposure to the sun without protection, according to the Spanish Society of Medical Oncology.
Nine of the ten towns with the highest risk of death from malignant tumors of the trachea, bronchi and lung are in Badajoz or Cáceres. Extremadura is precisely the community with higher percentage of smokers: 25.6% of the population, according to the Spanish Association Against Cancer.
The new atlas also draws attention to the distribution of the malignant tumor of the cervix, a disease associated with the human papillomavirus, sexually transmitted. The highest risk of dying from this cancer appears in tourist areas with beaches, such as the Canary Islands and the Balearic Islands. In Palma it is 96% higher than expected.
“Health, like disease, is not an individual matter. It depends on where you live ”, emphasizes epidemiologist Manuel Franco, from the University of Alcalá de Henares. Your team has studied the 128 neighborhoods of Madrid and has found that those with a lower socioeconomic status have fewer sports facilities and 62% more junk food stores around their schools. “The social gradient is creepy. There are neighborhoods with streets full of industrial bakery shops and frozen pizzas, one after another, ”he says. A man from the Salamanca district – one of the richest areas in Spain – has a life expectancy of 83.5 years, almost four more years than a neighbor of Puente de Vallecas, a working-class district. The new mortality atlas does not show these inequalities within the municipalities themselves, but Manuel Franco believes that it offers enough information to “guide public health research and identify areas that need more attention.”
“The zip code is one of the best indicators of health,” he recalls Ildefonso Hernandez, Professor of Public Health at the Miguel Hernández University, in Alicante. The data confirm this: the city with the most money per inhabitant in Spain, Pozuelo de Alarcón (Community of Madrid), has a life expectancy of almost 86 years, more than six years longer than La Línea de la Concepción (Cádiz), a of the poorest localities.
“What we see in the mortality atlas is a reflection of the policies of recent decades,” says Hernández, who was director general of Public Health of the Government of José Luis Rodríguez Zapatero between 2008 and 2011. The professor was the father of the current General Law of Public Health, a regulation approved in 2011 that established that all policies would include objectives to reduce social inequalities in health. The Law, according to Hernández’s complaint, was parked with the immediate arrival of Mariano Rajoy to the Government and has never been applied. “The new atlas should stimulate political action, by putting data on the table in such a visible way,” he says.
The director of the National Epidemiology Center, Marina Pollan, participated in 2014 in the preparation of cancer maps in Spain, with data on one million deaths registered between 1989 and 2008. Pollán highlights the “north-south gradient” evident in the new atlas and the worsening of the cancer map of lung in women. “It clearly reflects the effect that the tobacco epidemic has had on the female population in recent years,” he says. In his opinion, Martínez Beneito’s atlas is “a great work” that will allow experts to “generate hypotheses” about the roots of these deaths.
The National Atlas of Mortality in Spain It has been constructed with data on almost 10 million deaths between 1989 and 2014, obtained from the National Institute of Statistics (INE). The main data is a standardized and smoothed estimate of the risk of death for 75 causes of the 102 that the INE tabulates (those for which there are less than 10,000 deaths are not considered). The estimate is adjusted for the age of the inhabitants of the locality, to avoid that mortality seems higher where the people are older. In addition, to estimate the risk of each municipality and cause, a spatial modeling is used that assumes that nearby areas will resemble each other more than distant ones.
For each cause and each municipality, three data are reported: the standardized mortality ratio and the minimum and maximum values that define their 95% confidence interval. On the map, only the causes that have a risk at least 5% higher than expected (with that level of confidence) are colored in red. In green, the causes that have at least 5% less risk are colored.
The details of the methodology can be consulted on the atlas website made by the team of Miguel Ángel Martínez Beneito.
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