1Knowledge of the level, structure and trends of mortality at a finer scale than that of the country as a whole is necessary both for the scholarly purpose of better understanding the factors behind the variations and inequalities observed, and for reasons of public health, in order to decide where resources are most needed and to determine what type of intervention to apply and to which parts of the territory. This paper is part of a longstanding demographic tradition (Blayo, 1970; Caselli and Egidi, 1986a and 1986b; Daguet, 2005 and 2006; Meslé and Vallin, 1998; Nizard and Prioux, 1975; Noin, 1973; Salem et al., 2000; Caselli and Vallin, 2002; Leclerc et al., 2010). Its purpose is to describe the variations in mortality between France’s départements, their evolution over the last thirty years and their structural characteristics. [1] Specifically, the aim is to answer three questions:

• What is the current geography of overall mortality in metropolitan France and how has it changed over the last thirty years?
• Do differences in life expectancy between départements correspond to specific age patterns of mortality?
• What causes of death explain the geographical variations in mortality?

2To reduce the effect of random annual fluctuations due to small populations in some départements, we worked with three-year life tables using the arithmetic mean for a given indicator over three successive years. For simplicity, the text refers to the middle year of each three-year period. For example, life expectancy at birth in 2007 refers to the arithmetic mean of life expectancy at birth from 2006 to 2008.

I – Little change in the geography of life expectancy over the last thirty years

3In 2007, life expectancy at birth in metropolitan France was 77.2 years for men and 84.3 years for women, i.e. 8.1 and 7.0 years more than in 1977. These average figures conceal major geographical variations. In 2007, the difference between the life expectancies of the two départements at the top and bottom of the range (Hauts-de-Seine and Pas-de-Calais) was 6.0 years for men and 3.4 years for women, compared with 5.9 and 4.2 years in 1977 (Appendix Table A.2). Overall, geographical inequalities in mortality seem to have persisted for men, where they are more marked, but to have declined for women. In fact, both fell steadily – until the early 1990s for men and the early 2000s for women – and then increased noticeably for men and very slightly for women (Figure 1). At its narrowest, the gap in life expectancy at birth between the highest and lowest ranked départements was 5.1 years for men (in 1991) and 3.1 years for women (in 2002 and 2003).

Figure 1

Figure 1

Difference between highest and lowest life expectancy at birth recorded in the French départements, males and females
Note: The curves are the regression lines obtained by locally weighted scatterplot smoothing (LOWESS), i.e. by considering a window centred successively on each observation year and including a constant proportion of points, in this case, half the total points on the figure.

4Figures 2 and 3 show life expectancy at birth by sex in metropolitan France in 1977 (1976-1978) and 2007 (2006-2008). The départements are divided into five groups along the distribution scale. The middle group is around the mean (plus or minus half a standard deviation) and the other groups are bounded by one or two standard deviations on either side. It should be borne in mind that the range within groups on these maps is much smaller in absolute terms for women than for men, with a gap between the extremes of the top and bottom groups of 2.75 years in 1977 and 2.25 years in 2007 for women, versus 4.45 and 3.50 years for men. All the values are represented on these maps, but because of the small number of deaths in some sparsely populated départements, any relative excess or deficit of mortality seen in these départements may be due to chance and may not reflect the actual state of health of the local population.

Figure 2

Figure 2

Male and female life expectancy at birth by département, 1976-1978

Figure 3

Figure 3

Male and female life expectancy at birth by département, 2006-2008

5The maps show the persistence of geographical variations in life expectancy at birth, the general indicator of mortality. In 1977, the most disadvantaged départements were located in two geographical areas. The first was a crescent stretching from Alsace to the Nord-Pas-de-Calais region for both sexes, and as far as some départements in Normandy for men (Seine-Maritime and Calvados) including Lorraine (except Vosges for women), the north of the Champagne-Ardenne region and Picardy (except Oise for men). The second disadvantaged area, for men especially, extended across Brittany and the Loire-Atlantique département. For women this area only comprised the three easternmost départements of Brittany. In 2007, these two areas of relatively high mortality are still visible, although less so for Brittany, Alsace and Lorraine for men, and Champagne-Ardenne for women. The most striking change is the expansion of the area along France’s northern frontier, especially for men. It pushes down towards the centre of the country from Champagne-Ardenne to the north of Limousin.

6The geography of the départements with high life expectancy at birth has also changed. In 1977, they were to be found overwhelmingly in an area running from Île-de-France to the south-west and south-east. For men, this area comprised Île-de-France except Seine-Saint-Denis, the départements along the regional borders of Pays de la Loire and Centre, Poitou-Charentes, part of Limousin, Midi-Pyrénées and Languedoc-Roussillon. For women, it was broken by Sarthe and Loir-et-Cher, but stretched down to Aquitaine. The other area of low mortality covered the four départements in the south-east corner of France, plus Haute-Corse, and, for women, part of the Rhône-Alpes region. By 2007, this second area had shifted north, centring more on Rhône-Alpes than Provence-Alpes-Côte d’Azur, while the first area of high life expectancy at birth had broken into three distinct islands around Île-de-France, Pays de la Loire (especially for women) and, for men, a group of départements from the Atlantic coast to Hérault, except for those along the Spanish frontier, and, for women, covering Aquitaine (except Dordogne) and some of the départements in Midi-Pyrénées.

7Generally speaking, the advances made from 1976-1978 to 2006-2008 were greatest where life expectancy at birth was initially low (but not lowest). The correlation is statistically significant for both sexes but more marked for men. That the standard deviation barely moved between the two dates, from 1.4 to 1.1 for men and 0.9 to 0.8 for women, is due to a few départements at either end of the distribution.

II – The gender gap in life expectancy has narrowed in all départements

8There is a close correlation between male and female life expectancy at birth. Those départements where life expectancy is low for men are in general those where it is also low for women. For example, the lowest ranking départements for life expectancy (Pas-de-Calais, Nord and Aisne) and the highest (Paris and Hauts-de-Seine) are the same for both sexes.

9Figure 4 shows the correlation between the gender gap in life expectancy and the mean of male and female life expectancies. It demonstrates that the higher the mortality, the wider the gender gap. This finding is not new (Vallin, 1990; Meslé and Vallin, 1998) and is reflected in the local regression lines for the four clouds of points corresponding to the four periods considered. However, the correlation is not linear, as can be seen by the changing gradients of each regression line. The narrowing of the gender gap in life expectancy associated with each additional year of life expectancy is greater in those départements where life expectancy at birth is highest: in this group, life expectancy varies mainly for men, whereas in the départements with lowest life expectancy, the differences between départements are similar for men and women. This effect was very pronounced in the life tables for 1976-1978 and 1986-1988 but has lessened over time: the gradient change is much less marked for the 1996-1998 cloud of points and almost entirely disappears for the most recent period. Analysis of life expectancy trends for each sex shows that this reflects greater progress for women with respect to men in the départements with low life expectancy at birth than in the others, a finding consistent with the fact that geographical inequalities in mortality have shrunk since the 1970s for women but not for men.

Figure 4

Figure 4

Correlation between the gender gap in life expectancy and the mean of male and female life expectancies at birth, 1976-1978, 1986-1988, 1996-1998 and 2006-2008
Note: The curves are the regression lines obtained by locally weighted scatterplot smoothing (LOWESS), i.e. by considering a window centred successively on each observation year and including a constant proportion of points, in this case, half the total points on the figure.

10In Pas-de-Calais, Nord, Aisne, Somme, Meuse, Moselle and Oise in 2006-2008, the correlation between the gender gap in life expectancy and overall mortality is as strong as elsewhere, but at each level of life expectancy the gender gap is smaller than in other départements with similar life expectancies: whereas male life expectancy is similar in the northern départements and in those of Brittany, female life expectancy is lower in the former than the latter. This finding suggests that the factors behind geographical inequalities of mortality in the north of France affect both sexes equally and that, compared with women in other areas of excess mortality, those in the north have a particular disadvantage in terms of life expectancy at birth.

III – Impact of adult mortality on geographical variations in life expectancy

11To understand the reasons behind geographical variations in mortality, principal component analysis (PCA) [4] can be used to determine the various age patterns of mortality in French départements. The analysis was applied to the standardized mortality rates [5] for major age groups (0, 1-14, 15-29, 30-59, 60-79, 80+) in 2006-2008 in each of the 96 départements of metropolitan France. [6]

12The graphical presentation of the PCA results shows correlations between mortality rates at various ages (Figure 5). The proximity of the points in the factors space reflects a high positive correlation between the corresponding mortality rates. Life expectancy at birth is represented as a supplementary variable and does not contribute to the principal components. Its presence is useful because, as explained below, it shows the impact of various age groups on the variability between départements of life expectancy at birth.

Figure 5

Figure 5

Principal component analysis on mortality rates by sex and age in the French départements. Factor map of active and supplementary variables on axes 1 and 2 and on axes 2 and 3
Note: The percentages in brackets show the proportion of inertia for each axis. The life expectancies are supplementary variables of the analysis and do not contribute to the axes.

13The first three PCA axes express 68% of total inertia. Note that the closeness of the female and male rates by age on the first two PCA axes indicates that age-group impact on geographical variations in mortality is similar for both sexes.

14Axis 1 alone accounts for more than 40% of total territorial variability. All the mortality rates above age 30 contribute to this axis. They are positioned opposite life expectancy at birth, showing the high correlation between the two types of indicator: the higher the mortality above age 30 in a département, the lower life expectancy at birth and vice versa. In practice, mortality before age 30 has become so low in France that it no longer has any noticeable effect on life expectancy. It therefore does not affect territorial variations in overall mortality either. Axis 1 thus represents the intensity of mortality. It shows very clearly the difference between the départements in the Paris region (especially Paris, Hauts-de-Seine and Yvelines), where life expectancy at birth is high (at least 79.5 years for men, 85 years for women) and the northern départements (especially Pas-de-Calais, Nord and Aisne) where it is low (below 75 years for men, 81.2 years for women) (Figure 6).

Figure 6

Figure 6

Principal component analysis on mortality rates by sex and age in the French départements. Factor map of the départements on axes 1 and 2 and on axes 2 and 3
Note: The départements contributing most to each axis are identified by name and by a distinctive symbol (a green square, a green star and a green triangle for those contributing to the first, second and third axes, respectively). The four départements contributing significantly to two of the first three PCA axes are Paris (axes 1 and 2), Pas-de-Calais and Meuse (axes 1 and 3) and Alpes-de-Haute-Provence (axes 2 and 3).

15While mortality rates before age 30 contribute little or nothing to PCA axis 1, they are practically the sole contributors to axes 2 and 3, which, unlike axis 1, correlate only slightly with life expectancy at birth. Taking all the départements together, whatever their overall mortality levels, marked differences can be seen in the structure of young people’s mortality, which is due to low correlations between mortality rates at 0, 1-14 and 15-29 years, by contrast with the high correlations seen for mortality after age 30. PCA axis 2 distinguishes between those départements where child mortality is high and those where adolescent and young adult mortality is particularly high relative to life expectancy at birth (although these mortality levels may not necessarily be higher than for France as a whole). The former group of départements includes Hautes-Alpes, Gers, Lot, Haute-Loire, Alpes-de-Haute-Provence, Yonne, Haute-Corse and Orne, while the latter is well represented by Seine-Saint-Denis, Bas-Rhin and Paris.

16Axis 3 of the factorial plane adds some nuance to the contrast between child mortality on the one hand, and adolescent and young adult mortality on the other, by simply comparing the départements with high under-30 mortality and those with low under-30 mortality (particularly for women), relative to adult mortality. This axis also contrasts, though less markedly, the départements with high and low male 60-79 mortality, since high mortality at this age tends to be associated with low mortality for young people of both sexes and vice versa. The départements that contribute most to axis 3 are Ariège, Aveyron, Lot-et-Garonne, Meuse, Alpes-de-Haute-Provence and Tarn, where young women’s mortality is particularly high relative to that of young men, and Pas-de-Calais, where, conversely, under-30 mortality is particularly low with respect to the high level of overall mortality in that département.

17Table 1 summarizes the PCA findings by distinguishing five age patterns of mortality defined, first, by overall mortality (life expectancy at birth and over-30 mortality) and, second, by level and structure of under-30 mortality.

Table 1

Typical départements for five age patterns of mortality, metropolitan France, 2006-2008

Relative mortality Under age 15 (both sexes) High under age 30 (both sexes) Under age 30 (both sexes) Low High Low or moderate High Ages 15-29 (both sexes) Ages 60-79 (both sexes) High Low High Low Gers Bas-Rhin Alpes-de-Haute- Provence Aisne Meuse Haute-Corse Hauts-de-Seine Ariège Ardennes Haute-Loire Paris Aveyron Nord Hautes-Alpes Seine-Saint-Denis Lot-et-Garonne Moselle Lot Meuse Pas-de-Calais Orne Tarn Somme Yonne

Typical départements for five age patterns of mortality, metropolitan France, 2006-2008

Note: The most typical départements for each pattern were identified from their positions on each of the first three PCA axes.

IV – Territorial variations in mortality by cause of death

18In order to examine the medical causes of death for each of the major age groups identified above, we combined INSEE’s life tables with data on deaths by cause, sex and age supplied by INSERM, [7] and calculated mortality rates by sex, age group, cause of death and département in 2006-2008 (Appendix Table A.4). The codes of the International Classification of Diseases used by INSERM were combined into 26 categories, further collated under five major headings (Appendix Table A.5). These headings are those already used in INED’s annual report on the demographic situation. To facilitate comparison, deaths from ill-defined or unspecified causes were proportionally redistributed for each sex in each age group and département.

19It must be borne in mind that in any analysis of mortality in the French départements by sex, age group and cause of death, the numbers are almost always too small for any observed differences to be statistically significant. This holds especially for the 1-14 age group, since death has become a particularly rare event for children beyond the first few months of life. For this reason, the 1-14 and 15-29 age groups are combined. However, caution should be exercised in interpreting the findings given here and they must be seen as indicative rather than definitive.

20Table 2 shows the contribution of each category of causes of death to variations in mortality between départements for each age group, both sexes combined, and standardized mortality rates for the same age groups and causes (whole of France).

21The contributions of the various broad causes to the variability of mortality between départements do not necessarily correspond to their contributions to overall mortality (Table 2, final column): while cancers are the main cause of death in France, they are only the third cause of variability between départements. Cardiovascular diseases make the largest contribution and account for one-third of the variability between départements for all ages. This is due primarily to their impact at ages 80 and above, where they account for 47% of total variance. They also account for 28% of total variance at ages 60-79 but only 16% at 30-59. In these last two groups, cancers dominate, accounting for one-third of total variance, compared with one-quarter for all ages and only 8% at ages 80 and above. “Other diseases” also have a large impact, explaining 23% to 30% of variability between départements for all ages, except in the first year of life, where their contribution is overwhelming (94% of total variance), due primarily to perinatal diseases and congenital anomalies, and in the 1-29 age group, where it is minimal and deaths from external causes predominate (82% of total variance). Deaths from external causes also explain 17% of total variance at ages 30-59, but their contribution is negligible after age 60, at only 4%. Among the other causes, infectious diseases only become significant above age 60 (11% of variance at ages 60-79 and 14% at age 80 and above). We examine below in greater detail for each age group the contributions of the various causes to the geographical inequalities in mortality between départements, for both sexes under age 30 and for each sex above that age (see also Appendix Table A.4).

Table 2

Variability between départements of mortality rates by broad cause of death and age group, and standardized rates, both sexes, metropolitan France, 2006-2008

Cause of death Age group All ages Standardized rate (per 100,000) 0 1-29 30-59 60-7 80+ Cardiovascular diseases 0.3 1.0 16.3 27.6 46.8 33.3 259 Other diseases 93.6 10.4 29.9 23.2 27.1 26.3 190 Cancers 1.0 3.4 34.0 34.2 7.6 22.2 278 Infectious diseases 3.4 2.8 2.8 11.1 14.0 10.5 75 External causes 1.8 82.4 17.0 3.9 4.5 7.7 65 All causes 100.0 100.0 100.0 100.0 100.0 100.0 866 Standardized rate per 100,000 369 31 284 1?655 9?245 866

Variability between départements of mortality rates by broad cause of death and age group, and standardized rates, both sexes, metropolitan France, 2006-2008

Note: Ill-defined or unspecified causes of death are distributed proportionately by département, sex and age group. For each age group, the proportion of variability in mortality due to broad cause of death i is estimated by the ratio C(x_i) / Var(x) where
Var(x) = variance in all-cause mortality; C(x_i) = Var(x_i) + ?_j?i Covar(x_i,x_j)?;
Covar(x_i, x_j) = Covariance between mortality rate x_i by cause i and rate x_j by cause j.

The overwhelming impact of deaths from external causes among young adults

27The curve of probabilities of dying reaches its minimum around age 10, and deaths have become so rare after the first few months of life that it is impossible to establish a typology of départements according to their pattern of mortality by cause at ages 1-14. Deaths at ages 1-14 and 15-29 were therefore analysed together. Even so, the mortality rate at ages 1-29 for both sexes (strongly influenced by mortality above age 15) only differs significantly from the French average in twelve départements (of which five with much higher rates). These départements rank similarly for both sexes but female mortality rates are much lower. The départements in the Île-de-France region (particularly Paris, Hauts-de-Seine and Val-de-Marne), where the rates are below 30 per 100,000 for males and 16 for females, contrast with Aisne, Orne, Vaucluse and Yonne, where the rates are above 60 and 24 per 100,000, respectively, with Somme slightly below (Table 3).

Table 3

Standardized mortality rate (per 100,000) at ages 1-29 in metropolitan France and ratio between the rates by cause in selected départements and the national average (%), 2006-2008

Département Ratio between the standardized rate in each département and rate for metropolitan France as a whole (%) Standardized rate all causes (per 100,000) Cancers Cardiovascular diseases Infectious diseases Alcoholism / Cirrhosis Mental illness or nervous system disorder Other diseases Transport accidents Suicides Other external causes All causes Males Hauts-de-Seine 107 58 124 28 64 95 34 51 56 60 26.4 Paris 130 95 141 21 70 95 28 43 54 61 26.9 Val-de-Marne 104 76 140 0 71 127 48 32 68 66 29.0 Rhône 149 98 96 37 96 95 57 32 60 72 31.7 Essonne 54 106 50 87 74 83 60 93 74 72 31.9 Val-d’Oise 91 153 166 81 81 108 51 66 71 76 33.6 Yvelines 138 104 49 70 89 97 65 82 69 83 36.4 Somme 135 52 74 182 109 121 147 155 112 130 57.5 Vaucluse 189 79 204 103 115 168 159 106 130 143 63.1 Orne 130 124 160 258 265 153 130 180 86 143 63.2 Yonne 17 195 0 441 168 143 200 152 116 145 63.8 Aisne 115 118 102 321 147 131 152 169 147 146 64.6 France 100 100 100 100 100 100 100 100 100 100 44.1 Rate per cause 5.2 2.0 1.4 0.4 2.8 3.0 13.5 8.0 7.9 44.1 Females Hauts-de-Seine 76 76 100 0 80 82 58 94 73 78 14.2 Paris 49 69 136 0 115 153 39 73 59 79 14.5 Val-de-Marne 116 134 113 0 70 95 34 40 97 83 15.3 Rhône 85 75 194 0 44 92 86 46 115 87 16.0 Essonne 106 147 148 0 60 74 48 84 93 88 16.1 Val-d’Oise 115 78 185 0 125 95 76 54 62 93 17.1 Yvelines 112 120 92 0 125 128 42 57 97 94 17.2 Somme 80 117 122 0 40 223 116 138 86 118 21.6 Vaucluse 72 0 111 0 161 185 258 85 85 131 24.0 Orne 103 0 83 0 115 207 285 62 112 140 25.7 Yonne 193 88 33 0 87 125 215 51 184 142 26.1 Aisne 54 0 143 0 51 233 376 109 87 151 27.7 France 100 100 100 100 100 100 100 100 100 100 18.3 Rate per cause 3.7 1.3 1.1 0.0 1.6 2.8 3.3 2.2 2.3 18.3

Standardized mortality rate (per 100,000) at ages 1-29 in metropolitan France and ratio between the rates by cause in selected départements and the national average (%), 2006-2008

Notes: For each sex, the départements are ranked by their all-cause mortality rate at ages 1-29 and the dotted line separates the low mortality ones (above) from the high mortality ones (below). The reference population for the standardized rates is metropolitan France in 2007, both sexes.
Coverage: The twelve départements where the mortality rate at ages 1-29 differs significantly from that of metropolitan France.

28Deaths from external causes are the main explanation for differences in mortality between départements at these ages, accounting for more than 80% of variability (Table 2), although they represent barely more than 50% of overall mortality at ages 1-29. There is a strong correlation between mortality rates from all causes and from external causes (coefficient 0.93). Within this broad category, it is transport accidents and (for the 15-29 group) suicide that predominate. Focusing the analysis of causes of death on the 12 départements where the all-cause mortality rate for both sexes differs significantly (at the 5% level) from the French average, other diseases, for men only, show a clear divide between low mortality areas and high mortality areas (above and below the dotted line in Table 3). These diseases are mainly alcoholism and cirrhoses, plus mental illness and nervous system disorders. The rates for these diseases are extremely low, even in the most affected départements (Aisne, Yonne and Orne) and their contribution to overall mortality and variability between départements is negligible at these ages. However, they do reveal the problems that underlie excess mortality in these départements. All these causes linked to violent deaths indicate a high prevalence of high-risk behaviour in these population groups, reflecting difficulties of social and economic integration for the young men in these départements.

Cancers responsible for premature mortality at ages 30-60

29Above age 30, mortality increases and the populations at risk are large, so random fluctuations diminish and coherent geographical areas of high and low mortality appear. As for the previous age groups, we focus our analysis on those départements where the all-cause rate differs significantly (at the 5% level) from the national average, but now distinguishing between the sexes. A much higher number of départements deviate significantly from the mean: 47 for men and 29 for women (out of 96 départements in metropolitan France).

30The all-cause mortality rate at ages 30-59 varies by a factor of two between the extremes, from Haute-Savoie (278 per 100,000 for men and 119 for women) to Pas-de-Calais (571 and 236 respectively). The geography of mortality at these ages is similar to that of life expectancy at birth (Figure 7). For both men and women, mortality is high along the Belgian border and in part of Normandy (especially Eure for women). For men in particular, it is also high in Brittany and in an area centred on Cher and Nièvre and stretching into Lorraine. Conversely, mortality is relatively low in Rhône-Alpes and along an axis from Midi-Pyrénées (Gers and Haute-Garonne) almost as far as Rhône-Alpes, with the exception of Lozère which is more disadvantaged. Mortality at these ages is also low in Île-de-France, but less so for women than for men, and in Alsace, for men only. The final area of low mortality, particularly extensive for women, covers Pays de la Loire and part of Poitou-Charentes.

Figure 7

Figure 7

Mortality rate per 100,000 at ages 30-59 by département and sex, 2006-2008

31Most deaths at ages 30-59 are due to cancers, particularly among women, where this cause accounts for 50% of the all-cause rate (versus 38% for men). Just over one-third of the territorial variability in mortality at ages 30-59 is also due to cancers, equal to other diseases for women (versus one-quarter for men). Cardiovascular diseases account for 15% of the variance among men and 17% among women, and deaths from external causes 19% and 10%, respectively.

32Analysis of variability using more detailed causes of death is highly instructive. When the various types of cancer are separated out, the main cause of geographical inequality in mortality at these ages is lung cancer for men (10% of all-cause variance). For women, lung cancer (5% of variance) comes second to breast cancer (8%). Alcohol-related diseases (alcoholism and cirrhosis of the liver) account for most of the contribution of “other diseases” to territorial variations in mortality at ages 30-59 (17% for both men and women). Of all external causes, suicide accounts for the greatest proportion of variability (13% of total variance for men out of 19% for all deaths from external causes, and 6% for women out of 10%). Transport accidents are of negligible importance at these ages (1% of territorial variability for each sex).

33Table 4 shows the standardized rates of mortality by cause at ages 30-59 in the ten départements at either end of the distribution for each sex (among all those where the rate differs significantly from the national average) [10] and the ratio between their rate and that of metropolitan France as a whole. The results confirm the major trends described in the previous paragraph and are highly consistent: rates by cause are almost all below average in the départements with low overall mortality and higher in those with high mortality, especially for men, with the sole exception of transport accidents. However, some causes do appear to be of particular importance in explaining the excess mortality observed in the northern départements. For men, these are cancers, particularly lung cancer, cardiovascular diseases, suicide and, above all, alcohol-related diseases and the residual “other diseases”. For women, lung cancer and deaths from external causes are less systematically correlated with overall mortality, while cardiovascular diseases, mental and nervous system disorders, “other diseases” and, above all, as for men, alcoholism and cirrhosis of the liver establish a clear divide between high- and low-mortality départements. This highlights the impact of individual behaviour on mortality (particularly smoking and alcohol consumption) and the geographical variations in behaviour that were emerging in the previous age group. A study by Alfred Nizard and France Prioux (1975) showed the effect of individual behaviour, especially alcoholism, on geographical variations in mortality in general, and for men in this age group in particular, back in the 1960s.

Table 4

Standardized mortality rate (per 100,000) for the 30-59 age group in metropolitan France and ratio between the rates by cause in selected départements and the national average (%), 2006-2008

Département Ratio between standardized rate in each département and rate for metropolitan France as a whole (%) Standardized rate all causes (per 100,000) Lung cancer Other cancers Cardiovascular diseases Infectious diseases Alcoholism / Cirrhosis Mental illness or nervous system disorder Other diseases Transport accidents Suicides Other external causes All causes Males Haute-Savoie 71 72 66 62 54 66 57 105 75 105 71 278 Yvelines 72 79 76 73 66 73 69 56 67 61 72 283 Isère 73 70 84 49 56 72 65 105 73 92 73 286 Bas-Rhin 74 79 85 71 77 73 96 63 64 46 75 295 Haute-Garonne 88 81 75 72 46 91 87 87 52 92 76 298 Somme 113 113 131 113 133 113 138 113 121 115 120 469 Aisne 121 102 127 111 132 122 146 148 136 108 120 470 Finistère 126 112 103 102 145 136 120 85 156 142 121 475 Nord 128 140 138 135 182 120 145 61 123 127 136 534 Pas-de-Calais 150 147 138 122 211 108 153 96 149 119 146 571 France 100 100 100 100 100 100 100 100 100 100 100 391 Rate per cause 52 109 63 20 35 15 23 12 37 25 391 Females Haute-Savoie 73 66 64 76 58 63 55 92 93 55 67 119 Mayenne 55 64 93 65 90 91 58 100 117 85 74 132 Isère 87 80 77 53 71 70 64 93 68 58 75 133 Ain 79 83 67 61 49 64 90 111 74 80 77 136 Maine-et-Loire 81 82 73 48 52 98 68 91 95 57 77 137 Somme 52 118 138 104 131 114 145 134 125 136 117 207 Aisne 110 103 160 114 188 130 175 161 92 68 120 213 Ardennes 125 117 150 124 109 142 124 104 125 80 122 215 Nord 79 117 134 121 248 131 165 59 113 126 126 223 Pas-de-Calais 73 127 125 118 309 140 160 84 117 130 134 236 France 100 100 100 100 100 100 100 100 100 100 100 177 Rate per cause 17 77 20 8 11 9 12 3 13 8 177

Standardized mortality rate (per 100,000) for the 30-59 age group in metropolitan France and ratio between the rates by cause in selected départements and the national average (%), 2006-2008

Note: The départements are ranked by their all-cause mortality rate at ages 30-59 and the dotted line separates the low mortality ones (above) from the high mortality ones (below). The reference population for the standardized rates is metropolitan France in 2007, both sexes.
Coverage: For each sex separately, ten extreme départements from among those where the all-cause mortality rate of the 30-59 age group differs significantly from that of metropolitan France.

Cancers among men and cardiovascular diseases among women account for variations between départements at ages 60-79

34Even more than at ages 30-59, the territorial variations in mortality at ages 60-79 closely overlap with those of life expectancy at birth, and the correlation between these indicators peaks in this age group. This correlation is particularly high for men. The high mortality observed at ages 60-79 in the five most disadvantaged départements accounts for 40% to 50% of the total difference with respect to the national average in life expectancy at birth for men, and for 22% to 43% for women. The maps look very similar, with clear geographical concentrations (Figure 8). The all-cause rate varies from 1,769 per 100,000 in Tarn to 3,172 in Pas-de-Calais for men, and from 832 in Hautes-Alpes to 1,380 in Nord for women.

Figure 8

Figure 8

Mortality rate per 100,000 at ages 60-79 by département and sex, 2006-2008

35Three clusters of excess mortality can be seen on the maps, similar to those identified for mortality at ages 30-59, but more clearly delimited. The main cluster, affecting both sexes, is a wide band along the northern borders including all the départements in Haute-Normandie, Picardy, Nord-Pas-de-Calais, Champagne-Ardenne, Lorraine and Alsace (except Haut-Rhin for men). It also includes part of Île-de-France (Seine-Saint-Denis and Seine-et-Marne départements), and is joined by a second cluster stretching down to the centre of the country (broken by Aube, close to the national male average). The second cluster is concentrated in the départements bordering on the Centre, Burgundy and Auvergne regions and is slightly larger for men (with Cantal) than for women. For men the map also shows relative excess mortality in the three westernmost départements of Brittany.

36Markedly below-average mortality is seen in four clear areas in the south-east, south-west, centre-west and Île-de-France. The first low-mortality area covers almost all the départements in Rhône-Alpes, plus Jura for women. For women it also includes the départements in Provence-Alpes-Côte d’Azur (except Vaucluse and Bouches-du-Rhône), plus Haute-Corse. For men the area is smaller, and excludes Ardèche, Ain and Jura, but includes Corse-du-Sud. The second low-mortality area for men covers Languedoc-Roussillon and Midi-Pyrénées (except Hautes-Pyrénées and Pyrénées-Orientales), plus Pyrénées-Atlantiques to the west and Lot-et-Garonne to the north. For women, this second area is more broken up and centres on Aquitaine (less Dordogne), excluding Aude and Tarn-et-Garonne. The third low-mortality area centres on the départements of Pays de la Loire. It includes for both sexes Mayenne, Maine-et-Loire, Indre-et-Loire, Vienne and Deux-Sèvres. It also includes Sarthe for men, and the three départements to the west (Ille-et-Vilaine, Loire-Atlantique and Vendée) for women. The final area of low mortality at ages 60-79 comprises the south-east quarter of Île-de-France, namely Hauts-de-Seine, Yvelines and Essonne, and for men, Paris and Val-de-Marne.

37The pattern of causes behind the geographical variations in mortality at ages 60-79 is slightly different for men and women. Cancers continue to account for much of the geographical difference, especially for men, for whom they are still the main cause of variability, accounting for nearly 40% of variance in the all-cause rate, of which one-quarter (10%) from lung cancer alone. Male lung cancer mortality is 20% to 30% above the national average in those départements where all-cause mortality is high, and 10% to 25% below it in those with low overall mortality (Table 5). For women, cancers are now only in third position (27% of total variability at these ages, of which only 1% from lung cancer).

Table 5

Standardized mortality rate (per 100,000) for the 60-79 age group in metropolitan France and ratio between the rates by cause in selected départements and the national average (%), 2006-2008

Département Ratio between standardized rate in each département and rate for metropolitan France as a whole (%) Standardized rate all causes (per 100,000) Lung cancer Other cancers Heart diseases Cerebrovascular diseases Respiratory system diseases Other infectious diseases Alcoholism / Cirrhosis Mental illness or nervous system disorder Other diseases Deaths from external causes All causes Males Tarn 73 72 91 87 59 43 46 106 72 79 76 1,769 Gers 77 76 91 74 69 52 40 73 69 112 78 1,797 Paris 89 88 70 78 75 114 60 72 78 53 80 1,843 Alpes-Maritimes 83 80 77 80 82 92 63 89 85 80 81 1,865 Haute-Garonne 92 78 89 84 73 72 47 74 83 77 81 1,870 Somme 120 107 113 98 130 146 117 122 126 141 116 2,674 Ardennes 134 107 135 141 124 92 107 106 122 104 120 2,767 Aisne 126 112 126 123 143 119 132 121 131 127 122 2,832 Nord 124 126 128 136 173 132 178 117 144 123 132 3,059 Pas-de-Calais 127 128 139 134 216 131 172 122 143 118 137 3,172 France 100 100 100 100 100 100 100 100 100 100 100 2,315 Rate per cause 279 789 399 173 135 41 71 116 190 121 2,315 Females Hautes-Alpes 92 73 87 50 85 119 21 85 77 93 77 832 Haute-Corse 131 78 80 97 55 35 62 85 84 66 81 874 Tarn 78 82 87 102 56 80 33 83 78 77 81 880 Indre-et-Loire 87 90 74 80 73 50 94 77 66 86 81 881 Mayenne 56 94 69 80 40 31 56 95 72 143 83 896 Moselle 119 103 125 136 137 149 121 114 136 93 117 1,265 Somme 83 121 114 108 132 118 133 93 128 128 117 1,266 Aisne 93 114 142 136 123 181 130 122 157 111 126 1,369 Pas-de-Calais 59 111 153 144 144 139 221 119 149 108 126 1,369 Nord 73 112 138 148 151 138 242 122 151 122 127 1,380 France 100 100 100 100 100 100 100 100 100 100 100 1,084 Rate per cause 53 431 167 85 50 23 23 82 115 54 1,084

Standardized mortality rate (per 100,000) for the 60-79 age group in metropolitan France and ratio between the rates by cause in selected départements and the national average (%), 2006-2008

Note: The départements are ranked by their all-cause mortality rate at ages 60-79 and the dotted line separates the low mortality ones (above) from the high mortality ones (below). The reference population for the standardized rates is metropolitan France in 2007, both sexes.
Coverage: for each sex separately, ten extreme départements from among those where the 60-79 age group all-cause mortality rate differs significantly from that of metropolitan France.

38For women, cardiovascular diseases are the largest contributing factor to geographical variations in mortality (32% of total variability, compared with 26% for men), particularly heart disease (8% of variability due to coronary heart disease, the same as for men; 15% to other heart diseases versus 10% for men). For both sexes, there is a sharp contrast between the rates for these causes in départements where mortality is high with respect to the whole of France and in those where it is low. This is especially striking for women, for whom the rates are 30% to 50% higher than the national average in the three most disadvantaged départements, Aisne, Pas-de-Calais and Nord (Table 5).

39Among all other diseases, we note the impact of those related to high alcohol consumption in the two most disadvantaged départements: in Nord and Pas-de-Calais, the mortality rate from alcoholism and cirrhosis of the liver is over twice that of France as a whole for women, and 70% higher than the average for men. Taking all départements and not just those in Table 5, alcoholism also accounts for a non-negligible share of total variability (6% for men, 5% for women). Diseases of the respiratory system also account for much of the excess mortality in the northern départements, which is hardly surprising given that alcoholism and environmental pollution are major risk factors, as well as occupational exposure to certain pathogens. They account for 9% of geographical inequalities in mortality for men and 7% for women, ahead of ischaemic heart disease.

40This is the age group for which deaths from external causes contribute least to geographical variability in mortality (less than 5% for each sex), due to their minor contribution to overall mortality. Mortality rates from external causes do, however, correlate well with all-cause mortality rates, and are almost always higher for men in the high-mortality départements than in France as a whole (up to 40% higher in Somme).

At age 80 and above, all causes contribute to geographical variations in mortality

41The geography of mortality at age 80 and above is similar to that of the previous age group, but the variations between départements are much less marked (Figure 9). In fact, the statistical significance tests for the differences between départements and France as a whole show that for most of them, the variations cannot be distinguished from random fluctuations, especially for men, whose overall mortality rate only differs from the average in 22 départements, compared with 48 for women.

Figure 9

Figure 9

Mortality rate per 100,000 at ages 80 and above by département and sex, 2006-2008

42The high-mortality départements are found in the three clusters already identified for the other age groups: the three westernmost départements in Brittany, the Nord-Pas-de-Calais and Picardy regions with extensions to the east (Ardennes, Marne – men only –, Haute-Marne, all the départements in Lorraine and as far as Haute-Saône and Territoire de Belfort), plus, for women, the two départements in Alsace. A few other départements scattered across the centre of the country also have above-average mortality rates at ages 80 and above, namely, Yonne, Indre, Creuse, Haute-Loire for both sexes, Nièvre, Puy-de-Dôme, Cantal for men, and Lozère for women.

43There is one clear low-mortality area: it comprises Paris, Hauts-de-Seine, Val-de-Marne, Yvelines, Essonne, plus, to a lesser extent, particularly for women, a group in the Pays de la Loire and the west of the Centre region. The preventive measures taken after the 2003 heat wave may have played a role here. As the death toll was particularly high in the Paris area, the measures implemented there may have been more effective than elsewhere and contributed to a faster fall in old-age mortality than in the rest of the country (Toulemon and Barbieri, 2008; Rey et al., 2007).

44The mortality rate at these ages in the départements where it differs significantly from the average, varies from 9,639 per 100,000 in Paris to 14,168 in Pas-de-Calais for men and, in the same départements, from 6,443 to 9,646 for women. So the highest female rate is roughly the same as the lowest male rate.

45After age 80, cardiovascular diseases (mainly heart disease) loom largest for men and women, and account for nearly half of geographical variability. For women, mental illness and nervous system disorders are another major contributor (14%, compared with 8% for men) and, for men, respiratory diseases (19%, compared with 9% for women). Note that senile dementia and Alzheimer’s disease account for a large share of overall female mortality at these ages. Alzheimer’s is the second cause of female mortality at age 80 and above, after cardiac arrest (sixth for men, after certain diseases of the circulatory system, such as myocardial infarction, prostate cancer and lung cancer). Although cancer mortality rates are high at this age, the role of cancer in geographical disparity is now negligible, even for lung cancer (only 2% of total geographical variability for men, 1% for women). The contribution of deaths from external causes is barely higher than at ages 60-79 and accounts for less than 5% of geographical differences at ages 80 and above.

46All the causes of death given in Table 6 contribute to the situation in the most disadvantaged départements, including lung cancer for men and deaths from external causes for both sexes. For suicide, there is a particularly striking contrast between the départements of the Paris region and those in the north, with rates varying for men from 8 per 100,000 in Paris (but 72 in Yvelines) to 158 in Aisne (123 in Nord). Variations in this cause are therefore large, even among the best-placed départements. For women there is no systematic correlation between overall mortality and suicide rates. For the départements in Table 6 and the others, there is a high correlation for both sexes between overall mortality and mortality from cardiovascular diseases, alcohol consumption, infectious diseases (especially those of the respiratory system), mental illness and nervous system disorders.

Table 6

Standardized mortality rate (per 100,000) for ages 80 and above in metropolitan France and ratio between the rates by cause in selected départements and the national average (%), 2006-2008

Département Ratio between standardized rate in each département and rate for metropolitan France as a whole (%) Standardized rate all causes (per 100,000) Lung cancer Other cancers Cardiovascular diseases Respiratory system diseases Other infectious diseases Alcoholism / Cirrhosis Mental illness or nervous system disorder Other diseases Suicides Other external causes All causes Males Paris 103 90 74 84 114 82 81 86 9 93 83 9,639 Hauts-de-Seine 93 89 81 81 81 55 104 85 37 81 85 9,967 Val-de-Marne 120 94 81 90 109 106 89 97 20 101 90 10,498 Yvelines 91 94 87 85 109 56 98 96 78 105 92 10,700 Alpes-Maritimes 99 95 94 96 97 56 97 98 67 89 95 11,042 Haute-Marne 107 105 118 131 162 120 141 119 51 68 117 13,612 Aisne 123 115 115 118 156 179 115 134 171 92 118 13,825 Nord 124 108 116 166 125 115 103 121 133 106 119 13,866 Meuse 153 104 117 124 148 157 143 113 152 135 120 14,004 Pas-de-Calais 124 110 121 173 119 121 109 115 145 104 121 14,168 France 100 100 100 100 100 100 100 100 100 100 100 11,670 Rate per cause 404 2,511 4,219 1,168 247 52 1,086 1,361 93 530 11,670 Females Paris 170 98 73 96 89 99 73 80 31 96 83 6,443 Hauts-de-Seine 138 93 79 96 98 81 94 84 101 88 87 6,786 Val-de-Marne 150 95 84 104 113 92 87 96 41 98 91 7,127 Essonne 95 101 91 104 127 77 106 103 171 80 98 7,643 Haute-Vienne 76 100 101 78 106 57 107 99 141 88 99 7,714 Somme 93 113 116 156 131 69 116 124 78 120 120 9,332 Nord 85 111 120 135 129 186 112 128 108 122 120 9,342 Aisne 98 115 123 119 147 231 128 133 94 102 123 9,562 Moselle 124 112 128 125 138 111 126 122 63 121 124 9,640 Pas-de-Calais 65 113 128 125 127 143 120 132 160 118 124 9,646 France 100 100 100 100 100 100 100 100 100 100 100 7,804 Rate per cause 85 1,309 3,115 592 165 15 1,053 1,064 16 390 7,804

Standardized mortality rate (per 100,000) for ages 80 and above in metropolitan France and ratio between the rates by cause in selected départements and the national average (%), 2006-2008

Note: The départements are ranked by their all-cause mortality rate at ages 80 and above, and the dotted line separates the low mortality ones (above) from the high mortality ones (below). The reference population for the standardized rates is metropolitan France in 2007, both sexes.
Coverage: for each sex separately, ten extreme départements taken from those where the all-cause mortality rate of persons aged 80 and above differs significantly from that of metropolitan France.

Discussion and conclusion

47Large geographical disparities in mortality have persisted in metropolitan France over the last 30 years. Although they have narrowed among women, they have barely changed among men. As in the 1960s, the least advantaged regions are the North, Alsace and Brittany, despite faster than average progress in Brittany (Nizard and Prioux, 1975). Conversely, mortality is lower in Paris, in the south-western départements of Île-de-France, in the départements of the Rhône-Alpes and Midi-Pyrénées regions (especially for men), and, for women, in northern Poitou-Charentes and Pays de la Loire, a region that has enjoyed rapidly increasing life expectancy at birth over the last 30 years.

48Variations in life expectancy at birth between départements are closely linked to variations in mortality after age 30 and particularly at ages 60-79, but not systematically to variations in child mortality. For example, infant mortality is high in départements of Alsace and Lorraine, but close to average in Nord-Pas-de-Calais and low in Brittany. At ages 30-60, differences in cancer mortality account for most of the geographical variability (particularly lung cancer among men). Alcohol-related diseases and suicides contribute extensively to geographical inequalities in mortality in this and following age groups despite accounting for a low proportion of overall mortality. Variations in suicide mortality and alcohol-related disease rates between départements are generally correlated, but with many exceptions. Cancers still contribute to inequalities in mortality at ages 60-80 but, among women, cardiovascular (mainly heart) diseases have the strongest impact. Respiratory diseases have a similar impact for both sexes. At ages 80 and above, cardiovascular (including cerebrovascular) diseases play a major role in geographical variability, accounting for 50% of variation among women and 40% among men. But in the northern départements with low life expectancy at birth, alcohol-related mortality and, for men, suicides still contribute to this variability.

49The research literature identifies the impact of economic and social inequalities in France on geographical disparities in mortality and health (Nizard and Prioux, 1975; Caselli and Egidi, 1986b; Salem et al., 2000). Mortality differences between socioeconomic categories (by occupation and educational level), for example, explain the contrast between the Paris region départements with large proportions of higher categories (professionals/managers and higher intellectual occupations) and the northern départements with their high proportion of unskilled workers (Daguet, 2006). De-industrialization and rising unemployment in the mining areas of Nord-Pas-de-Calais and Picardy certainly favour health-damaging behaviour (especially alcohol and tobacco consumption), as well as suicide, mental illness and nervous system disorders. The excess mortality of manual workers, whose life expectancy increased less in the 1970s and 1980s than that of other social categories, and of the unemployed, is well documented, as is the role of these risk factors among these disadvantaged population groups (Desplanques, 1984). However, the relationship between economic situation and mortality in French départements is a complex one. Although levels of poverty, income inequality and unemployment are indeed high in northern France, they are quite low in Brittany, where life expectancy at birth is almost as low as in the north. In the départements along the Mediterranean, by contrast, where levels of disadvantage are also high, lifespans are close to or even above the national average. Socioeconomic disadvantage in the southern départements may be outweighed by other factors such as healthier eating habits (the well-known “Mediterranean diet”) that have a positive impact on the two main causes of death in France (cancer and cardiovascular disease).

50Selective migration is another potentially important explanatory factor for inequalities in mortality between French départements. This operates where there are differences between migrants and non-migrants in terms of health status or behaviours liable to affect health, as is typically the case with economic migration (or migration to enter higher education among the young): those who leave are generally healthier than those who stay, especially in depressed employment areas, and they seldom return to live in their native départements (Bentham, 1988; Norman et al., 2005; van Lenthe et al., 2007). Conversely, some migration is related to poor health, especially among older people who move closer to their children as their health declines. Specific research, especially on the northern départements and in Brittany, would help capture the relative contributions to observed excess mortality of individual characteristics, local conditions (health services and socioeconomic environment) or population movements between départements.

51The present study is essentially exploratory in nature, since mortality before age 60 in France has now fallen to such a low level that random fluctuations at département level are considerable, particularly when deaths are broken down by cause. Despite our best efforts to present only relatively stable findings, these need to be confirmed by further research and must be interpreted with caution. Continued research on these questions is all the more crucial because, after a period in which inequalities in mortality were seen to narrow somewhat, the trend has reversed since the mid-1990s, particularly for men.