Life expectancies of South African adults starting antiretroviral treatment: collaborative analysis of cohort studies

BACKGROUND Few estimates exist of the life expectancy of HIV-positive adults receiving antiretroviral treatment (ART) in low- and middle-income countries. We aimed to estimate the life expectancy of patients starting ART in South Africa and compare it with that of HIV-negative adults. METHODS AND FINDINGS Data were collected from six South African ART cohorts. Analysis was restricted to 37,740 HIV-positive adults starting ART for the first time. Estimates of mortality were obtained by linking patient records to the national population register. Relative survival models were used to estimate the excess mortality attributable to HIV by age, for different baseline CD4 categories and different durations. Non-HIV mortality was estimated using a South African demographic model. The average life expectancy of men starting ART varied between 27.6 y (95% CI: 25.2-30.2) at age 20 y and 10.1 y (95% CI: 9.3-10.8) at age 60 y, while estimates for women at the same ages were substantially higher, at 36.8 y (95% CI: 34.0-39.7) and 14.4 y (95% CI: 13.3-15.3), respectively. The life expectancy of a 20-y-old woman was 43.1 y (95% CI: 40.1-46.0) if her baseline CD4 count was ≥ 200 cells/µl, compared to 29.5 y (95% CI: 26.2-33.0) if her baseline CD4 count was <50 cells/µl. Life expectancies of patients with baseline CD4 counts ≥ 200 cells/µl were between 70% and 86% of those in HIV-negative adults of the same age and sex, and life expectancies were increased by 15%-20% in patients who had survived 2 y after starting ART. However, the analysis was limited by a lack of mortality data at longer durations. CONCLUSIONS South African HIV-positive adults can have a near-normal life expectancy, provided that they start ART before their CD4 count drops below 200 cells/µl. These findings demonstrate that the near-normal life expectancies of HIV-positive individuals receiving ART in high-income countries can apply to low- and middle-income countries as well. Please see later in the article for the Editors' Summary.

Level of incongruence during cardiac rehabilitation and prediction of future CVD-related hospitalizations plus all-cause mortality

Independent of traditional risk factors, psychosocial risk factors increase the risk of cardiovascular disease (CVD). Studies in the field of psychotherapy have shown that the construct of incongruence (meaning a discrepancy between desired and achieved goals) affects the outcome of therapy. We prospectively measured the impact of incongruence in patients after undergoing a cardiac rehabilitation program. We examined 198 CVD patients enrolled in a 8–12 week comprehensive cardiac rehabilitation program. Patients completed the German short version of the Incongruence Questionnaire and the SF-36 Health Questionnaire to measure quality of life (QoL) at discharge of rehabilitation. Endpoints at follow-up were CVD-related hospitalizations plus all-cause mortality. During a mean follow-up period of 54.3 months, 29 patients experienced a CVD-related hospitalization and 3 patients died. Incongruence at discharge of rehabilitation was independent of traditional risk factors a significant predictor for CVD-related hospitalizations plus all-cause mortality (HR 2.03, 95% CI 1.29–3.20, p = .002). We also found a significant interaction of incongruence with mental QoL (HR .96, 95% CI .92–.99, p = .027), i.e. incongruence predicted poor prognosis if QoL was low (p = .017), but not if QoL was high (p = .74). Incongruence at discharge predicted future CVD-related hospitalizations plus all-cause mortality and mental QoL moderated this relationship. Therefore, incongruence should be considered for effective treatment planning and outcome measurement.

Chronic lymphocytic leukemia: A study of the changing patterns of the natural history, clinical factors associated with prognosis, and risk of second cancers

A retrospective cohort study was conducted among 1542 patients diagnosed with CLL between 1970 and 2001 at the M. D. Anderson Cancer Center (MDACC). Changes in clinical characteristics and the impact of CLL on life expectancy were assessed across three decades (1970–2001) and the role of clinical factors on prognosis of CLL were evaluated among patients diagnosed between 1985 and 2001 using Kaplan-Meier and Cox proportional hazards method. Among 1485 CLL patients diagnosed from 1970 to 2001, patients in the recent cohort (1985–2001) were diagnosed at a younger age and an earlier stage compared to the earliest cohort (1970–1984). There was a 44% reduction in mortality among patients diagnosed in 1985–1995 compared to those diagnosed in 1970–1984 after adjusting for age, sex and Rai stage among patients who ever received treatment. There was an overall 11 years (5 years for stage 0) loss of life expectancy among 1485 patients compared with the expected life expectancy based on the age-, sex- and race-matched US general population, with a 43% decrease in the 10-year survival rate. Abnormal cytogenetics was associated with shorter progression-free (PF) survival after adjusting for age, sex, Rai stage and beta-2 microglobulin (beta-2M); whereas, older age, abnormal cytogenetics and a higher beta-2M level were adverse predictors for overall survival. No increased risk of second cancer overall was observed, however, patients who received treatment for CLL had an elevated risk of developing AML and HD. Two out of three patients who developed AML were treated with alkylating agents. In conclusion, CLL patients had improved survival over time. The identification of clinical predictors of PF/overall survival has important clinical significance. Close surveillance of the development of second cancer is critical to improve the quality of life of long-term survivors. ^

A study of the relationship of support systems and adolescent pregnancy outcomes in an adolescent family life project

This study analyzed the relationship of family support systems and adolescent pregnancy outcomes. The population for the study was 390 adolescents who had attended the Marion County Health Department Adolescent Family Life Project in Indianapolis, Indiana during a two-year period.^ The study is unique in that it afforded the opportunity to compare adolescent pregnancy-related characteristics, of white and non-white adolescents in the same study.^ The pregnancy outcomes studied were: Infant birthweight, school attendance, and pregnancy recidivism.^ Significant results were found in the analysis that supported other research in regard to factors that are associated with school attendance when family support, adolescent's age, and ethnicity were controlled. Infant birthweight and repeat pregnancy outcome relationships were not found to have any consistently significant relationship with independent variables anticipated to be associated. However, the comparisons of infant birthweight among the adolescents with, and without, family support, by ethnicity resulted in some interesting findings. Repeat pregnancy proved an enigma, in that there seemed to be almost no variables in this study that were associated with the adolescent having a repeat pregnancy.^ Familial support in this study seemed to be of less importance as a factor in adolescent pregnancy outcomes than was ethnicity. The non-white adolescents in this study had a better record for remaining in school, both those non-white adolescents who lived with parents, and those who did not live with parents. More low birthweight occurred in the non-white adolescent, both those adolescents who lived with parents, and those who did not live with parents. Repeat pregnancy occurred more in the non-white adolescent whether she lived with parents, or did not live with parents. ^

Sudden Infant Death disparities: A systematic review on health education and policy recommendations for decreasing Sudden Infant Death in the African-American community

Objective: To perform a systematic review of the literature on SIDS and SUID deaths concentrated in the African-American community, describe health education and policy recommendations and recommend a new approach that may aid in decreasing the disparity of infant mortality in the African-American community. ^ Methods: The PubMed database was systematically searched to identify relevant articles for final review and analysis. Using the CASP 2006 system to critique literature, twelve articles were found that met inclusion and exclusion criteria. ^ Results: Evidence in the literature confirmed there was a current disparity among African Americans' infant mortality rates in comparison to other US ethnic groups. The underlying reasons for these disparities included the following maternal and infant characteristics: mothers younger than eighteen, having more than one live infant, having a high school education or less, never been married, and have infants born preterm or with low birth weight. Maternal smoking, substance abuse, and breastfeeding did not have a significant impact on infant sleep environments among African Americans. ^ Conclusion: Tailored health education programs at the community level, better access to pre-pregnancy and prenatal care, and increased maternal perception of risk that is relevant to the infants sleeping environment are all possible solutions that may decrease African American infant mortality rates.^

Development and implementation of an air quality integrated assessment modelling system for the Iberian Peninsula

La mejora de la calidad del aire es una tarea eminentemente interdisciplinaria. Dada la gran variedad de ciencias y partes involucradas, dicha mejora requiere de herramientas de evaluación simples y completamente integradas. La modelización para la evaluación integrada (integrated assessment modeling) ha demostrado ser una solución adecuada para la descripción de los sistemas de contaminación atmosférica puesto que considera cada una de las etapas involucradas: emisiones, química y dispersión atmosférica, impactos ambientales asociados y potencial de disminución. Varios modelos de evaluación integrada ya están disponibles a escala continental, cubriendo cada una de las etapas antesmencionadas, siendo el modelo GAINS (Greenhouse Gas and Air Pollution Interactions and Synergies) el más reconocido y usado en el contexto europeo de toma de decisiones medioambientales. Sin embargo, el manejo de la calidad del aire a escala nacional/regional dentro del marco de la evaluación integrada es deseable. Esto sin embargo, no se lleva a cabo de manera satisfactoria con modelos a escala europea debido a la falta de resolución espacial o de detalle en los datos auxiliares, principalmente los inventarios de emisión y los patrones meteorológicos, entre otros. El objetivo de esta tesis es presentar los desarrollos en el diseño y aplicación de un modelo de evaluación integrada especialmente concebido para España y Portugal. El modelo AERIS (Atmospheric Evaluation and Research Integrated system for Spain) es capaz de cuantificar perfiles de concentración para varios contaminantes (NO2, SO2, PM10, PM2,5, NH3 y O3), el depósito atmosférico de especies de azufre y nitrógeno así como sus impactos en cultivos, vegetación, ecosistemas y salud como respuesta a cambios porcentuales en las emisiones de sectores relevantes. La versión actual de AERIS considera 20 sectores de emisión, ya sea equivalentes a sectores individuales SNAP o macrosectores, cuya contribución a los niveles de calidad del aire, depósito e impactos han sido modelados a través de matrices fuentereceptor (SRMs). Estas matrices son constantes de proporcionalidad que relacionan cambios en emisiones con diferentes indicadores de calidad del aire y han sido obtenidas a través de parametrizaciones estadísticas de un modelo de calidad del aire (AQM). Para el caso concreto de AERIS, su modelo de calidad del aire “de origen” consistió en el modelo WRF para la meteorología y en el modelo CMAQ para los procesos químico-atmosféricos. La cuantificación del depósito atmosférico, de los impactos en ecosistemas, cultivos, vegetación y salud humana se ha realizado siguiendo las metodologías estándar establecidas bajo los marcos internacionales de negociación, tales como CLRTAP. La estructura de programación está basada en MATLAB®, permitiendo gran compatibilidad con software típico de escritorio comoMicrosoft Excel® o ArcGIS®. En relación con los niveles de calidad del aire, AERIS es capaz de proveer datos de media anual y media mensual, así como el 19o valor horario más alto paraNO2, el 25o valor horario y el 4o valor diario más altos para SO2, el 36o valor diario más alto para PM10, el 26o valor octohorario más alto, SOMO35 y AOT40 para O3. En relación al depósito atmosférico, el depósito acumulado anual por unidad de area de especies de nitrógeno oxidado y reducido al igual que de azufre pueden ser determinados. Cuando los valores anteriormente mencionados se relacionan con características del dominio modelado tales como uso de suelo, cubiertas vegetales y forestales, censos poblacionales o estudios epidemiológicos, un gran número de impactos puede ser calculado. Centrándose en los impactos a ecosistemas y suelos, AERIS es capaz de estimar las superaciones de cargas críticas y las superaciones medias acumuladas para especies de nitrógeno y azufre. Los daños a bosques se calculan como una superación de los niveles críticos de NO2 y SO2 establecidos. Además, AERIS es capaz de cuantificar daños causados por O3 y SO2 en vid, maíz, patata, arroz, girasol, tabaco, tomate, sandía y trigo. Los impactos en salud humana han sido modelados como consecuencia de la exposición a PM2,5 y O3 y cuantificados como pérdidas en la esperanza de vida estadística e indicadores de mortalidad prematura. La exactitud del modelo de evaluación integrada ha sido contrastada estadísticamente con los resultados obtenidos por el modelo de calidad del aire convencional, exhibiendo en la mayoría de los casos un buen nivel de correspondencia. Debido a que la cuantificación de los impactos no es llevada a cabo directamente por el modelo de calidad del aire, un análisis de credibilidad ha sido realizado mediante la comparación de los resultados de AERIS con los de GAINS para un escenario de emisiones determinado. El análisis reveló un buen nivel de correspondencia en las medias y en las distribuciones probabilísticas de los conjuntos de datos. Las pruebas de verificación que fueron aplicadas a AERIS sugieren que los resultados son suficientemente consistentes para ser considerados como razonables y realistas. En conclusión, la principal motivación para la creación del modelo fue el producir una herramienta confiable y a la vez simple para el soporte de las partes involucradas en la toma de decisiones, de cara a analizar diferentes escenarios “y si” con un bajo coste computacional. La interacción con políticos y otros actores dictó encontrar un compromiso entre la complejidad del modeladomedioambiental con el carácter conciso de las políticas, siendo esto algo que AERIS refleja en sus estructuras conceptual y computacional. Finalmente, cabe decir que AERIS ha sido creado para su uso exclusivo dentro de un marco de evaluación y de ninguna manera debe ser considerado como un sustituto de los modelos de calidad del aire ordinarios. ABSTRACT Improving air quality is an eminently inter-disciplinary task. The wide variety of sciences and stakeholders that are involved call for having simple yet fully-integrated and reliable evaluation tools available. Integrated AssessmentModeling has proved to be a suitable solution for the description of air pollution systems due to the fact that it considers each of the involved stages: emissions, atmospheric chemistry, dispersion, environmental impacts and abatement potentials. Some integrated assessment models are available at European scale that cover each of the before mentioned stages, being the Greenhouse Gas and Air Pollution Interactions and Synergies (GAINS) model the most recognized and widely-used within a European policy-making context. However, addressing air quality at the national/regional scale under an integrated assessment framework is desirable. To do so, European-scale models do not provide enough spatial resolution or detail in their ancillary data sources, mainly emission inventories and local meteorology patterns as well as associated results. The objective of this dissertation is to present the developments in the design and application of an Integrated Assessment Model especially conceived for Spain and Portugal. The Atmospheric Evaluation and Research Integrated system for Spain (AERIS) is able to quantify concentration profiles for several pollutants (NO2, SO2, PM10, PM2.5, NH3 and O3), the atmospheric deposition of sulfur and nitrogen species and their related impacts on crops, vegetation, ecosystems and health as a response to percentual changes in the emissions of relevant sectors. The current version of AERIS considers 20 emission sectors, either corresponding to individual SNAP sectors or macrosectors, whose contribution to air quality levels, deposition and impacts have been modeled through the use of source-receptor matrices (SRMs). Thesematrices are proportionality constants that relate emission changes with different air quality indicators and have been derived through statistical parameterizations of an air qualitymodeling system (AQM). For the concrete case of AERIS, its parent AQM relied on the WRF model for meteorology and on the CMAQ model for atmospheric chemical processes. The quantification of atmospheric deposition, impacts on ecosystems, crops, vegetation and human health has been carried out following the standard methodologies established under international negotiation frameworks such as CLRTAP. The programming structure isMATLAB ® -based, allowing great compatibility with typical software such as Microsoft Excel ® or ArcGIS ® Regarding air quality levels, AERIS is able to provide mean annual andmean monthly concentration values, as well as the indicators established in Directive 2008/50/EC, namely the 19th highest hourly value for NO2, the 25th highest daily value and the 4th highest hourly value for SO2, the 36th highest daily value of PM10, the 26th highest maximum 8-hour daily value, SOMO35 and AOT40 for O3. Regarding atmospheric deposition, the annual accumulated deposition per unit of area of species of oxidized and reduced nitrogen as well as sulfur can be estimated. When relating the before mentioned values with specific characteristics of the modeling domain such as land use, forest and crops covers, population counts and epidemiological studies, a wide array of impacts can be calculated. When focusing on impacts on ecosystems and soils, AERIS is able to estimate critical load exceedances and accumulated average exceedances for nitrogen and sulfur species. Damage on forests is estimated as an exceedance of established critical levels of NO2 and SO2. Additionally, AERIS is able to quantify damage caused by O3 and SO2 on grapes, maize, potato, rice, sunflower, tobacco, tomato, watermelon and wheat. Impacts on human health aremodeled as a consequence of exposure to PM2.5 and O3 and quantified as losses in statistical life expectancy and premature mortality indicators. The accuracy of the IAM has been tested by statistically contrasting the obtained results with those yielded by the conventional AQM, exhibiting in most cases a good agreement level. Due to the fact that impacts cannot be directly produced by the AQM, a credibility analysis was carried out for the outputs of AERIS for a given emission scenario by comparing them through probability tests against the performance of GAINS for the same scenario. This analysis revealed a good correspondence in the mean behavior and the probabilistic distributions of the datasets. The verification tests that were applied to AERIS suggest that results are consistent enough to be credited as reasonable and realistic. In conclusion, the main reason thatmotivated the creation of this model was to produce a reliable yet simple screening tool that would provide decision and policy making support for different “what-if” scenarios at a low computing cost. The interaction with politicians and other stakeholders dictated that reconciling the complexity of modeling with the conciseness of policies should be reflected by AERIS in both, its conceptual and computational structures. It should be noted however, that AERIS has been created under a policy-driven framework and by no means should be considered as a substitute of the ordinary AQM.

Relationships of dehydroepiandrosterone sulfate in the elderly with functional, psychological, and mental status, and short-term mortality: A French community-based study

In human beings of both sexes, dehydroepiandrosterone sulfate (DHEAS) circulating in blood is mostly an adrenally secreted steroid whose serum concentration (in the micromolar range and 30–50% higher in men than in women) decreases with age, toward ≈20–10% of its value in young adults during the 8th and 9th decades. The mechanism of action of DHEA and DHEAS is poorly known and may include partial transformation into sex steroids, increase of bioavailable insulin-like growth factor I, and effects on neurotransmitter receptors. Whether there is a cause-to-effect relationship between the decreasing levels of DHEAS with age and physiological and pathological manifestations of aging is still undecided, but this is of obvious theoretical and practical interest in view of the easy restoration by DHEA administration. Here we report on 622 subjects over 65 years of age, studied for the 4 years since DHEAS baseline values had been obtained, in the frame of the PAQUID program, analyzing the functional, psychological, and mental status of a community-based population in the south-west of France. We confirm the continuing decrease of DHEAS serum concentration with age, more in men than in women, even if men retain higher levels. Significantly lower values of baseline DHEAS were recorded in women in cases of functional limitation (Instrumental Activities of Daily Living), confinement, dyspnea, depressive symptomatology, poor subjective perception of health and life satisfaction, and usage of various medications. In men, there was a trend for the same correlations, even though not statistically significant in most categories. No differences in DHEAS levels were found in cases of incident dementia in the following 4 years. In men (but not in women), lower DHEAS was significantly associated with increased short-term mortality at 2 and 4 years after baseline measurement. These results, statistically established by taking into account corrections for age, sex, and health indicators, suggest the need for further careful trials of the administration of replacement doses of DHEA in aging humans. Indeed, the first noted results of such “treatment” are consistent with correlations observed here between functional and psychological status and endogenous steroid serum concentrations.

Correlated effects of sperm competition and postmating female mortality

Adaptations in one sex may impair fitness in the opposite sex. Experiments with Drosophila melanogaster have shown that seminal fluid from the male accessory gland triggers a series of postmating responses in the female, including increased egg laying rate and lower remating propensity, but that accessory gland proteins also increase female death rate. Here, we tested the relationships among the longevity of females mated to males from 51 chromosome-extracted D. melanogaster lines, male-mating ability, and sperm-competitive ability. We found significant differences in longevity of females mated to males of different genotypes, and all mated females showed a higher death rate than control virgin females shortly after mating. Both the age-independent mortality parameter (the intercept of the female's survival function) and the slope of the mortality rate curve were significantly correlated with the proportion of progeny sired by the first male to mate relative to tester males (sperm-defense ability, P1). No significant correlation was found between the proportion of progeny sired by the second-mating male relative to tester males (sperm-offense ability, P2) and any mortality parameter. Our results support the hypothesis of a tradeoff between defensive sperm-competitive ability of males and life-history parameters of mated females.

Lifespan depends on month of birth

Month of birth influences adult life expectancy at ages 50+. Why? In two countries of the Northern Hemisphere–Austria and Denmark–people born in autumn (October–December) live longer than those born in spring (April–June). Data for Australia show that, in the Southern Hemisphere, the pattern is shifted by half a year. The lifespan pattern of British immigrants to Australia is similar to that of Austrians and Danes and significantly different from that of Australians. These findings are based on population data with more than a million observations and little or no selectivity. The differences in lifespan are independent of the seasonal distribution of deaths and the social differences in the seasonal distribution of births. In the Northern Hemisphere, the excess mortality in the first year of life of infants born in spring does not support the explanation of selective infant survival. Instead, remaining life expectancy at age 50 appears to depend on factors that arise in utero or early in infancy and that increase susceptibility to diseases later in life. This result is consistent with the finding that, at the turn of the last century, infants born in autumn had higher birth weights than those born in other seasons. Furthermore, differences in adult lifespan by month of birth decrease over time and are significantly smaller in more recent cohorts, which benefited from substantial improvements in maternal and infant health.

Thermotolerance and extended life-span conferred by single-gene mutations and induced by thermal stress.

We have discovered that three longevity mutants of the nematode Caenorhabditis elegans also exhibit increased intrinsic thermotolerance (Itt) as young adults. Mutation of the age-1 gene causes not only 65% longer life expectancy but also Itt. The Itt phenotype cosegregates with age-1. Long-lived spe-26 and daf-2 mutants also exhibit Itt. We investigated the relationship between increased thermotolerance and increased life-span by developing conditions for environmental induction of thermotolerance. Such pretreatments at sublethal temperatures induce significant increases in thermotolerance and small but statistically highly significant increases in life expectancy, consistent with a causal connection between these two traits. Thus, when an animal's resistance to stress is increased, by either genetic or environmental manipulation, we also observe an increase in life expectancy. These results suggest that ability to respond to stress limits the life expectancy of C. elegans and might do so in other metazoa as well.

Extending the human life span : social policy and social ethics /

"NSF/RA 770123."

Estimates of global and regional potential health gains from reducing multiple major risk factors

Background Estimates of the disease burden due to multiple risk factors can show the potential gain from combined preventive measures. But few such investigations have been attempted, and none on a global scale. Our aim was to estimate the potential health benefits from removal of multiple major risk factors. Methods We assessed the burden of disease and injury attributable to the joint effects of 20 selected leading risk factors in 14 epidemiological subregions of the world. We estimated population attributable fractions, defined as the proportional reduction in disease or mortality that would occur if exposure to a risk factor were reduced to an alternative level, from data for risk factor prevalence and hazard size. For every disease, we estimated joint population attributable fractions, for multiple risk factors, by age and sex, from the direct contributions of individual risk factors. To obtain the direct hazards, we reviewed publications and re-analysed cohort data to account for that part of hazard that is mediated through other risks. Results Globally, an estimated 47% of premature deaths and 39% of total disease burden in 2000 resulted from the joint effects of the risk factors considered. These risks caused a substantial proportion of important diseases, including diarrhoea (92%-94%), lower respiratory infections (55-62%), lung cancer (72%), chronic obstructive pulmonary disease (60%), ischaemic heart disease (83-89%), and stroke (70-76%). Removal of these risks would have increased global healthy life expectancy by 9.3 years (17%) ranging from 4.4 years (6%) in the developed countries of the western Pacific to 16.1 years (43%) in parts of sub-Saharan Africa. Interpretation Removal of major risk factors would not only increase healthy life expectancy in every region, but also reduce some of the differences between regions, The potential for disease prevention and health gain from tackling major known risks simultaneously would be substantial.

Depression and cardiovascular morbidity and mortality: cause or consequence?

Background Depression after myocardial infarction has been associated with increased cardiovascular mortality. This study assessed whether depressive symptoms were associated with adverse outcomes in people with a history of an acute coronary syndrome, and evaluated possible explanations for such an association. Methods and results Depressive symptoms were assessed using the General Health Questionnaire at least 5 months after hospital admission for acute myocardial infarction or unstable angina in 1130 participants of the Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study, a multicentre, placebo-controlled, clinical trial of cholesterol-lowering treatment. Cardiovascular symptoms, self-rated general health, cardiovascular risk factors, employment status, social support and life events were also assessed at the baseline visit. Cardiovascular death (n=114), non-fatal myocardial infarction (n=108), non-fatal stroke (n=53) and unstable angina (n=274) were documented during a median follow-up period of 8.1 years. Individuals with depressive symptoms (General. Health Questionnaire score greater than or equal to5; 22% of participants) were more likely to report angina, dyspnoea, claudication, poorer general health, not being in paid employment, few social contacts and/or adverse life events (P

Health investment, saving, and public policy

This paper develops an overlapping-generations model in which agents invest in health to prolong life in both working and retirement periods. It explores how unfunded social security with or without health subsidies affects life expectancy, economic growth, and welfare. In particular, by extending life at a possible cost of capital accumulation, health subsidies and a pay-as-you-go pension can improve welfare, especially in the short run.