Third, we think, non-health related factors (attitudes, culture, values) that constitute a population should receive more attention when discussing life expectancy. While the structures, performance and efficiency of Western European health care systems changed considerably in recent decades, Germany’s low ranking in life expectancy has been stable for about 30 years. This suggests that there are factors acting in the background, a nation´s ‘DNA’ or core, which remain quite stable over decades and influence life expectancy.

In the more recent literature, gross domestic product per capita, education, pension levels, but also a country’s culture have been associated with life expectancy. The grade of individuality in a society, its long or short-term orientation, gender, and socio-economic equality were described as possibly influential factors for life expectancy [7]. Very recently, using individual cohort data in the USA, after 25 years follow-up, a higher social network score was strongly associated with higher life expectancy – independent of age or frailty [8].

It is conceivable that the core, the “character” of a nation influences the response to disease and that this core builds the base for a population’s life expectancy, which then can be further increased by public health measures. Possibly, close family ties and regular contacts with friends and neighbours affect life expectancy more than high-tech health care offers.

This might explain roughly why a country’s rank in life expectancy was quite stable over time – and why life expectancy is increasing rather simultaneously in Western Europe – as health care progresses universally.