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I I I I I I CLOSING THE GAP r HEALTH POLICY PROJECT INTERIM SUMMARY The Carter Center of Emory University Health Policy Consultation November 26-28, 1984

CLOSING THE GAP NATIONAL HEALTH POLICY CONSULTATION ATLANTA, NOVEMBER 26-28, 1984 Chairpersons President Jimmy Carter Edward N. Brandt, Jr., M.D. Assistant Secretary for Health THE CARTER CENTER OF EMORY UNTVERSITY Executive Director Kenneth W. Stein, Ph.D. Health Policy Task Force Paul B. Hoffman Executive Director Emory University Hospital Richard M. Levinson, Ph.D. Associate Professor Dept. of Community Health Emory University School of Medicine James W. Phillips Director Office of Research & Extramural Support Emory University School of Medicine Douglas C. Rundle, D.D.S. Assistant Dean for Advanced Education Emory University School of Dentistry , I Thomas F. Sellers, M.D. Chairman, Dept. of Community Health Emory University School of Medicine le W. Douglas Skelton, M.D. Professor and Vice Chairman Dept. of Psychiatry Emory University School of Medicine William H. Foege, M.D. Assistant Surgeon General Special Assistant for Policy Developmen Centers for Disease Control Robert W. Amler, M.D. Medical Epidemiologist Office of the Director Centers for Disease Control

4 4 4 4 4 4 I I 4 N . I U I I I I PREFACE A national consultation on health policy was held at the Carter Center of Emory University, Atlanta, Georgia, November 26-28, 1984. National leaders from private, public, voluntary, and academic institutions met with specialists from many health fields to recommend and prioritize interventions directed at unnecessary morbidity and mortality in the United States. The consultation was the second in a three-part, five-year health project of research, planning and implementation known as "Closing the Gap," and was co-chaired by former President Jimmy Carter and Edward N. Brandt, M.D., Assistant Secretary for Health, U.S. Department of Health and Human Services. Rather than seek technologic breakthroughs, the project seeks to focus national health policy on the "gap" represented by health problems that are unnecessary in light of knowledge that already is at hand. Consultants from various medical specialties conducted extensive investigations of the burden imposed by cancer, heart disease, diabetes, and 11 other priority health problems. They quantified preventable morbidity and premature-~nortality associated with specific risk factors or available interventions. A cross-sectional study determined generic risk factors and generic problems with the greatest disease burden and the study findings were reviewed by a small team of health professionals. This procedure identified "highest priority" risk factors which were discussed in multi-disciplinary working groups that considered intervention strategies and recommended objectives for the nation. This interim document contains abstracted summaries of the consultants' investigations, the cross-sectional study, and intervention strategies recommended by the working groups. It has been drafted and made available for limited administrative use, but should not be quoted or distributed more widely without permission of the author(s) and the Carter Center. Presentation of findings and recommendations in this interim document does not indicate endorsement by the authors, the consultants, their respective organizations, or the Carter Center of Emory University. A more detailed report of the national health policy consultation and proceedings will be published soon. ' Information about forthcoming activities of the Carter Center is available from Pamela Willoughby, Emory University News Service, (404)-329-6216. I

I I I I I I I I I I I TABLE OF CONTENTS A. Background of the Health Policy Project Goals High Priority Preventable Health Problems B. Summaries of Presented Papers* Unintentional Injuries, Smith et al Diabetes Mellitus, Herman et al Depression, Stoudemire et al Alcoholism, Stoudemire et al Cancer, Rothenberg et al Homicide, Suicide and Domestic Violence, Rosenberg et al Substance Abuse, Goldstein and Hunt Infectious and Parasitic Diseases, Bennett et al ? Dental Diseases, Fritz and Rundle Respiratory Diseases, Farrer and Schieffelbein Arthritis and Low Back Pain, McDuffie et al Infant Mortality and Unintended Pregnancy, Brann et al Cardiovascular Diseases, Tolsma et al Gastrointestinal Illness, Johannes Al A2 B1 B16 B25 B29 B33 B41 B49 B54 B61 B67 B74 B80 B89 B104 C. Analysis and Discussion* Summary of Leading Risk Factors, Amler et al C1 ' Selection of Risk Factors, Working Group (Foege, Chmn) C11 Socioeconomic Level, Kaplan et al C18 D. Draft Recommendations of the Working Groups Health Problems & Associated Risk Factors D1 Generic Risk Factors & Generic Problems D2 Tobacco, Steinfeld D3 Unintentional Injuries, Baker - D14 Prevention Services, Breslow D27 Alcohol, Robbins D36 Depression, Violence and Substance Abuse, Bryant D45 Unintended Pregnancy, Klein and Smith D55 *NOTE: Provisional data. These summaries are pre-publication drafts and should not be quoted, distributed or reproduced without permission of the authors and the Carter Center of Emory University. I

I I I I I I I I I I I I I I I I SECTION A. BACKGROUND OF THE HEALTH POLICY PROJECT,~ I

I I I I I I I I I I I I Background of the Health Policy Project "Closing the Gap" Goals. When the Carter Center of Emory University was formed, President Carter's goal was to address major issues of global concern, such as domestic and international health policy. Traditionally, health policy studies have focused on a specific health problem or a range of related problems, and interventions have been suggested that specifically address those problems. The Carter Center, however, has chosen a unique approach to addressing health policy by developing a pro~ect that compares a wide variety of health problems using the same standards of comparison for all the problems. The project is also innovative in that it seeks to identify intervention strategies that address generic reasons, or risk factors, for unrelated health problems. The project has been designed so that it can be modified and used by any nation that wishes to undertake a similar endeavor. Though intended for subsequent extension to international health problems, the project will initially focus on the health of developed countries. A task force was established to identify domestic health needs. The task force chose to focus initially on the "GAP" between the current impact of selected high priority health problems, and what that impact could be reduced to, given full application of existing scientific and technical knowledge. - Al - I {

High Priority Preventable Health Problems Addressed by the "Closing the Gap" Health Policy Consultation 1. Unintentional Injuries 2. Diabetes Mellitus 3. Depression 4. Alcoholism 5. Cancer 6. Homicide, Suicide, and Domestic Violence 7. Substance Abuse 8. Infectious and Parasitic Diseases 9. Dental Diseases 10. Respiratory Diseases 11. Arthritis and Low Back Pain 12. Infant Mortality and Morbidity 13. Cardiovascular Diseases 14. Digestive Diseases

I I I I I I I I r I I I I I I I SECTION B. SUMARIES OF PRESENTED PAPERS * *NOTE: Provisional data. These summaries are pre-publication drafts and should not be quoted, distributed or reproduced without permission of the authors and the Carter Center of Emory University.

I I I I I I I I I I I I I I I I I Paper: Unintentional Injuries: Intervention Strategies and Their Potential for Reducing Human Losses Authros: Gordon S. Smith, M.B., M.P.H. Medical Epidemioloigist Special Studies Branch Center for Environmental Health, CDC Henry Falk, M.D., M.P.H. Chief, Special Studies Branch Center for Environmental Health, CDC Project Officer: Dan Horth Master of Public Health Program Emory University School of Medicine Reviewers: Susan Baker., M.P.H. Professor, Department of Health Policy and Management Johns Hopkins School of Public Health Lawrence Berger, M.D., M.P.H. Professor, Department of Pediatrics University of New Mexico Theodore Doege, M.D. Director, Environmental and Occupational Health Program American Medical Association Joseph Greensher Chairman, Committee on Accident and Poison Prevention American Academy of Pediatrics William Haddon, M.D. President, Insurance Institute for Highway Safety Jess Kraus, Ph.D. Professor, Epidemiology University of California, Los Angeles Kathleen Kriess, M.D. Chief, Occupational/Environmental Medicine Program National Jewish Hospital, Denver Albert Rauber, M.D. Director, Georgia Poison Control Center Leon Robertson, Ph.D. Research Scientist Department of Epidemiology and Public Health Yale University I

Julian Waller, M.D. Professor, Department of Medicine University of Vermont Acknowledgement: Assistance Provided by: Lawrence 0. Budnick, M.D. (Drowning section) Medical Epidemiologist Special Studies Branch Center for Environmental Health, CDC Patrick J. Coleman, Ph.D. (Occupational Health section) Chief, Data Analysis Section Division of Safety Research National Institute of Occupational Safety and Health, CDC Rudolph E. Jackson, M.D. (Burns section) Acting Chairman, Department of Pediatrics ~ Morehouse School of Medicin Edwin M. Kilbourne, M.D. (Environmental related injuries section) Section Chief, Special Studies Branch Center for Environmental Health, CDC _B2_ l