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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

I I I EXECUTIVE SUMMARY "Closing the Gap" Health Policy Project Carter Center, Emory University. Unintentional Injuries: Intervention Strategies and Their Potential for Reducing Human Losses. by Gordon S. Smith, M.B. Ch.B., M.P.H. and Henry Falk, M.D., M.P.H. INTRODUCTION  Unintentional injuries are the third leading cause of death I I I ( (following all circulatory diseases and cancer) in the United States. ~ They kill more people between ages 5 through 44 than all other causes combined. Since injuries affect a greater proportion of younger people than most other major health problems, they have become the leading cause of premature death (years of life lost before age 65), excluding infant mortality (Figure 1). • Until recently, little attention has been given to this most preventable U.S. health problem. The gap between what we already know about prevention and what is being implemented is larger than that for any other disease entity. Although our mandate from the Carter Center has been to discuss only unintentional injuries, many of,the interventions we propose will also reduce intentional injuries. For example, reduction of the carbon monoxide content of domestic gas in I Britain not only dramatically reduced unintentional (accidental) poisonings, it also significantly reduced suicide by carbon monoxide poisoning without a corresponding increase in suicide from other means. N a N c.n a - B3 - .~ -J G ~

I. PROBLFM DEFINITIUN Many of the sources of data on injuries do not classify them on the basis of cause or intent. This includes the National Center for Health Statistics (NCHS) and the International Classification of Diseases (ICD) coding system, which codes only the type of injury and body part injured without regard to cause or intent. Consequently, much of the detailed data are available only for all injuries combined rather than for specific causes. Therefore, in selecting priority health problems, we used the ICD Supplementary Classification of External Cause'''•(ICD E codes) in which injuries are coded on the basis of cause and apparent intent. The leading causes of morbidity are often not the leading causes of mortality. For example, of the 10 leading causes of emergency room visits due to injuries, only 2 are in the 10 leading causes of death due to unintentional injuries. This discrepancy, combined with the lack of good morbidity and hospitalization data, made selection of the priority problems difficult. Because of the good quality of data available on mortality, we chose mortality rates as the basis for selecting the injuries for consideration. Analyzing the causes of these injuries, the prime consideration is the interaction of host (person injured), agent (various forms of energy, e.g., mechanical and thermal), and environment, including the socioeconomic environment (e.g., road design or the marketing of alcohol). How these affect the human body is determined by the type of energy involved, its distribution in time and space, and the ability of the human body to withstand the energy. -B4-

I I I I I I I I I I I I ~ I I ~ „~ II. IMPACT OF UNINTENTIONAL INJURIES The 12 leading causes of injury mortality are shown in Table 1. Motor vehicle-related injuries account for more than half of all deaths due to unintentional injuries, and they account for over 60% of all years of life lost before age 65 (Figure 2). They have been more intensively studied than any other injury, and consequently data is available on incidence (almost 4.4 million injuries annually), number of hospital days (over 3.5 million), disability days (over 145.5 million), and on the costs associated with auto injuries ($20,120 million). The direct costs of medical care amount to almost $6,700 million, and the indirect costs of lost wages and economic productivity amount to over $13,400 million. Despite the magnitude of the problems caused by other injuries, little is ~ - known about their true incidence and other variables of individual injuries (see Table 1). Only aggregate data for all other injuries can be shown for many variables. The second leading cause of death due to unintentional injuries is falls, which primarily affect the elderly. Drowning is the third leading cause, -- and, as is evident from the large number of years of life lost before age 65 -- it largely affects younger people (Table 1). Mortality rates for all injuries are highest in the elderly, primarily because of their decreased injury threshold and increased complications following trauma. In children under 5, the leading causes of death are motor vehicles, drowning, and fires. Among persons 15 to 21 years, half of all deaths result from unintentional injuries, primarily associated with motor vehicle crashes, firearms, and drowning. Males have over 2.5 times the ~ ~ fatality rate of females. Alcohol abuse is a major risk factor for U1 ..G i

injuries, increasing as a causative factor as the severity of injury increases. About 50% of drivers killed are -- by legal definition -- intoxicated, as are 25% of seriously injured drivers. Alcohol is also involved in about 30% of fatal injuries from other causes. III. INTERVENTIONS "'Passive" interventions, or those that work automatically and do not require repetitive active participation ("active" interventions), have proved more effective in controlling injuries. For example; seatbelts are an effective means of protection in crashes, but only about 13% of all drivers in the U.S. use them. Air bags, on the other hand, work automatically and are able to reduce fatalities an estimated 30%, without requiring any action on the part of individuals. Possible intervention strategies were analyzed by dividing them into those aimed at 1) preventing the injury-producing event's occurrence (pre-event phase, e.g., raising the legal drinking or driving age), 2) reducing the extent of injury (event phase, e.g., airbags) and 3) reducing the consequences of injury once it occurs (post-event, e.g., emergency services and rehabilitation). At each phase, we consider how to modify each of the following factors: a) human (e.g., health education), b) vehicles and equipment (e.g., crashworthiness of cars), and c) environment (e.g., breakaway poles or restriction of alcohol advertising). Many of the interventions involve legislation that regulates the production, design, or use of hazardous products. One single regulation often can save thousands of lives. For example, the 55-mile-per-hour -B6-

I I I I I I I I I I I I I I speed limit is estimated to save 5,000 lives annually, and the available (but unused) crashworthiness standards for automobiles could save 9,000 lives annually if implemented. A tragic example of the failure of legislation to control injuries was the widespread repeal of compulsory -motorcyle helmet laws, which has resulted in approximately 1,400 unnecessary deaths every year. Much of the need for legislation derives from the failure of manufacturers to assume corporate responsibility for manufacturing products that are designed to be as safe as possible within the limits of available technology. For example, cigarettes can be made that will self-extinguish when left, considerably reducing the 2,300 house fire deaths caused by cigarettes annually. The increasing number of product liability suits may well expand self-motivated responsibility within corporations. To date, prevention efforts directed at voluntarily changing human behavior have been disappointing and at times even detrimental. For example, fatalities in teenagers decreased when school driver education courses were eliminated. Attempts to increase seatbelt usage with insurance incentives and intensive television advertising have been unsuccessful. By contrast, those interventions aimed at reducing the hazards in the environment, such as childproof caps on poisons and breakaway poles on roadsides, have met with considerable success. A variety of promising but largely untested interventions are suggested for controlling alcohol consumption. Many of the other interventions proposed will also dramatically reduce the consequences of alcohol-related crashes and other injury-producing events. .. N CO N Ln CO ~ - B, - CV __J 0 i N

IV. IMPACT OF AVAILABLE INTERVENTIONS In considering the numerous interventions currently available, it became evident that those programs most likely to succeed used a mixed strategy with a number of different interventions directed at the same problem. We have identified four mixed intervention strategies that between them could prevent more than half of all injury related deaths. In planning intervention programs, we have assumed that every effort will be made to use all available technology for reduction of the risk of injury. ~ The gap is defined as the difference in injury rates between what we could expect if the programs were fully implemented and the present injury rates. A distinction must also be made between the total injury burden attributed to something (e.g., alcohol) and what we have the ability to prevent with currently available knowledge and technology. Because interventions are not mutually exclusive in their impact, it is not possible to sum all interventions to get an estimate of the total reduction in disease burden possible using all available resources. The four mixed intervention strategies are: 1. Motor Vehicle Safety_ Program, We estimate that a broad-based mixed strategy could reduce motor vehicle-related fatalities, injuries, and costs by about 75% as indicated in Table 2. Such a program would include installation of air bags, enactment and enforcement of laws requiring the use of seatbelts and child-seat restraints, control of vehicle speed, improved road design, and the maximum use of available technology in designing a safe, crashworthy vehicle. -B8- ~^-.~-.... ,.

I I I I U I U I I I I U I I I I I I 2. Home Injury Control Program. About 23,000 deaths per year result from unintentional injuries that occur in the home: 6700 from fatal falls, 4400 from burns and fires, 2400 from suffocation, 3100 from poisonings, 1100 from unintentional injuries caused by firearms, and 900 from drownings. We estimate that a targeted intervention program directed at these and other home injuries could reduce all home-based injuries by about 50% 3. Occupational Injury Control Program. Of the estimated 13,000 ~ occupational injury deaths that occur each year, a third are due to motor vehicle crashes, of which an estimated 75% are preventable. The causes of the other two-thirds include falls, industrial equipment, being struck by objects, electrocutions, and firearms. Using what little data are available, we estimate that 25% of the other occupational injury deaths • (that is, the two-thirds not related to motor vehicles) could be prevented. This percentage may be significantly increased if basie , principles and further injury control research are applied to the occupational setting. For all causes combined, we estimate that about 40% of the occupational injury deaths and serious injuries could be prevented, resulting in about 5,200 fewer deaths annually (Table 2). 4. Alcohol Intervention Program. The exact impact of alcohol on nonfatal injuries is not well understood (Table 1). If a broad-based societal approach were initiated against alcohol usage, we believe that by using only alcohol countermeasures we could expect about a 25% reduction in all fatal and serious injuries and a somewhat smaller reduction in less serious injuries in which alcohol plays a less significant role. It should be noted that many other injury control measures such as seatbelts and air bags will also reduce alcohol-related -B9-

injuries. A specific program, highly targeted at problem drinkers, is an essential component of an effective alcohol control effort. Any program that reduces unintentional alcohol-related injuries will also greatly reduce the incidence of other alcohol-related diseases. CONCLUSION We believe that the gap for unintentional injuries is larger than a the gap for any other disease entity. The extent to which each of the four proposed injury control programs could reduce the large number of deaths that occur annually is shown in Figure 3. Many of the interventions proposed are likely to encounter considerable political barriers from special interest groups. However, if we are to , significantly increase life expectancy and reduce the burden of diseases in the United States, the most effective means we have with current technology is through intensive injury control programs such as are outlined in the report. - B10 -

I W s a a= rL aL a a 4 i i, t8L A t f t a TABLE 1: Summary of Negative Impact Resulting From Unintentional Injuries Year of Data: 1980 SPECIFIC HEALTH Number of Number of Years Number of Number of Cost Associated Lost Before Hosiptal Disability with each specific PROBLEM Deaths Age 65 Days Days Health Problem Motor Vehicles 53,172 1,694,601 3,548,000 145,432,000 $20,120 million Falls 13,294 87,662 * * * Drowning 7,257 269,203 * * * Fire & Flames 6,016 150,950 * * * Poisoning 4,331 113,376 * * * Suffocation 4,121 88,255 * * * Natural/Environ- mental Factors 3,194 32,328 * * * Firearms 1,955 71,299 * * * Air Transportation 1,494 43,275 * * * Machinery 1,471 34,758 * * * Electric Current 1,095 36,660 * * * Struck by Falling Object 1,037 27,576 * * * Total 105,718 2,769,084 * * $45,472 million Injuries addressed by proposed intervention programs. Motor Vehicle- related Injuries 53,172 1,694,601 3,548,000 145,432,000 $20,120 million Home Injuries 23,000 * * 187,950,000 $8,191 million Occupational Injuries 13,000 * * 184,636,000 $11,570 million Alcohol-related Injuries 42,000 * * * * *Data not available 9 l Lzt,oSZoZ - B11 -

TABLE 2: Summary of Negative Impact Which Could be Reduced or Eliminated Through Implementation of the Intervention Strategies for Unintentional Injuries. Year of Data: 1980 NEGATIVE IMPACT WHICH COULD BE REDUCED OR ELIMINATED THROUGH IMPLEMENTATION OF THE INTERVENTION STRATEGY Targeted injuries for -Intervention Strategy Deaths Years of Life Lost Hospital Days Number (% Total) Number Number Disability Days Number Cost Million Motor Vehicle Related Injuries 40,000 (75%) 1,271,000 2,661,000 109,074,000 15,090 Home Injuries 11,000 (50%) * * 93,978,000 4,096 Occupational Injuries 5,200 (40%) * * 78,854,000 4,628 Alcohol Related Injuries 13,000 (25%) * * * * *Data not available. M-ZnllSM - B12 -

M. ~ " M MM M M FIGURE 1 5 ~ " 4 C 0 4- 0 ~ ~ CO m >- Cancer ® M Heart Liver Disease Disease Undetermined Unintentional (Accidental) ® Stroke Pneumonia/ Diabetes Pulmonary Injuries Influenza Melitus Disease Potential years of life lost prior to age 65 from eight leading causes of death, 1980 BttzhQszoz - B13 -

Vehiclea Inp Inp cation Environ- arms Trans- ary Current Fallinp mental port Object Motor Fail. Drown- Burne Poiaon- 8u/fo- Natural/ Fire- Air Machin- Electric 8truck by Unintentional Injuries: Number of deaths by cause, 1980 .. C 0 Motor Drown- Burns Poiaon-8uffoca- Falle Firearms Air Other Vehicles Inp FIGURE 2 Inp tion Trans- portation Potential years of life lost prior to age 65 from unintentional injuries by cause of death, 1980 - B14 - 01 I

FIGURE 3 60 W Deaths- preventable with proposed interventions 50 C: v Cl 10 Motor Alcohol Home Occupa- Vehicles tional Total number of deaths and deaths preventable by proposed interventions gnzfiQSzoz

Paper: Diabetes Mellitus Authors: William H. Herman, M.D. EIS Officer Division of Diabetes Control Center for Prevention Services, CDC Steven M. Teutsch, M.D., M.P.H. Acting Chief Technology and Operational Research Branch Division of Diabetes Control Center for Prevention Services, CDC Linda Geiss, M.A. Statistician Division of Diabetes Control Center for Prevention Services, CDC Project Officer: Erica Frank, M.P.H. Master of Public Health Program Emory University School of Medicine 4 Reviewers: Bob Anderson, Ed.D. Diabetes Research and Training, Division of Education University of Virginia Nina Berlin Executive Director Pennsylvania Diabetes Task Force Jerry Brimberry Chief, Program Services Divsion of Diabetes Control Center for Prevention Services, CDC Fred A. Connell, M.D., M.P.H. Assistant Professor, Health Services University of Washington Marvin Cornblath, M.D. Private Physician John K. Davidson, M.D., Ph.D. Director, Diabetes Unit Grady Memorial Hospital Larry Deeb, M.D. Private Physician Florida State Department of Health and Rehabilitative Services - B16 -

I  I I  I I I U U r I I I I I r J. William Flynt, M.D. Consultant Flynt and Associates Richard F. Hamman, M.D., Dr. P.H. Associate Professor University of Colorado J. Michael Lane, M.D. Director Center for Prevention Services, CDC Alice R. Ring, M.D. Director, Division of Diabetes Control Center for Prevention Services, CDC Andrew Sumner, Sc.D. Chief, Management Systems Branch National Institute for Occupational Safety and Health, CDC ~ Judy Wylie, R.D., Ed.D. Assistant Professor of Community Health and Department of Medicine Albert Einstein College of Medicine N Q N O .~ - B17 - N Q tV IV U

Diabetes mellitus is a major public health problem and a leading cause of death, disability, and cost in the United States. Diabetes represents a group of disorders all characterized by high blood glucose levels. It occurs when the body does not make enough insulin or when cells cannot use available insulin. The person with diabetes must follow strict dietary and exercise regimens, must test blood or urine, and must make daily therapeutic decisions. These exigencies require major alterations in lifestyle and may cause emotional disequilibrium, impair self-esteem, and create interpersonal conflicts. 9 In the United States, there are approximately 5.5 million people with diagnosed diabetes, and there may be an equal number who are presently undiagnosed. Of the 5.5 million, over 5 million have Type II diabetes. Type II diabetes is most common in adults, 60 to 90 percent of whom have histories of being overweight. Approximately half a million people have Type I diabetes. Type I diabetes may occur at any age but most typically develops in childhood. The number of people with Type II diabetes is increasing and the number of people with Type I diabetes is relatively stable. In general, the life expectancy of a person with diabetes at diagnosis is one-third less than that of a non-diabetic person of the same age. Renal disease and ketoacidosis are significant causes of death for people with Type I diabetes. In the population with Type II diabetes, cardiovascular disease takes on a more important role, and accounts for almost three quarters of deaths in those with onset of diabetes over age 40. -B18-

   U  I I I I   I I I I Ketoacidosis is an acute, life-threatening complication of diabetes which occurs as a result of inadequate insulin levels. It is associated with high blood glucose levels and coma. Approximately 75,000 people are hospitalized each year for diabetic ketoacidosis. Women with diabetes are at increased risk of adverse outcomes of pregnancy, and their offspring have excessively high rates of neonatal hypoglycemia, respiratory distress syndrome, congenital malformations, and perinatal death. Approximately 10,000 women with overt diabetes become pregnant each year and 850 of their offspring have life-threatening congenital malformations. Diabetes is t}le leading cause of blindness in American adults under the age of 75, and causes 5,800 cases of blindness annually. Diabetes is the leading cause of kidney failure. Twenty-five percent of all new cases of renal failure requiring dialysis or transplantation are due to diabetes. In addition, diabetes causes 31,000, or over half, of all nontraumatic amputations performed each year in the United States. Twenty-three thousand people with diabetes have strokes each year, 85,000 have heart attacks, and 41,000 develop peripheral vascular disease. The direct costs of diabetes including office visits, hospitalizations, nursing home care, and drug therapy amount to almost eight billion dollars each year. The toll can be better appreciated from the disability these patients suffer. Approximately 37,000 person years are lost from work by employed people with diabetes and 53,000 more person years are lost by homemakers. One hundred sixteen thousand person years are lost because people with diabetes are unemployed. Although diabetes is more prevalent among the older population, the toll on younger people is considerable. Some 1,450,000 person years of life are lost each year prior to the age of 65 because of premature deaths among people with diabetes. - B19 - I

There are major opportunities for the prevention of diabetes itself and for prevention of the complications of established diabetes. Up to half of all cases of Type 11 diabetes may be prevented if obesity is eliminated. Because obesity control has been so difficult to achieve, however, the major focus has been on the prevention of the complications of established diabetes. All the complications of diabetes are amenable to intervention. Control of blood glucose levels remains the single greatest hope for the prevention of many complications. With improved glycemic control, some 70,,percent of hospitalizations for ketoacidosis and up to 70 percent of the serious congenital malformations associated with overt diabetes may be prevented. With timely ophthalmologic examination and appropriate laser photocoagulation therapy, up to 60 percent blindness can be prevented. With hypertension control, the rate of decline of renal function in diabetes may be slowed by 50 percent. With good foot care, hypertension control, and smoking cessation, rates of amputation can he reduced by up to 50 percent. With hypertension control and smoking cessation, rates of stroke may be reduced by 85 percent, coronary disease by 45 percent, and peripreral vascular disease by 60 percent. In the broadest sense, the greatest risk factor for the complications of diabetes is the lack of widespread practice of state-of-the-art care by patients and professionals. This occurs because of the lack of patient and professional knowledge and management skills, and because of lack of access to care. Patients must develop and apply appropriate self-management skills. Teams of health care providers can facilitate the process. Professionals must B20

I I 4 I I I I I I I I identify appropriate therapies, and assure that they are incorporated into practices as a part of routine care patterns. In addition, access to health care must he assured. The reimbursement system can be used to influence patient and professional behaviors and to assure access to care. Appropriate changes in lifestyle may be responsive to economic incentives provided by employers and insurers. Public and private funding for programs can be linked to adherence to standards for quality care. Reimbursement for outpatient educational programs Y and preventive services, such as prepregnancy counseling and eye examination, will allow patients to take advantage of these services. Promoting the adoption of healthful behaviors and lifestyles is the most important societal intervention to reduce the burden of diabetes in the United States. The required lifestyle changes will require the help of many parties. Major opportunities lie in schools and the work site. Balanced meals, programs that will promote lifelong changes in exercise patterns, and health education curricula which emphasize the positive aspects of health can help people to assume more responsibility for not smoking and for appropriate exercise, diet, and weight control. Role models, such as advertising, the media, public figures, and parents can all set the example for healthful behaviors, and public policy, such as agricultural and food policies, can be used to actively promote the public health. Psychosocial and peer support can reduce the emotional burdens of diabetes and improve the quality of life for people with diabetes and their families. N . a Bz '~ - l - I

Diabetes represents a complex disease with unique problems. People with diabetes also represent a population at high risk for many of the problems which are generic in our society. Many of these problems can be addressed with available techniques. The diabetes community has begun to make important strides in solving these problems, but much remains to be done. N ~ N LJ'I Q - B22 - ~ ~ N -~I

U 0  N U No TABLE I ESTIMATED NUMBERS OF INCIDENT AND PREVALENT CASES OF DIABETES AND ITS COMPLICATIONS UNITED STATES, 1980 Incident Prevalent Cases Cases Type I Diabetes Mellitus 19,000 435,000 Type II Diabetes Mellitus 586,000 5,069,000 Cestational Diabetes Mellitus 86,000 Diabetic Ketoacidosis 75,000 Serious Congenital Malformations 850 Stroke 23,000 320,000 Coronary Heart Disease 85,000 650,000 Peripheral Vascular Disease 41,000 497,000 Blindness 5,800 40,000 End-Stage Renal Disease 4,000 7,600 Amputation 31,000 71,000 - B23 -

TABLE 2 StJMMARY OF MAJOR INTERVENTIONS AND ESTIMATE OF THEIR POTENTIAL IMPACT ON DIABETES AND PROBLEM INTERVENTIONS % PREVENTABLE Type I Diabetes Type II Diabetes Gestational Diabetes - Obesity Control Obesity Control - 50% 33% Ketoacidosis Education, Gly Control 70% 4 Serious Congenital Malformations Gly Control, Education 70% Stroke Htn Control 85% Coronary Heart Disease Htn Control, Smoking Cessation, Lipid Control 45% Peripheral Vascular Disease Htn Control, Smoking Cessation 60% Blindness Education, Laser Rx 60% End-Stage Renal Disease Htn Control 50% Amputations Education, Htn Control, Smoking Cessation, 50% Gly Control ITS COMPLICATIONS PREVENTABLE CASES/YF.AI` - 293,000 28,000 52,000 500 19,000 38,000 24,000 3,500 2,000 15,000 Obesity Control= weight loss, diet, and exercise. Education= education to assure optimal diabetes self-care and professional care. Htn Control= blood pressure control and/or normalization of blood pressure. Smoking Cessation= prevention or cessation of cigarette smoking. Gly Control= improved glycemic control and/or normalization of blood glucose level. Lipid Control= treatment of hyperlipidemia including improved glycemic control. Laser Rx= panretinal laser photocoagulation. - B24 -

U I I I I I I U I I I r I I I Paper: The Prevention of Depression Authors: Alan Stoudemire, M.D. Assistant Professor of Psychiatry Emory University School of Medicine Richard Frank, Ph.D. Assistant Professor of Psychiatry and Economics University of Pittsburgh Mark Kamlet Assistant Professor of Social Sciences Carnegie-Mellon University Nancy Hedemark, B.S. Graduate Research Assistant Emory University School of Public Health Project Officer: Thomas Welty, M.D. Chronic Diseases Division Center for Environmental Health, CDC Reviewers: Alvin Cruze, Ph.D. Vice President, Economic and Social Systems Research Triangle Institute Sherryl Goodman, Ph.D. Assistant Professor of Psychology Emory University Ricardo F. Munoz, Ph.D. Associate Professor of Psychology University of California, San Francisco Robert E. Roberts, Ph.D. Professor of Sociology and Epidemiology University of Texas Health Sciences Center - B25 -

Lawrence Wallack, Dr.P.H. Scientific Director Prevention Research Center Milton Weinstein, Ph.D. Professor of Policy and Decision Sciences Harvard University School of Public Uealth Myrna M. Weissman, Ph.D. Professor, Psychiatry and Epidemiology Yale University School of Medicine 4

N I I I I I I I I I I I I 9 Depression as defined in this paper is a major psychiatric disorder that is characterized by a pervasive disturbance in mood and loss of interest in life. Physical symptoms of the disorder include insomnia, decreased appetite, weight loss, fatigue, irritability, anxiety, and agitation. In severe forms of depression psychosis may be present. The condition is usually accompanied by pessimism, hopelessness, decreased self esteem and suicidal thoughts. Depression may lead to severe disruptions in marital, work and other interpersonal relationships. High risk groups for the development of depression incluae those undergoing major life stresses, such as divorce, separation, and bereavement; the children of the mentally ill; those who have suffered the loss of a parent at an early age; and those with chronic physical problems. Depression is the most common major psychiatric disorder and the prevalence rate in the general adult population is approximately 3 - 4 percent with the rates for women being much higher than for men (six month prevalence rates are 4035/100,000 for females and 1698/100,000 for males.) The mortality of depression is based on the suicide rate. Since a very conservative estimate would access that 60 percent of suicides are secondary to depression, this would result in 16,111 deaths per year. Since the 60 percent figure is a conservative estimate, and many suicides are not reported as such, the overall deaths per year probably exceeds 20,000. The total social cost of depression per year approximates 16.5 billion dollars. - B27 -

No known primary preventative interventions have been documented for depression and the most practical, realistic strategies at the present include increasing the number of individuals who receive effective treatment. The multiple manifestations of depressive illness are poorly understood by the public. In addition, the disorder is poorly and inconsistently recognized and treated by professionals who are in the best position to detect signs of the illness. Lack of public and professional awareness of this disorder leads to large numbers of affected individuals who never receive the benefit of the currently available effective treatments. The strategies proposed for decreasing the morbidity and mortality of this illness are broadly aimed at (a) improving public awareness of the problems in order that more individuals will seek timely treatment, (b) improving the ability of health and educational professionals to recognize the illness--particularly in children, adolescents and adults who develop symptoms that "mask" the presence of the illness, (c) to decrease the stigma of psychiatric illness by public educational campaigns at the grassroots level, (d) integrating psychological health education into the public school system, (e) development of support and outreach programs for those at high risk--such as the recently bereaved, and (f) public mental health policy initiatives to increase private and public insurance coverage for psychiatric disorders. The basic premise of these proposed interventions is that effective treatment for this severe, disabling and potentially lethal disorder are available if the barriers to obtaining effective treatment were overcome, and that once within the health care system, affected individuals were recognized and appropriately treated. - B28 -

 w  U U  U  U U I N I I  Paper: The Prevention of Alcoholism Authors: Alan Stoudemire, M.D. Assistant Professor of Psychiatry Emory University School of Medicine Lawrence Wallack, Dr.P.H. Scientific Director Prevention Research Center Nancy Hedemark, B.S. Graduate'Re'search Assistant Emory University School of Public Health Richard Frank, Ph.D. Assistant Professor of Psychiatry University of Pittsburgh and Economics i Mark Kamlet Assistant Professor of Social Sciences Carnegie-Mellon University Project Officer: Thomas Welty, M.D. Chronic Diseases Division Center for Environmental Health, CDC Reviewers: Alvin Cruze, Ph.D. Vice President, Economic and Social Systems Research Triangle Institute Sherryl Goodman, Ph.D. Assistant Professor of Psychology Emory University Ricardo F. Munoz, Ph.D. Associate Professor of Psychology University of California, San Francisco Robert E. Roberts, Ph.D. Professor of Sociology and Epidemiology University of Texas Health Sciences Center -B29- 

Morton Silverman, M.D. Chief, Centers for Prevention Research National Institute of Mental Health Lawrence Wallack, Dr.P.H. Scientific Director Prevention Research Center Milton Weinstein, Ph.D. Professor of Policy and Decision Sciences Harvard University School of Public Health Myrna M. Weissman, Ph.D. Professor, Psychiatry and Epidemiology Yale University School of Medicine a

r  U U  11 U  U  U U  U I I  I Alcohol abuse refers to a pattern of pathological use of alcohol that results in an impairment in social or occupational functioning. Alcohol dependence usually associated with increased tolerance to the effects of the drug and evidence of withdrawal symptoms if it is discontinued. The precise cause of alcoholism has never been determined but probably is multifactionally determined by a combination of genetic, psychological, cultural and social factors. - is The manifestations of the illness in society are pervasive and include a plethora of health related problems (cirrhosis, dementiA, nutritional deficiencies, fetal alcohol syndrome, cancer of the oropharynx and digestive tract). In addition, alcohol misuse is a major contributor to crime, violence, homicide, suicide, and traffic accidents. Alcohol is more prevalent in men (9,709 cases/100,000 adults) than in women (1,687 cases/100,000 adults). These data suggest that the disorder (strictly defined) affects 5=6 percent of the adult American population. Ptortality figures may be divided into deaths (a) directly attributable to alcohol (i.e., alcohol related illnesses (19,751/year), (b) those attributable to motor vehicle accidents (24,000/year) and those indirectly attributed to alcohol (32,000/year; i.e. falls, fires, homicide, suicide). These figures lead to a total of approximately 75,000 deaths per year. The total social costs from alcoholism per year are approximately 116 billion. - B31 -

Disability from alcohol misuse may be measured partly by alcohol related trauma complete paralysis (5100 cases per year), partial (900 cases per year), complete loss of extremity (2400 cases per year), partial loss (70,000 cases per year), and complete disability (201,600 cases per year). Mental illness related disability related to alcoholism yields reates of 2,420/100,000 affected individuals. Prevention strategies advocated in this paper include (a) a systems approach that addresses economic, social and cultural factors that facilitate excessive I alcohol consumption and (b) specific measures to decrease the mortality of alcohol.related motor vehicle accidents. The systems approach includes intervening to decrease excessive consumption and to decrease the social acceptability of inappropriate use of alcohol. Policy recommendations to achieve these goals include (a) increasing the price of alcohol through tax policy, (b) counter alcoholic beverage advertising that promotes alcohol as a social status symbol, (c) promote server intervention programs, (d) promote accurate portrayal of drinking on television and (e) promote increased involvement in prevention efforts on the community level. The second approach is to decrease the morbidity of alcohol misuse by decreasing the deaths due to alcohol related vehicular accidents. Specific recommendations include full implementation of mandatory seat belt and airhag use, and stricter drunk driving law enforcement. Both types of strategies are intended to diminish the enormous social and human costs of alcohol misuse.

Paper: Closing the Cap: Risks and Interventions for Cancer Authors: Richard Rothenberg, M.D., M.P.H., F.A.C.P. Director, Bureau of Chronic Diseases Prevention New York State Department of Health Philip C. Nasca, Ph.D. Director, Cancer Control Section New York State Department of Health Jaromir Mikl, M.P.H. Research Assistant New York State Department of Health Project Officer: Thomas Welty, M.D. Chronic Diseases Division Center for Environmental Health, CDC Reviewers: Lester Breslow, M.D., M.P.H. Professor of Public Health University of California School of Public Health Saxon Graham, Ph.D. Chairman, Department of Social and Preventive Medicine State University of New York at Buffalo Peter Greenwald, M.D. Director, Division of Cancer Prevention and Control National Cancer Institute Thomas A. Hodgson, Ph.D. Chief Economist, Office of Analysis and Epidemiology National Center for Health Statistics Dwight Janerich, D.D.S., M.P.H. Director, Division of Community Health and Epidemiology New York State Department of Health Earl S. Pollack, Sc.D. Chief, Biometry Branch National Caner Institute David Schottenfeld, M.D. Director of Cancer Control Department of Epidemiology Memorial Sloan-Kettering Cancer Center Edward Sondik, M.D. Director, Operationa Research in Division of Cancer Prevention and Control National Cancer Institute ^ Kenneth E. Warner, Ph.D. Professor and Chairman, Health Planning and Administration University of Michigan School of Public Health - B33 -

A minimum of 23% of current cancer incidence may be attributed to the action of four major risk factors: smoking, alcohol use, high fat diet and occupational exposures to carcinogens. It is estimated that 113,966 cancer deaths (27.5% of total), 409,195 working years of lost life, 4,823,000 days of hospitalization and close to $3 billion in direct costs for 1980 may be attributed to these factors. These estimates derive from a detailed assessment of nine cancer sites: colon, rectum, pancreas, larynx, lung, female breast, cervix, prostate and bladder. The primary focus of this review is the examination of direct human evidence of the relationship of exposure and disease. In addition, laboratory and animal studies are evaluated and "ecologic" comparisons considered (these compare aggregate population exposure rates with aggregate population disease rates). Finally, concensus estimates were used in areas of ongoing assessment. What emerges is a sub5tantiation of the notion that much of cancer is related to external factors - things imposed on us by the environment or things that we do to ourselves. For these nine tumors, representing almost two-thirds of cancer incidence, elimination of risk from smoking, alcohol use and occupational exposure would reduce their incidence by 27%, primarily through their action on cervix, hladder,•pancreas, larynx and lung. The best consensus estimates suggest that approximately 20% of breast and colon cancer would he eliminated through alteration of dietary fat and protection offerred by cruciferous vegetables and retinoids. The total number of incident cancers attributable to these four_risks (182,868), divided by the total number of cancers for 1980 (807,364) produces the figure of 23%. This is a minimum - B34 -

 a U  U   r I  U U U  figure for the reduction of cancer incidence, since it does not take into account the potential effect of these and other risks on other tumors, nor the potential interaction among risks. In addition to attribution of cancer to specific risks, current evidence also suggests that substantial decreases in cancer mortality are possible through secondary prevention, i.e. early screening and detection of disease. For cancer of the breast, for example, a decrease of 30% in mortality may be attributed to the screening process (mammography, breast self-exam and physician examination). In cancer of the cervix, routine cervical cytology screening may be responsible for prevention of between 10% and 22% of deaths from cervical cancer. Though estimates are more difficult for colorectal disease, there appears to be the potential for substantial benefits from periodic screening as well. The gap to be closed in cancer, then, amounts to one-quarter to one-third of, the current disease burden, based on our current understanding of risks. In choosing targets for intervention, the strength of the association of cancer with risk, the prevalence of the exposure to risk, the feasibility of the interventive program and its potential effects, both positive and negative, must be carefully considered. The primary factors identified here - smoking, eating, drinking and working - are intimately tied to the fabric of our lives, and interventions must be assessed in their broad social, economic and demographic perspective. The social goal is to continue to address the part of the gap that is yet uncharted, and to close as much of it as our current knowledge and ability allow. ..G ~

In the following pages, this review addresses the evidence for risks and potential interventions. Chapter i deals with the data set for cancer (documented in the appendices). Chapter 2 describes those elements of the quality of life that are affected by cancer and a possible framework for viewing that effect. Chapter 3 discusses the problem of attribution, and describes the method used to assess the intensity of a risk and the proportion of dtsease associated with it. Chapter 4, in eight subsections (colon and rectal cancers are considered together) describes the major risks identified for each tumor. In chapter 5, a brief discussion of secondary, prevention, as applied to those diseases where it appears to he beneficial, is offered. Finally, in Chapter 6, the overview of risks and cancers is presented.

SU111AP.Y TABLE 1 Summary of Negative Impact Resulting from the Health Problem Health Problem Area: Cancer NEGATIVE IMPACT RESULTING FROM THE HEALTH PROBLEM SPECIFIC HEALTH Nur,ber of Number of Years Lost PROBLEM Deaths (1980) Before Age 65 Nur;ber of Hospital Days* Cost Associated with Each Specific Health Problem** Colon 46418 110455 ) 915 ) 3225 Rectum 10804 27273 ~ 386 Pancreas 22988 61498 524 244 Larynx 3449 12475 268 240 Lung 88459 334213 3357 1598 Breast 37518 217270 2243 1265 Cervix 5457 39133 565 179 Prostate 22572 12650 1333 519 Bladder 11000 14228 482 409 (+281) TOTAL 248665 829195 12303 6036 h OF ALL CANCER 60lo' 47'~ 57:0 44 -1' * In thousands ** In millions; includes hospital, physician visits, pha rmaceutical costs, home care & 281 million for nursing ho,:e care, not reflected in these categories ziltzIlusZQ[. - B37 - .~

SUMMARY.TABLE 2 Summary of Negative Impact Which Could Be Reduced or. Eliminated Through Implementation of the Intervention Strategies Health Problem Area: Cancer NEGATIVE IMPACT WHICH COULD BE REDUCED OR ELIMINATED THROUGH IMPLEMENTATION OF THE INTERVENTION STRATEGY SPECIFIC HEALTH PROBLEM RISK FACTOR (AR-°o) Number of Deaths (1980) Number of Years Lost Before Age 65 Number of Hospital Days* Cost Associated with Each Specific Health Problem** Cervical Smoking (24.1„) 1320 9431 136000 43 Bladder Smoking (39.0;m-N) , 4347 4513 153000 131 (16. 4%'-F) Occupation (23~) 2530 3272 111000 94 Pancreas Smoking (25.8°0) 5931 15866 135000 63 Larynx Smoking (74°~) 2552 9232 198000 178 Alcohol (16.9;;) 583 2108 45000 41 Lung Smoking (75.9",'~) 67140 253667 2548000 1213 Occupation (12%) 10615 40106 403000 192 Breast Diet (20%) 7504 43454 449000 253 Colorectal Diet (20°0) 11444 27546 645000 260 TOTALS 113966 409195 4823000 2468 % OF ALL CAidCERS 28% 23Z y 23" 18rw * In thousands ** -in millions; includes hospital, physician visits, pharmaceutical costs, home care - B38 - EhL[.ilUisC.uG

a CANC ER: YEARS: 65 Ln '-T a  I I I 1 I I I I I I I Thousands Thousands 250 0 80 / Coln Panc Cerx Rect B1ad Prst Larx CANCER: DEATHS Lung Brst Coln Panc Cerx Rect Blad Prst Larx -B39- N

CANCER: HOSPITAL DAYS Millions 3.5 2.5 1.5 0.5 Lung Brst V/ V/, Coln Panc Cerx And Rect T r V ~,/j ~/ iz/~ Blad Prst Larx CANCER: COSTS Billions of Dollars Lung Br st m Coln Panc - B40 - Cerx Rect Blad % F Prst Larx

Paper: Violenc-e: Homicide, Domestic Violence, and Suicide I I I I I I I I Authors: Mark L. Rosenberg, M.D., M.P.P. Chief, Violence Epidemiology Branch Center for Health Promotion and Education, CDC Richard J. Gelles, Ph.D. Dean, Faculty of Arts & Sciences University of Rhode Island Paul C. Holinger, M.D., M.P.H. Department of Psychiatry Michael Reese Hospital and Rush-Presbyterian-St. Luke Medical Center Margaret A. Zahn, Ph.D. Professor of Sociology Temple University Judith M. Conn, M.S. Statistician, Violence Epidemiology Branch Center for Health Promotion and Education, CDC Nancy N. Fajman, M.M.Sc. Graduate Student, M.P.H. Program Emory University School of Medicine Trudy A. Karlson, Ph.D. Center for Health Systems and Analysis University of Wisconsin Project Officer: Nancy Fajman, M.M.Sc. Master of Public Health Program Emory University School of Medicine Reviewers: Mary Pat Brygger Domestic Abuse Project Minneapolis, Minnesota Evan Clark, Ph.D. Office of the Mayor Bridegeport, Connecticut E. Michael Corman, Ph.D., M.P.H. EIS Officer, Violence Epidemiology Branch Center for Health Promotion and Education, CDC Trudy Karlson, Ph.D. Center for Health Systems Research and Analysis University of Wisconsin Thomas Lalley, M.A. Assistant Chief Center for Antisocial and Violent Behavior National Institute of Mental Health - B41 - ~.,...-„,

James A. Mercy, Ph.D. Assistant Branch Chief, Violence Epidemiology Branch Center for Health Promotion and Education, CDC Jill D. Rosenberg, M.S.W. Educational Specialist, M.P.H. Program Emory University School of Medicine Linda Saltzman, Ph.D. Visiting Scientist, Violence Epidemiology Branch Center for Health Promotion and Education, CDC Thomas Schelling, Ph.D. Professor of Economics Kennedy School of Government Harvard University Jack Smith, M.S. Branch Chief, Research and Statistics Branch Division of Reproductive Health Center for Health Promotion and Education, CDC i

w I I I I I I r I I I I I This paper looks at the general problem of interpersonal and self-directed violence in the United States. We focused on suicde and homicide because better data are available for fatal outcomes than for nonfatal injuries. We also examined several types of assault, including aggravated assault, spouse abuse, and child abuse. Other, nonfatal types of violence--including rape, incest, and other forms fo assault--are tremendously important social problems that remain to be addressed. The costs of violence--in terms of morbidity, mortality, effect on the quality of life and costs of health care--are great. In terms of potential years of life lost, for example, homicide and suicide rank fourth and fifth because the lives lost are most often young lives. And spouse abuse may be the single major cause of physcial injury for which women seek medical attention, more common than auto accidents, rape and mugging combined. Suicide, homicide and aggravated assaults, together account for more than 50,000 deaths, 1.3 million potential years of life lost, 1.8 million hospital days; and $754 million in' health-care costs in 1980 alone. In this paper, we also attempted to quantify the costs of spouse and child abuse and of suicide attempts. This says nothing about the intangible costs incurred by a society whose activity in public or private places is impeded by fear. Although numerous cultural, social, behavioral, and biological causes and risk factors have been associated with these problems, some of these are obviously more amenable to intervention than others. Among the many interventions that ~ have been proposed to reduce the incidence of violence, the emphasis here is at the community rather than the individual level and on the modifying aspects f'J ~ r F%J LF1 ~ ~ - B43 - ~ .~ ~ I

of the social environment rather than individual behavior. Further, we believe it is possible to broaden the scope and effectiveness of intervention even in lieu of much needed research into the causal chains that lead to violence. Three broad themes reoccur throughout the literature on homicide, assault, and suicide: the importance of unacceptable levels of poverty, racial discrimination and gender inequaltiy; the cultural acceptance of violence as a way to manage the dilemmmas these and other situations pose; and the ready availability of lethal agents that can be used in violence against others of self. The intervention for which we were able to project the greatest impact was limiting the availability and use of lethal agents (firearms and medications). However, reducing the persistent strain created by structural inequities and re-educating the potential perpetrators and victims of violence are equally important steps to which we devote considerable attention.

M s M M. = i i it = SI M. = i = MIL MIL Diagram 1 Factors that precede or predispose a person to kill a friend or acquaintance, and proposed prevention strategies.* FACTORS Broad-scale social (structural) • Poverty/unemployment • Idealogy that masculinity means a dominant male social role • Racial segregation Cultural • Male belief In physical prowess, search for thrills and action • Underdeveloped verbal skills • Belief that one should not intervene in another's fights • Televised violence and media support • Encouragement of fighting by bystanders PREVENTION STRATEGIES Structural • Eliminate poverty and unemployment • Change conceptions of masculinity • Reduce racial segregation Cultural . • Reduce media violence • Increase community and witness intolerance for violence Interactlonlat • Drug and alcohol consumption • Weapons possession Interactionist • Reduce alcohol and drug consumption • Reduce firearm In]uries • Teach conflict resolution skills for young males •Model parnaHy adopled Irom Richsrd Gellea, "Cruld Alwse as Poychopatho{opy: A Sodolopicel Crllpue and Retormulatioq" wi Valonce in the FamidX pp.200-20I. L17LZ71OSGOZ Biologlcal • Male sex • Youth (20-29) /

Diat, . Factors that precede or predispose a person to kill or abuse a child, and proposed prevention strategies.* FACTORS Broad-scale social Cultural Interactionlst Biological Psychosocial (structural) • Belief in violence and/or • Lack of • Young • Parents abused • Poverty and/or physical punishment as adequate parental age as children unemployment socializing agent support • Physical or • Parents had • Too many and/or • Belief that parents have facilities mental violent role unplanned-for children ultimate right to do what disabilities model • Lack of education about they want with child of child child rearing • Parents' unrealistic • Parental dominance expectations of children ideology (see (especially for children with cultural beliefs) mental or physical t disabilities) • Prolonged marital stress ~ ~ • Social isolation of a` nuclear family PREVENTION STRATEGIES Structural Cultural Interactlontat Biological Psychosoclal • Eliminate poverty • Establish alternate ways • Establish • Prevent/treat • Treat identified from families to socialize child community/ childhood abused children • Reduce isolation of • Provide high-quality child- neighborhood disabilities nuclear family care faciiitles to reduce intervention • Educate about parental stress centers and planned parenthood • Aid handicapped children hot lines and child rearing • Change parental expectations of children •Model partially adopted from Richard Gelles, `Child Abuse as Psychopathology: A Sociological Crihque and Relormulation," in Violence In the Family, pp.2eo-2ot. Which factors dislinpuish between child abuse and kilGng of a child is unknown. lsaIIIJi'(,.UIG

Iai il i i i i i i i Ti W Diagrane J -i i i ai i iAnn Factors that precede or predispose a person to kill hist her spouse, and proposed prevention strategies. lI FACTORS Broad-scale social (structural) • Poverty/unemployment • Masculine dominance over females • Isolation of nuclear family Cultural • Male belief in physical Prowess, toughness, that he's "head of house" and has control over females • Criminal justice view of "hands-off" domestic disputes • Televised violence and other media supports PREVENTION STRATEGIES Structural • Eliminate poverty for men and women • Eliminate sexual inequality (especially in child-rearing and employment) and notions that masculinity requires dominance • Reduce isolation of nuclear family Cultural • Increase verbal ability and means of problem-solving • Initiate criminal-justice and social-service interventions • Reduce media violence Interactionist • Alcohol and drug consumption • Weapons possession • Male use of force to compensate for verbal disadvantage • No safe place for woman to go Interactlonlmt • Reduce alcohol and drug consumption • Reduce firearm Injuries • Teach how to 'f' ~ ht fair" and resolve conflicts non-violenntly ` • Teach how to walk away from a potentially-violent situation • Increase availability of shelters r ZS1_Zfi0SZ0Z.

Diagram 4 Factors that precede or predispose a person to commit a robbery-motivated killing, and proposed prevention strategies. FACTORS Broad-scale social (structurat) • Poverty • Ideology that masculinity means a dominant male social role • Racial segregation • Lack of role for adolescents • Urban (population) density Cultural • Materialism • Male belief In thrills and action • Belief that perpetrator will not be caught or severely punished • Criminal way of life condoned, and opportunities provided to engage in it • Belief that victims are not real and are to be used • Externalization of blame • Televised violence and media support for"bad guy" Interactionist • Lack of criminal justice and legal prosecution • Alcohol and drug consumption • Weapons possession Biological • Male sex • Youth (teenagers) Psychosociat • From disorganized home • Developmental tack in empathy PREVENTION STRATEGIES Structural • Reduce poverty • Reduce racial segregation and urban density • Create integrated, meaningful role for adolescents Cultural • Reduce media violence • Increase empathy • Increase community intolerance for robbery • Swift, sure criminal justice response to robbery and special handling of offenders who injure ES12hQsZQZ Interactionlat • Educate potential victims • Initiate witness- cooperation- and-assistance programs • Have "defensible space con- struction" (ie., light up streets; construct safer places) • Initiate new patterns of police surveillance

 I I I I I I I I Paper: The Health Consequences of Drug Abuse Authors: Paul J. Goldstein, Ph.D. Principal Tnvestigator Narcotic. and Drug Research, Inc. Dana Hunt, Ph.D. Principal Investigator Narcotic and Drug Research, Inc. Project Officer: Craig ~Aite, M.D. Medical Epidemiologist Behavioral Epidemiology and Evaluation Branch Center for Health Promotion and Education, CDC Reviewers: Edgar Adams, M.D Acting Director Division of Epidemiology and Statistical Analysis National Institute on Drug Abuse Michae). Backenheimer, Ph.D. Research Sociologist National Institute on Drug Abuse Barry Brown, Ph.D. Director, Division of Clinical Research National Institute on Drug Abuse John French Chief, Research and Evaluation New Jersey State Department of Health I I 1 I Douglas S. Lipton Deputy Director for Research and Evaluation New York State Division of Substance Abuse Services - B49 -

The impact of drug abuse on the health of the nation is enormous, complex, and stubbornly resistant to full and accurate documentation. There are no natinnr3l health data bases that specify a broad range of physical dysfunction5 and enumerate the incidence and prevalence of these conditions as related to antecedent drug use. There are no national criminal justice data bases that specify a range of crimanally violent acts, enumerate resultant injuries, and link these acts to antecedent drug use of victim or perpetrator. Yet, even though such data do not exist, there is stilll overwhelming evidence that drug use is a major social and health problem in the United States. q For example, 2,500,000 Americans, about 2% of the adult population, are estimated to have serious drug problems. The societal costs from drug abuse have been variously estimated from 10 billion to 47 billion dollars per year. The health consequences of drug abuse are especially serious because most indicators of ne ative im act such rtai ob tiv l C g p ~ users are young peop e. e jec , n e as loss of life or work productivity, are very high because whole adult lifetimes may be lost. The leading causes of death among teenagers and young adults are accidents, suicide, and homicide. These phenomena have all been strongly linked to drug abuse. Drug-related physical or mental health problems that begin during adolescence or young adulthood may persist for a lifetime, sapping the resources of the medical care system and leading to difficulties for the user in such areas as employment and family life. The consequences of drug abuse are far-reaching, as varied as the substances available for use and the multiple methods of ingestion. Because of the wide - B50 - d

I I I I I I I I I I I I I I I i I range of health consequences only three areas were selected for detailed description in this report. These areas are infectious diseases, poisoning/overdose, and violence. ldithin the area of infectious diseases the following conditions are discussed: serum B hepatitis, acute bacterial endocarditis, and AIDS. About 800 deaths, 31,000 years of life lost, 73,000 days of hsopitalization, and over 18 million dollars of hsopital costs are attributed to these conditions in a subgke year from drug related causes. These conditions are transmitted to and from intravenous drug users through the use of unstdrile equipment, mainly through needle-sharing. This repdrt recommends decriminalization of possession of works, and allowing needles and syringes to be sold over the counter without prescription, as an intervention strategy to redue the spread of infectious disease-among intravenous drug users. The effects of "poisoning/overdose" are shown to vary considerably depending upon the type off drug used, the method of ingestion, interactive effects with other drugs used, the method of ingestion, interactive effects with other drugs and alcohol, patterns of use, and dilutants or other substances consumed along with the primary substance. Approximately 1500 deaths, 44,000 years of life lost, 519,000 days of hospitalization and 129 million dollars of hospitalization costs are attributed on an annual basis to drug poisoning or overdose. This report suggests strategies for getting more drug abusers into treatment as a means of reducing this problem. - B51 - I

Drugs and violence are related in three possible ways: the psychopharmacological, the economically compulsive, and the systemic. The psychopharmacological model suggests that some persons, as a result of short or long term ingestion of specific substances may exhibit irrational andfor violent behavior. The economically compulsive model suggests that some drug users may engage in violent crime, such as robbery, tn order to support costly drug use. Systemic violence refers to aggressive patterns of interaction within the system of drug use and distribution. Included here are territorial disputes between rival drug dealers, assaults or homicides committed within dealing hierrchies as a means of enforcing normative codes, robberies of drug dealers and the usually violent retaliation, elimination of informers, punishment for selling adulterated or phony drugs or for failing to pay one's debts. Within the area of violence, this report examines only drug related homicides and assaults. Over 2,000 deaths, 67,000 years of life lost, 45,000 days of hospitalization, and 11 million dollars in hospitalization costs are attributed to these phenomena over the course of one year. Additional intervention strategies that are recommended in the report because they address all three of the above problem areas include: identification of users early in their drug - using careers; improvement and expansion of existing drug treatment services and employee assistance programs; increased federal funding of programs for youth. The importance of expanding and improving the quality of data bases in order that we might better understand the full nature and scope of drug related health problems is stressed in the report. Better information will enable more promising intervention stratagies to be proposed. - B52 -

I i I I I I I I Thousands Homicide DRUG ABUSE: YEARS<65 LOST q a T Poison Drug HBV Bact. AIDS Assults Overdose Depend Endo- carditis DRUG ABUSE: DEATHS

Paper: Position Paper on Infectious and Parasitic Diseases Authors: John V. Bennett, M.D. Assistant Director for Medical Science Office of the Director Center for Infectious Diseases, CDC Scott D. Holmberg, M.D. Medical Epidemiologist Division of Bacterial Diseases Center for Infectious Diseases, CDC Martha F. Rogers, M.D. Medical Epidemiologist AIDS Activity, Office of the Director Center for Infectious Diseases, CDC Steven L. Solomon, M.D. Medical Epidemiologist Hospital Infections Program Center for Infectious Diseases, CDC Project Officer: Craig White, M.D. Medical Epidemiologist Behavioral Epidemiology and Evaluation Branch Center for Health Promotion and Education, CDC Reviewers: Libero Ajello, Ph.D. Director, Division of Mycotic Diseases Center for Infectious Diseases, CDC Walter R. Dowdle, Ph.D. Director, Center for Infectious Diseases, CDC John C. Feeley, Ph.D. Director, Division of Bacterial Diseases Center for Infectious Diseases, CDC James M. Hughes, M.D. Director, Hospital Infections Program Center for Infectious Diseases, CDC Robert L. Kaiser, M.D. Director, Division of Parasitic Diseases Center for Infectious Diseases, CDC Thomas P. Monath, M.D. Director, Division of Vector-Borne Viral Diseases Center for Infectious Diseases, CDC Frederick A. Murphy, D.V.M., Ph.D. Director, Division of Viral Diseases Center for Infectious Diseases, CDC - B54 -

r I I I I I I I I I I I I Ladene H. Newton, M.S. Program Analyst, Office of the Director Center for Infectious Diseases, CDC ~ N ~ - B55 - ~ ~ ~ O

Professional staff of the Center for Infectious Diseases were surveyed and asked to provide estimates for each of 117 specific infections. Estimates were requested for the true incidence, case-fatality ratio now and in the foreseeable future, and the effectiveness of all public and private prevention efforts in preventing cases now and in the foreseeable future. Each infection was put, as appropriate, into one or more of the following categories: bacterial, cutaneous, day care-related, enteric including hepatitis, foodborne, fungal, meningitis, noaocomial, parasitic, perinatal, pneumonia and i lower respiratory, upper respiratory, vaccine preventable, vectorborne, and waterborne. The information provided was used to establish the numbers of cases and deaths prevented now and potentially preventable in the foreseeable future, as well as cases and deaths occurring at present. Consultants to the project independently developed information on .morbidity, mortality, and costs, based largely on published literature. Information requested by the Carter Health Policy Task Force was developed for the following health infection groupings: Acquired Immunodeficiency Syndrome, Central Nervous System Disease, Enteric Diseases Including Hepatitis, Genitourinary Infections, Lower Respiratory Infections, Miscellaneous, Mycotic and Fungal Infections, Nosocomial Infections--Acute and Chronic Care, Sexually 'Transmitted Infections, Skin and Soft Tissue Infections, Tuberculosis, Upper Respiratory Infections, Vaccine Preventable Infections, and Vectorborne Infections. Strategies for prevention of each were also prepared. Whenever possible, cost data from the consultants' data were combined with prevention data from CDC survey data. The data sets proved highly ~ complementary to each other in assessing morbidity, mortality, and costs (Table 1) and the impact of prevention on them. About 742 million clinically a N LM significant infections were estimated to have occurred in the United States ~ _1J 704 deaths attributable to them (Table 2). The costs in 1980 with 194 O~ , , ~ - B56 -

 a       I  I I I I I associated with infections (excluding costs of deaths, sequelae of infections, home care, and reactions to treatment) were estimated to exceed 17 billion dollars. Table 3 presents information concerning potentially preventable annual morbidity in the foreseeable future, as well as costs, after adjusting preventable cases and deaths from CDC survey data upwards by differences in incidence between CDC survey and consultants' data, since the latter was considered more accurate. The overall incidence of infections in the consultants' data was about 5 times larger. These adjusted data indicate that about 265 million cases and the expenditure of 6.1 billion dollars are potentially preventable annually. Table 4 presents information on deaths and years of life lost annually that are potentially preventable in the foreseeable future. These data were •adjusted for differences in incidence in a fashion similar to that used in Table 3. The adjusted data indicate that more than 320,000 deaths and 3.6 million years of life lost might be preventable annually in the future. After the unadjusted CDC survey data on prevention in Table 5 is adjusted as noted above, an estimated 157 million cases and 173,000 deaths can be estimated to have been prevented in 1980, and the gap between current accomplishments and potential future accomplishments in prevention involve 108.5 million cases and 147,953 deaths (Table 5). Thus, these data suggest that there is nearly as much that remains to be accomplished in preventing infections as has already been achieved. The paper also develops and presents a system for establishing priority infections and infection groups based on equally weighted measurements of of magnitude, severity, and preventability. clverall, about 30% of all infections appear preventable in the foreseeable future. - B57 -

Table 2: Summary of Negative lapect Resulting from the Health Problem Health Probleo Area: Infectloue Diseaeee SPECEPIC HEALTH NEGATIVE IMPACT RESULTING FROM THE HEALTH PROBLEM (1) PROBLEM Number of Yeara Number of Lost Before Deaths Cases Age 65 Number of Hospital Days Number of Disability Days (2) Acquired Iauunodeflcienc) Syndrome 861 2,360 23,974 124,482 732,190 Central Nervous System Diseases 6,160 153,985 205,670 715,100 2,882,000 Enteric Diseasea including Hepatitis 37,541 224,250,000 570,463 8,913,000 991,150,000 Genitourinary Infectlone 11,313 16,080,289 47,291 5,000,000 20,241,000 Lower Respiratory Infections 78,680 22,448,000 919,575 7,329,700 220,282,000 Miacellaneoua 1,683 160,000 54,972 1,900,000 5,600,000 Mycotic and Aungal Infections 600 18 050 000 11 180 500 111 224,800 I ~ ~ Nosocomial Infections- Acute and Chronic Care 49,645 , , 4,030,759 , 259,260 , 11,861,000 14,934,000 CO Pregnancy and Abortion Related Infectiona 197 196,166 7,716 1,961,660 3,923,320 Sexually Transmitted Infectiona 3,790 5,590,000 23,031 140,400 280,400 Skin and Soft Tissue Infectfone (4) 1,063 22,349,998 13,130 2,916,700 37,700,000 Tuberculoafa 2,001 27,003 12,348 354,000 1,019,000 Upper Respiratory Infections 583 429,050,548 25,323 580,111 601,538,130 Vaccine Preventable Infections (5) 167 85.913 7,887 74,071 1,250,865 Vectorborne Infections 420 9,240 10,550 47,900 90.000 A11 Infections (6) )94,704 742,248,261 2,192,370 42,029,624 1,901,847,705 1- All negative impacts recur annually 2 - Days of majority activity lost annually were aubatituted. 3 - In ailliona. Excludes costs of deaths, sequelae of lnfection, hoae care, reactlone to treatment. 4 - Excludea fungal infections ` 5- Limited to the 7 infections encompassed in Appendix I 6 - Pro summary tablee. Appendix 1. Coat Associated with each specific Health Problem (3) 44.0 210.3 2,972.0 2,444.5 2,131.0 491.4 116.5 3,373.7 495.6 146.6 2,055.7 127.0 2,550.3 20.6 12.2 17,191.4 C 9Lzf,0sZoZ

_:;..~a.s~aaaaaasaaas 1a-.1<• l: t-.., tlI r .;p.~-t ~~. .-rbldlty tlnf~h G~uId br R' nr F1.:. ~... . Thr„ugb Imple~^~~t.:cl at ,, - lntrrvr~~tlun S t:. tegl.,et --,~6 trr to Conraultanta' 1n_' iSraItl. f. ~.'cti A:ea: 1-.!r:'tlnvv Uil•~-rs C SPcC;FI•, n:'ALaI PRJH~: H Acquired I~unodeflciency Syndrome Central Nervous Systea D1®ease 8nteric Dieeaaea Including Hepatitis Cenitourlnary Infections (2) Lower Respiratory infectione Hiscellaneous (2) Hycotlc and Fungal Infections Nosocomial Infections- Acute and Chronic Care Pregnancy and Abortion Related Infections (2) Sexually Tranamitted Infections Skin and Soft Tiasue Infectioos Tuberculoaia Upper Respiratory Infectlons Vaccina Preventable Infections Vectorborne Infections All Categories All Infections .:GA1 ivE 4H:t-N COULD BF REDU.-ED OR E!.I'S.'VAlY? _ T~IRU~i~:H IYPLY.Y_!':~,TAiION OF TNC Ifirt'RVENTION STRATCCY (1) C.,ve® ~ H,~pttal UAyv Disability Days Cost r (I Total) tl'nP.er (Z intal) N,uohPr (Z Tntal) Number (Z Tntsl) 3,148,207 27,741 183,950 1,034.886 33.963 1,705,637 2,803,120 18,000 43,345,477 2,463,502 10,787 379,806,110 264,939,231 ( <.1) 78,131 ( .4) 459,558 ( <.1) 27.6 ( .4) ( <.1) 94,708 ( .4) 381,696 ( <.1) 27.9 ( .4) (84.8) 12,606,925 ( 59.6) 1,424,165,700 ( 90.9) 4,270.8 ( 58.2) ( .7) + IJI, 8;66,914® ( , 4.0) 3,509,580 ( .2)~I 423.8 ( 5.8) (.8) 1,027,949 ( 4.8) 30,893,320 ( 2.0) 298.8 ( 4.1) (<.1) 329,434 ( 1.5) 970,961 (<.1) 85.2 ( 1.2) ( <.1) 1,136 ( <.1) 2,291 ( <.1) 1.2 ( <.l) (.3) 3.045,278 ( 14.2) 3,834,263 ( .2) 866.2 ( 11.8) (<.1) 339,627 ( 1.6) 679,253 (<.l) 85.9 ( 1.2) ( .5) 42,839 ( .2) 85,556 ( <.1) 44.7 ( .6) (.7) 365,810 ( 1.7) 4,728,306 ( .3) 257.8 ( 3.5) (<.1) 235,974 ( 1.1) 679,258 (<.1) 84.7 ( 1.2) (11.4) 58,611 ( .3) 60,771,295 ( 3.9) 257.9 ( 3.5) (.6) 2,123,941 ( 9.9) 35,867,784 ( 2.3) 590.6 ( 8.0) ( <.i) 55,923 ( .3) 105,075 ( <.1) 14.2 ( .2) (99.8) 21,473,234 (100.0) 1,567,133,900 ( 99.8) 7,337.3 (100.1) 15,302,117 678,848,432 6,136.2 I - Reductions recur annually 2 - Aa.unes adjustment factor of 1.41, the average for the 12 health problems for which direct cooparinona could be .ade. 71WZ1lIJsZLlC.

Table 4: Sumn;,ry of NeKattve Impect on Mortality Vhtch Could be Reduced or Eliminated Through Implementation of the lntervention Strategies I{ealth Problem Area: Infectioua Dtweasen SPECIPIC HEALTH INTRRVENTION NEGATIVE 1MPACT WHICH COULD BE REDUCED OR ELIMINATED PROBLEM Acquired Imaunodeficiency Syndrome Central Nervous Syste Dlseasa Bnteric Diseases Including Hepatitis Genltourlnary Infections (2) Lover Reepiratory Infections Miscellaneous (2) Mycotic and Fungal Infectinns No.ocomial Infectlons- Acut• and Chronic Care Pregnancy and Abortion (2) Related Infections Sexually Transmitted Infectfons Skin and Soft Tiseue (3) Tliberculos is Upper @rsplratory Infections Vaccine (4) Preventable Diseases Vectorborne Infectfons All Categories All Infections STRATEGY TIIROUGIi iMPLP.MP.NTA.TION OP TNE INTF.RVENTION STRATEGY(1) Unad)uvted ~ Ad]uated Deaths Yre. of Life Lost ue a t h a Yrs. of Life Lost No. (Z Total) Number (Z Total) Number (Z Total) Number (Z Total) Multiple 1,406 ( 1.8) 39,149 ( 3.5) 1,111 ( .4) 30,928 (.8) Multiple 1,871 ( 2.3) 62,469 ( 5.5) 1,347 ( .5) 44,978 ( 1.1) Multiple 22,038 ( 27.5) 334,883 ( 29.6) 183,577 ( 74.1) 2,789,574 (69.3) Muitiple 4,766 ( 5.9) 19,923 ( 1.8) 4,766 ( 1.9) 19.923 (.5) MLltiple 22,693 ( 28.2) 265,225 ( 23.5) 17,247 ( 7.0) 201,571 ( 5.0) Multiple 709 ( .9) 23,158 ( 2.0) 709 ( .3) 23,158 (.6) Mult iple 609 ( .8) 11,348 ( 1.0) 609 ( .2) 11,348 (.3) Multiple 12,979 16.2 67,780 ( 6.0) 12,719 ( 5.1) 60,873 ( 1.5) Multiple 83 ( .1) 3,250 ( .3) 83 ( <.1) 3,250 ( .1) Multiple 2,470 .( 3.1) 15,010 ( 1.3) 865 ( .4) 5,254 (.1) Multiple 4,527 ( 5.6) 55,917 ( 4.9) 3,486 ( 1.4) 43,056 ( 1.1) Multlple 990 ( 1.2) 6,109 ( .5) 990 ( .4) 6,109 (.2) Multiple 1,119 ( 1.4) 48,605 ( 4.3) 13,484 ( 5.4) 585,690 (14.5) Multiple 3,579 ( 4.5) 169,027 ( 14.9) 4,116 ( 1.7) 194,381 ( 4.8) Multiple 349 ( .4) 8,766 ( .8) 2.505 ( 1.0) 6.136 (.2) Multiple 80,188 ( 99.9) 1,130,619 ( 99.9) 247,614 ( 99.9) 4,026,229 (99.9) Multiple 69,461 782,132 320,544 3,609.331 1 - Reductions recur annually. 2- Asauaes preventable deaths/current deaths occur in aame proportion as for all lnfectfons (82,0111194,666), and that preventable cases/current cases occur in same proportion as for all infections (91,152,234/741,247,613). 3 - Excludes fungall infectlons. 4 - LiL.itod to the 7 infections encompassed in Appendix 1. s9tZfiasZ0Z

N a I I I U U  Paper: Closing the Gap: Dental Disease Authors: Michael E. Fritz, D.D.S., Ph.D. Dean, and Charles Howard Candler Professor of Periodontology Emory University School of Dentistry Douglas G. Rundle, D.M.D., M.P.H., M.S. Assistant Dean for Advanced Education Emory University School of Dentistry Project - Ufficer: Nancy Fajman, M.M.Sc. Master of Public Health Program Emory University School of Medicine Reviewers: William_A1len, D.D.S. Member, Future of Dentistry Committee American Dental Association Howard Bailit, D.M.D., Ph.D. Professor and Head, Division of Health Administration Columbia University School of Public Health Otis R. Butler, D.D.S. President Georgia Dental Association  a I U U I I U I Peter DeGrazia, D.M.D. President Anerican Association of Dental Examiners Chester Douglass, D.D.S., Ph.D. Associate Professor and Chairman Department of Dental Care Administration Harvard School of Dental Medicine Anne Hanse, D.D.S. Member Georgia Board of Dentistry Charles R. Jerge, D.D.S. Professor and Chairman, Department of Dentistry Wake Forest University Robert__Mecklenburg, D.D.S. Chief Dental Officer U.S. Public Health Service Kent Nash, Ph.D. Director, Bureau of Economic and Behavioral Research P~1 American Dental Association ~ N G -G - B 61 ~ ~

Richard Schoessler, D.D.S. Trustee, Tenth District American Dental Association Phillip Swango, D.D.S. Associate Director of Epidemiology National Institue of Dental Research Raymond P. White, Jr., D.D.S., Ph.D. Program Director Dental Research Scholars Program Robert Wood Johnson Foundation

1% 9 I I I I I I I I I I I I SUMMARY CLOSING THE GAP -- DENTAL DISEASE The present paper on "Closing the Gap -- Dental Disease" has ~)een limited to caries and periodontal diseases rather than encoT,Nassing all dental diseases. The reasoning for this is that these diseases are the most prevalent in American society and are related to each other because of their possible infectious nature. ;~ational epidemiological studies on dental caries and periodontal disease are in fact sparse. The NHANES I of 1971-74 describing approximately 21,000 patients aged 1 through 74 was utilized for dental caries. In addition, an NIDRystudy of approximately 40,000 children aged 5-17, conducted in 1979-80, was utilized. The periodontal disease estimates were based on the NHANES I data of approximately 13,000 patients 18 through 74 years of age, compiled in 1971-74. The data, when extrapolated to the 1980 target year, show that caries and periodontal disease are enormous problems of community health. For example, it is estimated that the number of decayed, missing and filled teeth in society, based on 1980 population cens~;s, approaches 3 billion. Similarly, the periodontal diseases inciuoing gingivitis-and periodontitis would be present in 43 r'.illicn people over age 18 in our society. The costs of treating these two diseases, based on 1980 population data, approaches S17 billion per year. Although neither of these diseases is life threatening or causes major disability, they do influence markedly t!-,e ouality of life in the United States and dental problems are now being found to impact many of the other diseases found in society. Most notably, from the perspective of the Carter Center, there are data currently being generated to support the contention - B63 -

that periodontal disease can alter the course of such diseases a~ diabetes and inflamrr,atory bowel c9isease~'~, and rh~~umatoid types of diseases. Thus, dental disease would seem to be important in any system of community health. Preventive measures to control dental caries and periodont,.:l diseases have been divided into three areas: the agent, the host and the environment. Reg-arding dental caries, intervention stratecies were ranked according to priorities and cascade in the following manner: 1) community and institutional water fluoridation; 2) school and institutional fluoride diet'supplements and mouthrinse programs; 3) dental health education and promotion of personal preventive maintenance regimens; 4) regular institutional dental examinations and screenings for treatment of high-risk populations; 5) a combined regimen of quarterly professional hygiene prophylaxis, topical fluoride application, hygiene instruction and adhesive tooth sealants. Regarding periodontal disease, intervention strategies were ranked in the following manner: 1) dental health education and promotion of personal preventive maintenance regimens;•2) regular institutional dental examinations and screenings for treatment of' high-risk populations; 3) a combined regimen of quarterly professional hygiene prophylaxis, hygiene instruction and monitoring of disease activity; and 4) treatment of advanced disease cases by private practitioners. It was noted often in the body of the text that the data describing the various forms of periodontal diseases is not as good as that describing dental caries. A further emphasis on ~ ~ primary intervention strategy could well be a directive toward a N ~ ram to collect data for the periodontal diseases. national ro ~ p g Problems inherent in this strategy were discussed. N -.I ~ - B64 -

IMM i iMMi i i i i i i i i i i ia TABLE 1: Summary of Negative Impact Resulting fro© the Health Problem Health Problem Area: Dental Diseases L"ECATIVE IMPACT RESULTItiG FROM TI{E IEALTH PROBLEM of Cost Associated ; SPECIFIC }{rALTH ~ Number of Number of Years Number of Number ~ PROBLEN I Deaths ~ Lost Before I Hospital Disability with each epeciflc p e 65 I Da s Da s Health Problem I Caries and ~ i , Periodontal Dideases ~ I I $ 17 billion i I I ~ ~ I ~ ~ I I ~ ~ I ~ OuzhQszQz

TABLE 2: Summary of Negative Impact Nhich Could b,-- Reduced or Elimiuated Through Implementation of%the Intervention Strategies Health Problem Area: Dental Diseases :IFIC HEALTH 'ROBLEH INTERVENTION STRATFGY NP;GATIVE IHPACT llHICH COULD BE REDUCED OR ELIMINATED THROUGII IM PLEMENTATION OF THE INTERVENTION STRATEGY _ Dcaths Years Lost of Life Hos ital Da s Disability Da s Cost _ - - Numbe_~X Total -~ - Number_ X Totai - Number X Total --- Nu-~nber (X Total_ - r_ To t al Nu^: he ~X -- ter Dental fluoridation NA NA NA NA $7.14 B (50%) Caries ns i io ri e e-upplc3nents & r - ses $4.28 B (30%) uca on prcmotion Unknown egular school Lns & screeni ombines fluorid 0 terly prophy 04iI ealth a3ucation rarotion a ~2e3ular sch~l exams & screenin Hygienist nonsur io t-herany D entist nonsurgi St, i<-al thPray s, *Bas©3 on total e~x~nditures of $21 billion, for treatment of which 68% relatcxi to caries and 32% relata3 to periodontal diseases. See RTI stuciy (41) , I NA r~ NA 4 ntKI-I(-)j8M Un_knn _ $6.05 B (904) SF (14 ~~ Wzhoszoz

i Brian A. Boehlecke Representing ATSScientific Assembly onEnvironmental and Occupational Health American Thoracic Society Philip A. Bromberg, M.D. Representing ATS Board of Directors American Thoracic Society John C. Brooks, M.D. Representing ATS Scientific Assembly on Pediatrics American Thoracic Society Susan Pingleton, M.D. Representing ATS Scientific Assembly onClinical Problems American Thoracic Society Herbert T. Reynolds, M.D. Representing ATS Scientific Assembly on Allergy and Clinical Immunology American Thoracic Society - B67 - Paper: Position Paper on Respiratory Diseases Authors: Laurence S. Farer, M.D., M.P.H. Director, Division of Tuberculosis Control Center for Prevention Services, CDC Project Officer: Carl W. Schieffelbein Public Health Advisor Division of Tu_berculosis Control Center for Prevention Services, CDC William li. Herman, M.D. Medical Epidemiologist Technical and Operational Research Branch Center for Prevention Services, CDC Reviewers: .John B. Bass, Jr., M.D. Representing ATS Scientific Assembly on Microbiology. Tuberculosis and Pulmonary Infections AmericanThoracic Society

EXECIJTIVE SUMMARY Respiratory diseases, including chronic lung diseases, acute respiratory infections, and lung cancer, constitute a tremendous health problem as measured by the number of persons affected, the number of days of productive activity and years of productive life lost, and the direct costs of caring for persons suffering from them. ' Lung diseases 4re a leading cause of death and disability in the United States, causing 1 of every 8 deaths and contributing to an equal number. There are almost 17 million Americans with chronic bronchitis, emphysema, or asthma. More than 100 million cases of inf luenza, pneumonia, and acute bronchitis occur annually. Respiratory diseases account for about 2.5 million hospital discharges, 21 million days of hospital care, and 25 million physician visits per year. The costs for these services exceed t29 billion. Lung diseases account for more workdays lost (over 31 million person-days annually) than any other category of illness. To this economic impact must be added the social costs and human suffering associated with these diseases. The devastating psychosocial and personal economic effects of a chronic, incurable lung disease are obvious. Progressive pulmonary impairment results in decreasing ability of the afflicted person to carry on usual activities of daily living. This may eventually lead to severe limitation of function, with loss of earning capacity and dependency on public assistance. Worry and anxiety may produce intense stress, as the patient and the family face the prospects for the future. As smoking is unquestionably the main cause of chronic lung disease, the single most important thing that can be done to reduce morbidity and mortality from lung disease is to eliminate smoking. COPD and lung cancer are directly related to smoking; asthma and other chronic lung diseases are exacerbated by smoking; and smoking may interact synergistically with occupational exposures, particularly to asbestos, to greatly increase the risks for workers. Although smoking elimination is an obvious intervention with huge potential impact, it presents many controversial policy issues. Among these are those relating to the economics of tobacco growing and marketing, the role of taxes on tobacco as a source of government revenues, the regulation of advertising in a free society, and the propriety of limiting individual rights when smoking is restricted in public places. Behavior modification, which is not easy, is the basis of smoking cessation programs, but the most effective approach to smoking elimination is behavior modification to prevent nonsmokers from starting to smoke. The long-term payoff of this approach will be the prevention of morbidity and premature mortality in people who are now young and whose productive years still lie largely before them, which is undoubtedly more cost-effective than postponing the death of chronically ill older persons through treatment. Other exogenous causes of chronic lung disease are hazardous substances found in the workplace, allergens, and infectious agents. Some lung diseases are hereditary. Many acquired lung diseases are of unknown cause. Acute viral respiratory infections in children may contribute to chronic lung disease later in life. Air pollution probably does not cause, but clearly can exacerbate, chronic lung disease. Other interventions to ameliorate the chronic lung disease problem consist of reducing occupational exposures to hazardous substances; enforcing estabished clean air standards; providing -B68-

`N I I I I I I I I I I I I I to the public and to health professionals on how to prevent lung disease; educating patients and health care providers about clinical management and treatment of chronic lung diseases, including self-help skills; and assuring access to health care, including home health care, for chronic lung disease patients. For most patients, these interventions can enhance functional ability and help them to cope with chronic illness, but, in general, once the manifestations of disease are present, the course of the process cannot be substantially altered. An exception is tuberculosis, once an incurable, highly fatal lung disease which is now curable and preventable. The effort to control it provides an example of how tools can be applied to control a disease, even as better ones continue to be sought, and it is a model for the potential control of other diseases, such as asthma, for which there is no cure or primary prevention, but which is amenable to interventions which could substantially affect morbidity, health care costs, absenteeism, and quality of life. However, for much chronic lung disease, major advances in control will depend on new insights into therapy and prevention which can only be acquired through continued research. I I I N ~ - B69 - L.rY O .~ PV ~.J ~. I

t t sttznQszQz TABLE 1: 5ummary of NeRative Impact ResultlnR from the Health Problem Health Problem Area: Re9pf}'atory Diseases NEGATIVE IMPACT RESULTING FROM THE HEALTH f'ROBLFM SPECIFIC IfEALTH PROBLEM Number of Deaths Number of Years Lost Before e 65 Number of Number of Hospital Disability D_ays Da~s 2 Cost Associated with each specific flealth Probl_em COPD & Allied Conditions 53,159 Zero 4.736000 263 m (3) Occu?ational Lung Diseases 1 1,422 N/A 57,000 (4) Asthma 2,891 18,791 2 059 000 1 (3) Tuberculosis 1,978 6,107 527.000 6 5 (3) Cystic fibrosis 505 23,230 164,000 N A (4) Ac~ionchjolitis N/A N A N A Interstitial lung disease N/A N/A 70.000 (4) $17.0 million Sarcoidosis 364 N/A 104,000 N/A (4) $27.7 million (1) Excludes lung cancer (2) Includes estimate of restricted activity days, bed days, and loss of work days (3) Includes direct and indirect cost estimates (4) Includes only direct cost estimates N/A Information not available

j m M M M M M M -M i S -i MAR a M M i M at TAR1.F. 2: Sumwnry of Nee.tlve lwpact tAxlch Could be 1¢educed or E11.1nnted Through I.ple.MOnt.tlon of thc totervcntlon Strate6tea Ile.lth Problea Area: Reepiratory Dtecasep SPECIFIC IIF.nLTII PROOLIN INTERVENTION STRAT[CT NEGArtVL' IMPACT UIIICII COULD DE R7:1)UCED OR ELIMINATEO TIIn0UG11 IMPLF.II£NTATION OF T11E IItTF.RVF.NTION STRATECC Dcath• Ycwr• of Li[c Lnst flospitnl Dayo Dls.bllltY Da a Cost Nun,bcr 2 Tut.1 _Nue.ber (_2_To_talj_ N~~mbcr_ Z Totnl Nu~.hor Z 1'ntn N~e I T Tn COPD L/1111ed [.Ond iC10M Eli~nate a 42.527 (80%) Not appllcable 3,788,000 (80Z) 261,046,400 (80I) $5.2 billion (80I Occupational Lung Di e Elirminate exposure 1,422,(100Z) Informatlon not available 57,000 (100%) Infor.eatlon not available $15.6 tmillion ( seas Asthma Kedlcal care INTENSIVE HEDICA HANAGEMF}7T OF TNES COPrDTTIOHS SH 6E ABLE TO SIIDST TIALI.T REDUCE Tuberculosis " ^ Others « n 7L L C ,i7~~~.lJC. LC,i7~~~.lJC. - B71 - ~

-Respiratory: Years <65 Lost and Deaths ~ ~~.. v 120 -, 100~ COPD El Years <65 Lost ® Deaths L= I ksn I !,~ n F~ Occup. Asthma Cystic Other TB Fibrosis Resp. r60 LZZZfi0Sz0Z

Respiratory: Hospital Days & Direct Costs URf,QSZQZ COPD ® ® Occup. Rsthma Cystic Other Fibrosis Resp. TB ~ 0 (/I ~ ~ ~

Paper: The Impact of Arthritis on the Health and Productivity of the People of the United States Authors: Frederic C. McDuffie, M.D. Senior Vice President for Medical Affairs Arthritis Foundation and Professor of Medicine Emory University School of Medicine William R. Felts, M.D. Professor of Medicine George Washington University School of Medicine Marc C. Hochberg, M.D., M.P.H. Director, Statistical Core Unit Johns Hopkins Multipurpose Arthritis Center Reva C. Lawrence, M.P.H. Arthritis Epidemiology/Data Systems Program Officer National Institutes of Health Kenneth Mitchell, Ph.D. Director, Rehabilitation Division Ohio State University - Ohio Industrial Commission Morey Moreland, M.D. Head, Section of Pediatric Orthopedics University of Vermont College of Medicine Lawrence E. Shulman, M.D., Ph.D. Director, Division of Arthritis, Musculoskeletal & Skin Disease National Institutes of Health Project Officer: Dan Horht Master of Public Health Program Emory University School of Medicine Reviewer: Susan M. Manfred, M.A.S.A. Vice President for Public Education Arthritis Foundation

I I I SUMMARY Of the more than one hundred diseases associated with arthritis or.back pain we selected osteoarthritis, rheumatoid arthritis, gout and back pain (especially back pain due to either occupational factors, osteoporosis or scoliosis) for special attention. Musculoskeletal and connective tissue diseases are not impor-tant causes of mortality (0.031/; of deaths from 1968 to 1978) but they are extremely common causes of morbidity. The approximate prevalence per thousand in certain selected United States population groups is as follows (from Tables VII, VIII, IX, X, XII): DISEASE TYPE AGE FEMALE/MALE APPROXIMATE NUMBER I GROUP PER 1,000 Osteoarthritis hands 55-75 2:1 250 . (moderate & knees 55-75 2:1 25 ,/ severe) hips 55-75 1:1 15 Rheumatoid definite & 20-80 2:1 10 . Arthritis classical 55-75 2:1 45 ,/ Gout self all ages 1:3 9 reported 45-80 1:3 25 ~ Back Pain Duration of 25-74 1:1 10 one month Osteolorosis Post meno-- 50-64 6:1 550 , pausal ' by X-ray 65-75 6:1 800 Scoliosis = 12-17 2:1 15 ( Adults 2:1 30 I It can be seen that most of these diseases have their greatest I impact on an older largely female population though for some, such as scoliosis and ostuoarthritis, symptoms may begin early in life. the processes leading to eventual N ~ ~ - B75 - tJ'1 ~ -~ N ~ ~ O

About 60 of short-term hospitalizations in 1982 were due to musculoskeletal diseases. However, most such patients are managed on an ambulatory basis and in fact musculoskeletal symptoms are the most common reason for visits to the doctor's office in the United States'(10`0 of the total in 1981). The direct and indirect costs of these conditions severely strain our national economy. A review of data analysis from several sources (Tables XV-XXI) shows that total costs have risen from approximately 3.5 billion dollars in 1968 to 23 billion dollars in 1983 and are projected to reach 95 billion present day dollars by the year 2000. Since the different estimates cited are based on somewhat different assumptions and a varying mix of diagnostic categories the ratio of direct to indirect costs ranges--from 1:2 to 2:1. Of the several diseases covered,back pain accounts for the largest share of the costs. Idiopathic back pain, osteoporosis and lumbar disc disease, account for almost 75% of the total of which 4414 is indirect. Indirect costs represent a smaller fraction of the total for the several • kinds of arthritis (22%) since they affect an older group of individuals less likely to be regularly employed. As one might expect from the above figures, these diseases produce considerable disability, both with respect to normal daily activities and employment. Arthritis and heart disease are the leading causes of disability,each being responsible for about 15% of the total. Most major forms of arthritis,especially osteo- arthritis, affect a population that is older, poorer, less well educated than average and is mostly female. Thus the greatest impact of arthritis is on housekeeping activities, which are crucial in an older population primarily retired. Osteoporosis also affects an older female population, mainly of Caucasian background. Nonetheless musculoskeletal diseases also produce considerable job related economic loss. People with rheumatoid arthritis, for example, suffer an average 60'/0 decline in earnings ~ ~ fV L11 - B76 - ~ -.~ fV ~ CG 0

I I I I I I I I I I I I I I over the first six years of illness. Back pain is the most frequent cause of limitation of activity in people under 45 and second only to respiratory infections as the reason for hours lost from work. Recent social and epidemiologic research indicates that personal and job related factors are more important than disease related factors in determining whether a person will continue to work. Particularly important are marital status, social adjustment, amount of job autonomy, educational level, physical demands of occupation, length of time in job and transportation facilities. We recommend that the Carter Center explore four preventive interventions that are likely to reduce the prevalence and morbidity of musculoskeletal diseases in this country. 1. Osteoporosis - Proven effective measures in people over 50 are cyclic administration of estrogens to women whose ovaries,have been removed prior to age 50, a calcium intake of 1 to 1.5 grams a day, regular weight bearing exercises and measures to reduce the likelihood of falls. Low doses of vitamin D may also be beneficial 2. Rheumatoid Arthritis - A strategy aimed at improving working conditions for people with this disease could substantially-reduce the current burden. Major elements would be increased job autonomy, improved transportation, job redesign,-vocational training of selected individuals and developing home based job opportunities. - B77 -

3. Back Pain - A reduction in the proportion of back pain.due to occupational factors could be achieved by a program emphasizing job screening based on a proper ratio of individual muscular strength to job demand, use of a profile of employee characteristics (height, weight, spinal curvature, etc.), and appropriate job modification techniques. 4. Scoliosis ~ The amount of psychological stress, back pain and cardiorespiratory impairment resulting from the long term effects of scoliosis as well as the expense of much corrective surgery could be reduced by enlarged scoliosis screening programs of teenagers and close follow up of all abnormalities detect~d. ~ Q ~ LI ~ - B78 - ~ ~.I Cc LJ

I I I I I I I I I I I Table 1: Surrmary of Negative Impact Resulting from Health Problems Health•Problem Area: Arthritis and Musculoskeletal Diseases NUMBER OF NUMBER OF COSTS IN MILLIONS OF DOLLARS I HEALTH HOSPITAL DISABILITY PROBLEM DAYS/YEAR DAYS/YEAR Direct Indirect Total Musculoskeletal 18,303,0001 Diseases Arthritis Rheumatism 416,000,0002 4,5813 1,2563 5,8373 and Gout Arthritis and 17,6673 5,4143 23,0713 Back Pain Rheumatoid 800•,0004 9,100,0004 7773 2153 9923 Arthritis Osteoarthritis 2,800,0004 253,200,0004 2,0663 2203 2,2803 Back Pain5 13,0743 4,1583 17,2323 Osteoporosis 3,400,0006 3,4163 4153 3,8213 11982 21976 31983 41980 ~ 5Includes idiopathic, disc disease, osteoporosis N LM ~ ..G 6 ~ 1972-78 ~ -~ - B79 -

UNINTENDED PREGNANCY AND INFANT MORTALITY AND MORBIDITY: STRATEGIES FOR CLOSING THE CAP From the World Health Organization Collaborative Center for Perinatal Care and Health Service Research in Maternal and Child Health, Atlanta, Georgia Alfred W. Brann, Jr., M.D. Chairperson and Principal Investigator

4 I 4 I I  I I I I I I . I I I I I EXECUTIVE SUt4{ARY "Closing the Gap" Issues Regarding Reproductive Health and Preonancy Outcome Human history becomes more and more a race between education and catastrophe. - H. G. Wells - 1865-1936 The gap between "what is" and "what could be" in infant mortality, morbidity and unintended pregnancy is larRe and unacceptable. The problem can be described in four simple statements: 1) There are too many unintended pregnancies; 2) There are too many deaths to normal birthweight infants; 3) There are too many low birthweight infants being born; 4) There are too many cases of developmental disabilities. This longstanding gap is an indication that our society has yet to deal effectively with .+hat should be our greatest concern: our reproductive health and the raising of healthy children, our most precious natural resource. The gap exists at all levels of our society, but it is concentrated in women who have one or more of these characteristics: they are an adolescent, they are black, or they are on lower socioeconomic levels. Our ability to reduce the gap is within our reach through current medical knowledge and technology, and improvements in our standard of living. We need to generate a public policy that clearly articulates the goal that every child born in the United States should be intended and as healthy as possible. From a humanitarian and socioeconomic perspective, to achieve this goal the nation must not only improve access to current modern technologies but as importantly address the underlying economic and social disadvantage of some of its citizens, particularly minorities and women. UNINTENDED PREGNANCIES More than half (55x) of all pregnancies (Figure 1) in the United States are unintended. Four of ten of our nation's young women become pregnant during their teen years, 80% of them unintentionally, when they should be completing high school and preparing for adult roles. Early teenage childbearing usually terminates education, leaving the young woman unemployable a.nd dependent on public welfare and public sources of medical care. The woman and her children are often confined to poverty for the rest of their lives with all the accompanying problems--preventable by prevention of untimely early pregnancy and completion of education including parenting skills. Women experiencing unintended births tend to have similiar characteristics to women who experience an infant death. Hence reductions in unintended births could lead to a reduction in the infant mortality rate. - B81 - if

interventions: ~ There presently exist interventions which if applied more widely could prevent each year 2.2 million unintended pregnancies (657G of the 3.3 million unintended pregnancies in 1980). Reductions in the number of unintended pregnancies could also lead to more than an 8% reduction in the infant mortality rate. Assumption of personal responsibility and planning of their reproductive careers by both men and women are the basic tenets of a public policy to redice unintended pregnancy. We believe critical strategies to develop such a policy include: 1. Consciousness raising by media (informing the public and of the magnitude of the problem); health professionala 2. Concerted effort by public education to teach personal reproductive responsibility; 3. Information (the media and public education) for the public concerning the 4. 5. relatively low magnitude of risks associated with current birth control methods compared to the risks of pregnancy; Improved access to contraceptive methods (especially for high risk groups, such as adolescents, and the educationally and economically disadvantaged); Improved access to children; sterilization procedures for persons who do not want more 6. Access to abortion,for those women who choose it; 7. Research of: a. safer and more b. more effective adolescents. acceptable birth control methods, and strategies to communicate the risks of pregnancy to iNFANT MORTALITY AND MORBIDITY Infant mortality in the postneonatal period is largely due to preventable causes .+hen SIDS and congenital anomalies are excluded. The gap in infant mortality is caused ?rimarily by an excess of low birthweight infants (infants weighing <2500 grams or 5.5 pounds at birth), and an excess of postneonatal* deaths of normal birthweight >2500 gram =.nfants. The effect of excessive low birthweight and postneonatal mortality among :)abies of normal birthweight on infant mortality is illustrated in the "ladder of infant aortality" (Table I). White, non-adolescent upper class women have the lowest infant aortality (6.0 deaths per 1000 live births) because they have low rates of both low Dirthweight and postneonatal mortality among normal birthweight babies. nfant Mortality The gap is largest in the postneonatal rate and is present for both white and black .nfants. Infants of white adolescent mothers are 6 times more likely to die in the >ostneonatal period than a "best" white standard population*; the increased risk is 8 . old for black infants of adolescent mothers. (Figure 2). Substantial gaps in >ostneonatal mortality also exist for black and white infants born to nonadolescNnt romen with 12 years or less of education. Black normal birthweight infants are four imes more likely to die in the neonatal period, white infants 2.5 times mdre likely, han the "best" standard (Figure 2). Infants of black women are almost 4 times more likely to be of low birthweight than -nose in the "best" standard population.** The increase risk is 1.3 for white 1 month to 1 year of age *The "best" population selected was comprised of infants of white women 20 yeur:: of age ,r older, with 13 years or more education, who sought early prenatal care. -B82-

9 I I I I I I I I I I I I I I I I I infanta. Adolescent and educationally disadvantaged women in both white and black -pulations are more likely to have low birthweight infants (Table II). These fferences in the rate of low bicthweight infants are indications of the socioeconomic gap that exists in our society. Interventions for In_Eant.Horta_lities: year: There presently exist interventions which if applied more widely could prevent each - 7,500 postneonatal deaths between one month and one year of age (60% of the 13,000 postneonatal deaths in 1980); - 4,000 neonatal deaths at less than one month of age (15% of the 28,000 neonatal deaths in 1980); - 50,000 low birthweight infants and 4,000 infant deaths associated with low birthweight Effective interventions will vary from region to region depending on the number of low birthweight infants and the birthweight specific mortality rates. Areas 2xperiencing a gap in postneonatal mortality should benefit from: (1) access to care for sick infants; (2) an active follow-up program to support families of infants at high risk of postneonatal disease (e.g., adolescents, educationally and economically disadvantaged); (3) Injury control, such as seat belt laws, poison control regulations and information centers, smoke alarms, and access to child care; (4) Efforts by public -ducacion ana the media to teach critical parenting skills. Areas experiencing a gap in neonatal mortality in infants of normal birthweight aiil benefit from: (1) efforts to increase referral of high risk pregnancies to deliver -, tertiary centers; and (2) improving the capacity in smaller hospitals for management the obstetric emergencies and identification, stabilization and transport of the sick ~eonat.e. - Areas experiencing a gap in infant mortality due to higher than average ubpcpulations of women who have a higher chance of having a low birthweight infant will :enefit from clustered interventions which include: (1) early prenatal obstetrical care, :r.d (2) ensuring adequate prenatal nutrition (3) maintaining regionalized perinatal care :ensuring that hospital cost containment does not impede access to quality care) (4) mokirg cessacion. far.f No_-bid_,tY: If infant mortality represents the visible tip of an iceberg of poor child health, hen infant morbidity represents the unseen portion. Major short term morbidity is ssociated with hospitalization for low birthweight and for surgery for correctible ongenital anomalies; long term mental and physical disabilities are associated with -)ncocrectible congenital anomalies and neurological sequelae in some very low •irthweight infants. - B83 - ~ ~

Interventions: Interventions which will reduce mortality will most probably reduce morbidity. :re are presently a few prenatal technologies which if applied more widely could erfect the outcome of 1000 cases of Down syndrome and spina bifida. Each of these two genetic disorders occurs approximately once in every 1000 live births, and, both can be diagnosed by amniocentesis during pregnancy. This diagnostic procedure allows prospective parents to choose to plan for optimal care at birth or to terminate the pregnancy. Public policy to reduce the burden of illness associated with congenital anomalies and other developmental disabilities should be directed at (1) maintaining regionalized care (ensuring that hospital cost containment strategies do not impede access to high risk perinatal care and corrective surgery), (2) providing every pregnant woman access to prenatal diagnosis for Down Syndrome and spina bifida, (3) maintaining current newborn screening at least for phenylketonuria (PKU) and hypothyroidism, and (4) continuing research (a) to prevent congenital anomalies and other developmental disabilities, (b) to learn the most effective methods of habilitating affected infants. RECOHMENDATIONS: We recommend a reproductive health policy be implemented now so that the following -oals can be reached by the year 2000: 1) A reduction in unintended pregnancies by 65%. 2) A reduction of the low birthweight rate by 20%. 3) A reduction of postneonatal infant mortality by 60%. Leaders in public education, media, community groups, organized medicine, and ;overnment must make a concentrated effort if these goals are to be met. We need: 1) Public education and information dissemination at the local level, i.e., schools, community, groups, and churches. - to teach our children to plan their reproductive careers and to understand the benefits of delaying childbirth to the post teenage years. - to promote the value of prenatal care and parenting skills. 2) Legislation to - ensure access to family planning, prenatal care (including prenatal diagnosis), for all women - ensure access to acute and preventive care for all infants. 3) Accurate and timely information from the public health sector to monitor regional progress towards these goals. 4) Creative strategies to - maintain access to abortion for women who desire to use it. - prevent cost containment efforts and threat of malpractice from limiting access to quality care. - improve the standard of education and standard of living. - provide incentives for women - especially young women - to assume active roles in those activities that make life in our society productive and rewarding.

 a TABLE I Tt{E "LADDER" OF INFANT MORTALITY IN SELECTED SUB POPULATIONS Infant The Number Mortality of Infants Rate (per <2500 grams Birthweight Specific 1,000 live per 100 live Infant Mortality births) Population Characteristics births (LBWR) Rate >2500 gms 0 Ideal, no infant deaths 0 4.0 LBWR that of nonsmoking white 3.4 best US population,* and BWSMR that of "best" white US population* 5.3 LBWR that of Norway, and BWSMR that 3.9 of "best" white US population* 6 0 For white US population only: LBWR 4.5 that of high SES white group**, and BWSl4t that of "best" white US population* 7.4 Present LBWR and BWSM that of white 4.5 high SES group** from ADB 9.8 Current US white population from ADB 5.7 11.1 For black population only: the black 10.1 LBWR and BWSMR that of "best" white US population* 11.6 Current US population from ADB , 6.8 white to black ratio 84:16 13.: For black population only: 10.1 LBWR and BSWMR that of black high SES group** from ADB 20.4 Current US black population from ADB 12.5 Risk Ratio 3.7 Infant Neonatal Postneonatal Mortality Mortality Mortality 0 0 0 1.5 .7 .8 1.5 .7 .8 1.5 .7 .8 3.0 1.7 1.3 4.3 1.8 2.5 1.5 .7 .8 4.7 1.9 2.8 4.9 2.8 2.1 7.2 2.6 4.6 4.8 3.7 5.8 .4_BBREYIATIONS: LBWR - low birth weight rate BWSliR - birth weight specific mortality rate ADB - aggregated data base, see technical note Ko. 3 ^ Best US population: Infants born to women who are 20 years of age or older, with 13 years or more of education who sought prenatal care in the first trimester. BWSMR of >2500 gram birth weight group in "best" population is further reduced by using rates in rhites for black infants and by excluding from the rate computation deaths reportedly due to causes thought preventable (i.e., obstetrical trauma, hypoxia, infection and injury). h* High SES group: Infants born to women who are 20 years or older with 13 years or more of education. - B85 -

Table II itace of Low Birth Weight (<2500 grams) in U.S. SubpopulatLons Perceat of All Lnfants in Racial Croup Rate of Low Birth Weight Nhite, High SES 32% 4.5X 47hite, Inw SES 51% 6.0% White, Adolescent 17x 7.8% Black, kiigh SES 20x 10.1X Black, Low SES 50% 12.7% Black, kiolescent 30% 14.1% High SES - infants of women 20 years of age and older, with 13 or more years of education. Low SES - infancs of women 20 years of age and older, with 12 years or less of education. Adolescent - infants of women 19 years of age and younger. - B86 -

rr~ a an an ai i i M a a i a AM a a FE; .,-~EN-i DiSTf~II~U ! IUf~ Ui= Fi-I;--G~,\V,,:~'CiES BY I[\1 i-NI IUN STATU':-') AND OUTcoME lN T NE U.S.,19,50 h'Zlrr7a A icz 1~;5nMED 40X UNW?.NTED 15X o-INTENDED PREGNANCIES (N=2,694,000) /ARTL*C {0.S FD7Rrf Q 16Z INTFIIDED 45X TOTAL PREGNANCIES e Vet ann o 41% rrtx lau 'tx Lht xrna 4u , rc1x t.x lu i-- UNWANTED PREGNANCIES 10--UNINTENDED PREGNANCIES (y=3,349,000) tztlntttone: Unvanted: Tnt pregnant motner r.portedly never wanted to nave anotner pregnancy. tUttta,ed: The pregnant .otner reportedly vanted a subsequent pregnancy but at a later t1mt. Incended: Tnt pregnant .otner reportedly intended to btcooe pregnant at tne tl®e ent dld. Fetal loar: Inch3dev tpnnr•. -,3r, a9orrl-na ~,A rrtl,+.l- - ZIJtZi71.lSZUZ tht brrma , mK ta, t>~ va-MISTIMED PREGNANCIES TOTAL PREGNANCIES C n! I P r r'• ~aA V E;\ir r,Nr, I r, c*c, -~

FIGURE 2 POSTN RELATIVE RISK OF NEONATAL MSD BY SESEAONDTRACE DEATH FOR INFANTS >2500 GRA Mint EiLf CK 10 9 8 7 6 J L L I r STD CRPS GRP2 GRP3 STD CRPS CRP2 O-R'3 N EC hL:TAL PO STNEJ RATAL Relative Risk: Ratio of the risk in one group to the risk in another. In this figure, if the relative risk is 1, the risk is equal to that of the standard. If the relative risk is 2, the risk is twice that of the standard. The standard group: Infants of white women 20 years or more of age, with 13 years of more education, who sought prenatal care in the first trimester. The birthweight specific mortality rate of the >2500 gram birthweight group is further reduced by excluding from the rate computation deaths reportedly due to causes thought preventable (i.e. obstetrical trauma, hypoxia, infection, and injury) and by using rates in white infants for black infants. Group 1: infants of women 20 years or more of age, with 13 years or more education. ~.1 Group 2: Infants of women 20 years or more of age, with 12 years or less of education. Group 3: Infants of women 19 years or less of age. Neonatal Period: Birth through 1 month of age. Postneonatal Period: 1 month through 1 year of age. - B88 -

 r I I I a I I I I I I ka~tr: Closing the Cap for Cardiovascular Disease Presenter: Dennis D. Tolsma, M.D., M.P.H. Director Center for Health Promotion and Education, CDC Project officer: Craig C. White, M.D. Medical Epidemiologist Behavioral Epidemiology and Evaluation Branch Center for Health Promotion and Education, CDC Consultants: Manning Feinlieb, M.D., M.P.H. Director National Center for Health Statistics Suzanne G. Haynes, Ph.D. Research Associate Professor of Epidemiology School of Public Health University of north Carolina at Chapell Hill Mary Jane Jesse, M.D. Deputy Director of Reserch American Heart Association Dan L. McGee, Ph.D. Senior Statistician Agent Orange Projects, CDc Dan McGee, Jr. Programmer The Carter Center "Closing the Gap" Health Policy Project, CDC Jeffrey M. Newman, M.D., M.P.H. Medical Epidemiologist Behavioral Epidemiology and Evaluation Branch Center for Healtlh Promotion and Education, CDC Leonard Syme, Ph.D. Professor of Epidemiology School of Public Health University of California at Berkeley H.A. Tyroler, M.D. Professor of Epidemiology School of Public Health University of North Carolina at Chapel Hill - B89 - r

Lawrence Watkins, M.D. Cardiologist Section of Cardiology Medical College of Georgia Craig C. White, M.D. Medical Epidemiologist Behavioral Epidemiology and Evaluation Branch Center for Health Promotion and Education, CDC

I I I I I I I I I I I I I I I I I 0 CARTER CENTER HEALTH POLICY PROJECT Position Paper: Closing the Gap for Cardiovascular Disease Executive Sunmary Authored by Suzanne G. Haynes, Ph.D, Craig White, M.D., Dennis D. Tolsma, M.P.H., Daniel McGee, Jr, and Jeffrey M. Newman, M.D., M.P.H. EXTENT AND IMPACT OF THE CARDIOVASCULAR DISEASE PROBLEM Today, more than half of all deaths in the United States are attributed to diseases of the heart and vascular system. This paper reviews the status and potential reductions of negative consequences for coronary heart disease (CHD), cerebrovascular disease (stroke), and total cardiovascular disease (all forms of circulatory disease, including CHD and stroke.) Although heart disease and stroke have been the leading and third leading causes of death, respectively, over the period 1940-1980, a significant decline has occurred in the rates of these diseases over the last 16 years. Between 1968 and 1979, the noncardiovascular disease mortality rate declined by 12 percent, while CHD ~ (1~ dropped by 27 percent and stroke dropped by 40 percent. Nevertheless, Lil cardiovascular diseases (CVD) continue to contribute significantly to the N -w1 burden of death, illness, disability and economic costs in the United States. ~ , C711 -B91-

On the basis of 30 years of research, a great deal is known about the risk factors of CVD. Of the many risk factors that have been studied, at least six have come to ba considered standard risk factors for CVD: age; male sex; cigarette smoking; serum cholesterol; systolic or diastolic blood pressure; and glucose intolerance. This paper presents specific estimates of the amount of CHD, stroke, and total CVD that is attributable to changes in each of three risk factors: smoking; elevated serum cholesterol (greater than 219 mg/dl); and elevated systolic blood pressure (greater than 139 mmHg). Specific estimates for three other factors, exercise, diabetes, and obesity, will be added later. The tables of data accompanying this paper document a number of important differences in the distribution of CVD in subgroups of the population. Age-adjusted death rates show that males are at higher risk than females, and blacks are at higher risk than whites. Hence, black males are the race/sex group at highest risk of CVD. In general, blacks have about the same death rates from CHD as whites, but an almost two-fold higher death rate from stroke. Death rates rise steadily from age 35 onward; after age 45, the rates rise about 2 1/2-fold from each 10-year age group to the next. Many of these deaths are premature. One way to quantify the prematurity of death is "potential years of life lost" before the age of 65. For example, a death at age 60 represents 5 potential years represents 20. Nearly 2.5 million years of life lost, one at age 45 of life are lost prematurely because of CVD; CHD accounts for 1.4 million years, while stroke adds 0.3 million. Deaths among males contribute 70 percent of these life years lost. - B92 -

I  I I 4  I I I I I There are no national data with which to monitor either incidence (new cases occurring in a year) or prevalence (the amount of disease existing at a point in time) of CVD. This paper presents estimates of period prevalence of CVD for 1980. although CVD mortality rates have been declining, it appears that the prevalence has increased between 1972 and 1980. Approximately 48 million Americans suffered from some form of cardiovascular disease in 1980. Not suprisingly, morbidity of this magnitude is associated with very large expenditures for personal health care. Expenditures for medical care for heart diseases totaled over $14 billion in 1980, along with $5 billion for stroke. The total medical care expenditures for CVD exceeded $33 billion in that year. POTENTIAL IMPACT OF ELIMINATING CARDIOVASCULAR RISK FACTORS The three risk factors for which estimates are presented in this paper make a major contribution to cardiovascular disease rates. In order to compute the number of deaths or cases of CV1) attributable to each risk factor, we calculated the Population Attributable Risk Fraction (PARF) for each risk factor. -B93- 9

Simply stated, this statistic is the percentage of total events (e.g., deaths) in a population that are attributable to a particular risk factor. Hence, PARF can be interpreted from an etiologic point of view--the causal outcome of a risk factor-or from a prevention view point--the events that would not occur if the risk factor were eliminated. The size of the percentage is influenced by two things: The magnitude of the relative risk, and the prevalence of the risk factor in the population. The larger the relative risk, the larger the PARF, all other things being equal. Similarly, the larger the percentage of the population with that risk factor, the larger the PARF. For example, a very powerful risk factor would have a large relative risk. However, if only a few persons have that risk factor, it would only contribute to a small fraction of cardiovascular deaths. Conversely, even if a risk factor has only a moderate relative risk, but many persons have it, the risk factor can contribute to a large fraction of deaths. In determining the attributable risk for smoking, high blood pressure, and elevated serum cholesterol, the following assumptions were made: o high blood pressure: The paper focuses on the risk from defined hypertension (systolic blood pressure over 159 mmHg) as well as borderline hypertension (systolic blood pressure over 139 mmHg.) In the Hypertension Detection and Follow-up Program, substantial reductions in CVD followed treatment of mild hypertension. o elevated serum cholesterol: The paper defines the risk from elevated serum cholesterol as greater than 219 mg/dl. - B94 -

I I I I I I I I I I I I I r I I I I o cigarette smoking: Since the purpose of the analysis is to define the total CVD attributable to a risk factor, we calculated the PARF assuming the elimination of cigarette smoking. The Population Attributable Risk Fractions presented in this report are based on manipulations of logistic regression equations derived from a CDC-sponsored report by Dr. Lester Breslow and colleagues. Basically, equations from major CVD studies conducted during the past 30 years were pooled to develop a series of equations--for men and women, for whites and blacks, for MI morbidity and mortality and for stroke morbidity and mortality. Prevalence estimates for the three risk factors (by age, race, and sex) are inserted in the equation, and CVD mortality or morbidity outcomes are calculated for those distributions of the risk factors. Outcomes are then recalculated separately assuming the elimination of one of the risk factors. The PARF for that risk factor is the difference between the two outcomes, divided by the CVD mortality or morbidity outcome from the first calculation. The PARF is thus a fraction. We computed it separately for white males, black males, white females, and black females for the age groups 25-44, 45-64, and 65 and older. The actual number of deaths attributed to a risk factor is computed by multiplying that fraction and the 1980 deaths in each age/sex/race group. A number of assumptions must be made in using these equations, which are reviewed in the paper. Smoking Attributable Risk. While smoking has declined overall during the past 15-20 years, this decline masks an increase in the number of cigarettes consumed per smoker and an increase in the prevalence of smoking among women. -B95- IN

A significant portion of the public understands that smoking is harmful--for example, that is causes cancer--but fewer seem to understand that the number of cardiovascular deaths due to smoking actually exceeds smoking-related cancer deaths. A significantly greater proportion of CHn deaths can be attributed to smoking in males, particularly black males, than in females. The PARF for smoking is 33 percent for black males and 21 percent for white males; it is 22.2 percent for males as compared to 3.7 percent for females. This relationship is similar for CHD morbidity, but the 2-fold difference between males and females is less pronounced. Overall, 14 percent of CHD deaths, or about 78,000 deaths, are attributable to smoking. Similarly, cigarette smoking accounts for 14 percent of CHD morbidity, more than three-quarters of a million cases. For smoking and stroke, the PARFs for male morbidity and mortality are almost identical to those for CHn. Overall, about 11 percent, or 240,000 cases, of stroke could be prevented if smoking were eliminated. Smoking is responsible for a total of 145,319 cardiovascular disease deaths in 1980. In excess of 7 million cases of CVD can be attributed to smoking. CVn cases attributable to smoking are not substantially different between white men and white women; however, there are about 80 percent more cases among black men than among black women.

 I  I I I I I I I I I I I I I I I Years of life lost due to smoking-related CVD show some striking differences. Overall, smoking accounts for 15 percent of CVD deaths but 28 percent of CVD lifeyears lost--more than 700,000 person years of premature death. the largest percentage differences are among white women and white men, but the highest PARF--36 percent--was for black men. There is little difference in CHD and stroke fractions for men, but there is a fourfold larger PARF for stroke among both white and black females compared to CHD. All four race/sex groups have very similar patterns. Hypertension Attributable Risk. Reduction of systolic blood pressure for all hypertensives and borderline hypertensives to 139 mmHg or less has dramatic impact on cardiovascular disease mortality. ADproximately 29 percent of CHn deaths, 32 percent of stroke deaths, and 30 percent of total CVD deaths are attributable to high blood pressure. There are no substantial differences among any race/sex group in any of these categories.. The number of CVD deaths averted if high blood pressure were eliminated is 292,504. Some 148,988 of these occur among men, and 142,514 among women. More (164,837) are CHD deaths, and 54,642 are stroke deaths. than half Thc population attributable risk fractions for potential years of life lost are virtually identical for CHID, stroke, and total CVD-about one-fifth of all years of life lost are attributable to high blood pressure, a total of 488,233 years of life annually. However, there is a a striking difference between racial groups. Compared to whites, the PARF for blacks is more than 40 percent higher. - B97 - 

With regard to hypertension-attributable morbidity, the fractions for blacks are again higher than for whites, but only modestly so. Stroke morbidity is consistently higher than CHD for all race/sex groups. More than 7 million cases of CVD cam be attribIted to blood pressure greater than 139 mmHg, and with them nearly 10 million hospital days, 155 million disability days, and $6.3 billion in expenditures for personal medical care. Cholesterol-attributable risk. Ten percent of the nearly 1 million CVD deaths that occur each year is attributable to serum cholesterol greater than 219 mg/dl. Only 5 percent of the CHD deaths and 3 percent of the stroke deaths among men are attributable to elevated serum cholesterol. However, among women, the comparable figures are 19 percent of CHD deaths and 8 percent of the stroke deaths. Thus, 80 percent of the deaths attributable to eleveated ~serum cholesterol occur among women. These tend to be among older persons, so cholesterol accounts for a smaller fraction (9 percent) of potential life years lost than for total mortality. This is especially true for stroke, where cholesterol accounts for only 4 percent of potential lifeyears lost. Population attributable risk fractions for CHD morbidity are much higher than for stroke morbidity-CHD accounts for 22 percent, or 1,162,248 cases of CHD, while stroke only accounts for 2 percent, or 51,724 cases. There is little difference by race or sex in the PARFs. Yet, there are very large differences in hospitalization days and disability days for women compared to men, both for CHD and for total CVD. Elevated serum cholesterol accounts for 184 million or 20 percent of all CVD disability days. Women account for 76 - B98 -

19 11 I I I I I r I I I I I I r I I I percent of the disability days and 86 percent of the hospital days associated with choleaterol-related CVD. Some $7.68 billion in medical care expenditures--23 percent of all CVD expenditures--are attributable to elevated serum cholesterbl. CONCLUSION It is clear from these estimates that a very substantial proportion of cardiovascular disease is attributable to three major risk factors. The paper presents detailed estimates that document a large gap between cardiovascular diseases risks in the population today and those that would exist if these risk factors were not present. For example, for total cardiovascular disease mortality, there are an excess of approximately 150,000 deaths from smoking, 290,000 deaths from high blood pressure, and 100,000 deaths from elevated serum cholesterol. There is an excess of 714,000 potential lifeyears lost due to smoking, 488,000 due to high blood pressure, and 237,000 de to elevated serum cholesterol. Actions to reduce these three risk factors alone have potential to affect between 40 and 50 percent of morbidity and mortality from CHD, stroke, and total CVD. - B99 -

GARaI O\/ASCU LAR' aI TEATE MO BY DISEASE AND RISK FACTOR CHD ® All smokers quit SQ8zhasZQz STROKE SBP's ) 139 become 139 ® RTLI TY TOTAL CVD CHOL's > 219 become 219

a a a a 300 280 260 240 220 200 ~ .-~ 180 0 a~ 160 o 1 40 u Lx s ~ ~ 120 100 80 60 40 20 0 a w a ft w w M w M ft ft ft M M ft CARDIOVASCU LA.R DISEASE BY DISEASE AND RISK FACTOR CHD © All smokers quit V// STROKE SBP's > 139 become 139 M ORTALI TY TOTAL CVD CHOL's > 219 become 219 9U4Gh1.QsL.IlC.

Table 1: Summary of Negative Impact Resulting from Cardiovascular Disease Year of Data: 1980 Number of Deaths Number of Life Years Before 65 Cases Number of Hospital Days Number of Disability Days Cost Associated With Each Specific Health Problem Coronary Heart Disease 565,453 1,426,969 5,404,713 17,080,205 205,636,214 14,606,000,000 Cerobrovascular Disease 169,480 337,673 2,101,274 9,989,321 56,745,625 5,081,000,000 Cardiovascular Disease 984,780 2,555,189 48,283,455 50,631,474 907,388,317 33,184,000,000 L1.lozi7l1szoG - B102 - 1

KKARKARKi i RK i Ann a a& Table 2: Cardiovaacular Di.ea.e Year of Data: 1 980 SPECIFIC NEGATIVF. IHPA CT ATTRIBUTABLE TO SPECIFIC RISK FACTORS HF,ALTH Rlak Deaths Y ears of Life Lost Ho®yi[al Days Diaabllity Dava Co®t (in milliona) Caeen PROBLEM Factor Nu¢ber x Total N umbe r 1 T otal Number Z Total Number z Total Number 1 T otal Number Z'rotal Coronary Smoking 78,418 (14) 397,699 (2R) 2,455,572 (14) 29,314,R09 (14) 1,009 (11) 77n,47R (14) Heart SBP > 140 164,839 (29) 285,103 (20) 3,051,468 (18) 34,127,706 (17) 2,542 (17) 896,975 (17) Di®eaae Chol > 220 62,481 (11) 143,326 (10) 3,680,679 (22) 44,220,709 (22) 1,550 , (24) 1,162,244 (V) Total 305,738 (54) , 826,128 (58) 9,187,719 (54) 107,663,224 (52) I 8,001 (55) 2,929,701 (52) Cerebrovascular Smoking 34,654 (20) 119,142 (35) 875,243 ( 9) 6,477,293 (11) 431 ( R) 239,952 (It) Di.eaee SBP > 140 54,642 (32) 63,804 (19) 2,593,864 (26) 14,457,600 (25) 1,289 (25) 5"iS,361 (25) Chol > 220 9,561 ( 6) 12,828 ( 4) 188,934 (21) 1,396,R20 ( 2) 96 ( 2) 51,724 ( 2) Total 98,862 (58) 195,774 (58) 3,658,041 (37) 22,331,713 (39) 1,816 (36) R26,937 (l9) ~ All Snoking 145,319 (15) 714,423 (28) 6,555,216 (13) 127,742,058 (14) 4,n21 (12) 7 4FR (16) 5?1 0 Cardiovascular S6P > 140 292,504 (30) 488,233 (19) 9,917,397 (20) 155 631 580 (17) 6 293 (19) , , 7 1R2 1n9 (1S) w Diaea.e Chol > 220 101,545 (10) 237,098 ( 9) 9,547,462 (19) , , 184,321,907 (20) , 7,690 (23) , , In,4vn,v06 (22) Total 549,368 (55) 1,439,754 (56) 26,020,075 (51) 467,695,545 (52) 17,994 (54) 25,134,4R3 (52) G1.! Qzi7oszlliz

Paper: Report on Digestive Diseases Author: Richard S. Johannes, M.D. Assistant Professor of Medicine Johns Hopkins University School of Medicine Project - Officer: William H: Herman, M.D. Medical Epidemiologist Technical and Operational Research Branch Center for Prevention Services, CDC Reviewers: Stephen N. Kahane, M.D. Johns Hopkins University School of Medicine John Kurata, M.D. Assistant Professor of Medicine Center for Ulcer Research Veterans Administration Wadsworth Kurt Maurer Chief, Survey Planning and Development National Center for Health Statistics Albert I. Mendeloff, M.D. Professor oT Medicine Senior Asso-ciate, Epidemiology Johns Hopkins University School of Medicine Harold Roth, M.D. Director, Division of Digestive Diseases and Nutrition National Institutes of Health

I I I I I I I I I I I I I I I I I I Executive Summary Carter Center Project Closing the Gap Report on Digestive Diseases Authored by R.S. Johannes, Stephen N. Kahane, H.P. Roth, A.I. Mendeloff, & John H.Kurata. Cla,sification of Digestive Diseases Whenever data such as the information needed for the Carter Center project is_ requested of the Digestive Disease Community, we are reminded that some very elementary epidemiologic data relating to the incidence and prevalence of major gastro- intestinal illnesses are not readily available. There are a variety of reasons for this. It is worth the slight diversion of purpose to examine some of them. First of all, digestive diseases as a group have not had the organization and general support level that has been enjoyed by some other disease oriented disciplines, for example cardiology and oncology. But more important than that is the lack of a clear definition of what is the rubric of digestive diseases. When considering building a system of classification, the designer should consider the basic principles upon which classification systems are built. There are five general axioms commonly used to define the specifications of a classification system. These are exhaustiveness, disjointedness, simplicity, usefulness and constructability. The first two criteria refe'r to the importance of being able to classify every element and to being able to uniquely classify any given element. These are obviously ideal situations but every effort must be made to bring the system of classification as close as possible to these ideals. The next two, simplicity and usefulness, are as pragmatic as exhaustiveness and disjointedness are ideal. The idea is to make a classification system such that its underlying structure can be easily remembered or reconstructed by recalling some fundamental rational for the classification. Usefulness in most cases really means useful to whom. The final idea of constructability is the notion of justification of the overall classification schema. Simple appeal to empirical utility is insufficient to the substantiation of the constuctable nature of a classification system. It is also very important to recognize that classification and nomenclature are not at all the same. A classification implies grouping items with similar traits. A nomenclature is an approved set of terms used to describe a single item. Classification implies data reduction, whereas the - B105 -

use of a first seem importance nomenclature implies data detail. All of this may at off the main target but such a discussion is of major to digestive disease. There is an area for digestive diseases within the International Classification of Disease Codes (ICD) codes . These codes extend from ICD 520 to ICD 579. The recent compilation of and reconciliation of the two most recent ICD coding schemas, versions 8 and 9, completed by the National Digestive Diseases Advisory Board showed many more codes referable to digestive diseases than those contained by the definition of the 530-570 series. In fact, only 66 of 218 codes for digestive diseases fell in the 530-570 series. Many of these codes are of much interest to the digestive disease community. For example, Whipple's disease is listed under infectious disease, hemorrhoids under cardiovascular disease, Zollinger-Ellison under endocrine disorders -- to name but a few. It is the lack of a focused definition that has lead, in large part, to the disparate figures occasionally reported for digestive A fin turning t group dee in measur the table in diseases. al note o a med discu wort ement of , consid classification affairs as we mo DR the in advent of the incentives on have or are report disease. the quality interest oriented T of d in accura recommend group that a conc on the quality o undertaking by an disease. on classification needs to be made prior to ssion of the four digestive diseases which our hy of mention. With the problem of difficulty disease quantity, frequency and impact out on er the adverse effect of even more imprecision than already exists. This is the state of ve into the second half of the 1980's. The G classification system is placing economic pattern of disease reporting. Many hospitals the process of reviewing the methods used to his has a distinct chance of further degrading isease reporting precisely at the time when an te data has peaked. While it is not a disease ation, it was the unanimous feeling of our erted effort to study the impact of DRG coding f disease reporting would be a worthwhile y group with an interest in closing the gap on Digestive Diseases for Discussion 1) Colorectal Cancer 2) Gallbladder Illness 3) Cirrhosis of the Liver 4) Inflamatory Bowel Colorectal Cancer This form of cancer ranks second among causes of cancer deaths. In 1977, there were 92,153 deaths due to colon cancer. The death rate for the same period was 19.6 per 100,100 overall, 18.9 per 100,000 for men and 20.2 for women. The data from the SEER manual compares closely with the above data reported by the NCHS. There are a number of factors of importance in colorectal cancer. First, due to the work of Basil Morson in England, the pathogenesis of the illness is now better understood . Morson's efforts to define the life history of the colonic polyp have revolutionized the thinking about colon cancer. It is now felt - B106 -

I I I I I I I I I I I by Morson that in excess of 98% of all colon cancer takes it origin in preexisting colonic polyps. An NIH panel of experts, convened to discuss screening protocols, felt that a minimum of 85% of cancers arise in preexisting polyps. The time lag from detectability to malignant transformation is of the order of 5 years. This is because polyp size, one of the major factors in determining the sensitivity for detection, is also a major factor determining the risk of malignancy. The key facts relevant to colonic cancer must be assembled from a variety of somewhat disparate data. First of all, Gilbertson in Minnesota was able to demonstrate in a closed population that careful surveillance and removal of polyps can reduce the expected incidence rate of colorectal cancer. Likewise, it has been well recognized that early detection at a time when the extent of the tumor is of Dukes' class A or B rather than C or D will positively influence mortality. There has been some tendency for more early cancers and fewer advanced cancers in recent years. Demonstration that this translates to an overall improved survivorship since 1970 is not available. However, the situation is much the same as cervical cancer in that there is 1) a known preceding lesion, 2) a long lag-time until malignant transformation & 3) effective methods for detecting those at risk. Unfortunately, the methods for detection are neither so inexpensive nor so easy to apply to large populations as is the Pap smear. The methods for searching out polyp bearing adults include: Fecal Occult Blood Testing (FOBT), Flexible and Rigid Sigmoidoscopy, Barium enema, and Colonoscopy. Importantly, colonoscopy can also be used to remove polyps in a non-surgical manner. In fact, colonoscopy is now being widely performed as an outpatient procedure. It is, however, expensive both in terms of dollars and time requirements. Carried to an extreme, if one were to colonoscope all Americans each day, colonic cancer could be largely if not completely eradicated. Since such a wholesale approach to the problem would not be acceptable to patients or health planners, the question become_s one of determining the best strategy. Data pertinent to the problem will be coming from Drs. Sherlock and Winnower at Cornell and from Dr. David Eddy at Duke. Both of these groups are in the midst of studies designed to assess the risk of recurrent polyps and to determine the best overall screening procedures for colonic cancer. The early data from Dr. Eddy has shown that the cost/benefit curve is much flatter than was originallyanticipated. Eddy's data were analyzed by a unique method. Decision analysis methods were used to address the problem. Decision analysis is a formal method for describing a complex interaction of events each of which carries its own probability of occurrence. There are two kinds of events, choice events where the doctor and patient have a the opportunity to make a decision, and chance events where the outcome can not be modified by choice. For example, one can decide based upon conjunctival pallor whether or not to obtain a hematocrit level. Once that decision is made, the actual level of the hemoglobin within the patient is independent of the decision to measure the level and subject to chance. One can speculate on the result, but it remains whatever it is. - B107 -

Consequently, one can have a total of four possibilities, an anemic patient who- went unstudied, and anemic patient who was detected, a normal patient who was not studied and a normal patient whose hematocrit was demonstrated to be normal. It is clear that such reasoning can quickly become very complex, but there are formal mathematical approaches to such problems and it is this methodology involving Markov Chain Modeling that is a the heart of the Eddy models. From the accompanying figures (Fig 1,2,3,4) it can be seen that the greatest benefit occurs with the FOBT in conjunction with one of the forms of flexible sigmoidoscopy. Likewise, there is little apparent benefit from beginning the screening younger than 45. Using a similar but far more simplistic model for estimating overall cost, it became evident that the problem was to bring the cost of such a program into the range of current costs of the natural history of colonic cancer as -treated today. If either the cost of the flexible endoscopies could fall in the order of 30%, or the false positive rate of the FOBT were to be reduced to under 5%, then the cost of a surveillance program could justify itself on the basis of cost. As colonic cancer is the second leading digestive disease in terms of cost, and the leading in terms of deaths, it is fortunate that it is one of the few areas in digestive diseases where a true closing of the gap is possible. Attention to the remaining work needed to define the proper strategy, followed by an aggressive appro`ach to primary prevention of colorectal cancer may be the best opportunity for the Carter Center as regards digestive disease. Gallbladder Disease By all accounts gallbladder disease is a major factor in the numbers of persons affected and in the health care costs which go into its management. The full medicare review of the state of Maine for 1978-1977 done by Dr. John Wennberg for the National Digestive Disease Advisory Board showed that surgery alone for the gallbladder accounted for more total procedures than any other disease. It occurred at a cost of $520,894 and amounted to 19.09% of all claims. This data is in keeping with all efforts to document the magnitude of the problem. Gallstones are indeed common. The real issue, which remains unsettled is: How common? Previously, contrast radiography was used to substantiate the diagnosis. Abnormal oral chole- cystography is knowri to be highly accurate. In the recent past, abdominal ultrasono-graphy has largely replaced the oral cholecystogram. It carries no radiologic exposure and is co- equally accurate. Because of this, more persons are being discovered with gallstones. This occurs just at the time when the first effective oral medications for treatment are coming to market. Admittedly, these agents will offer benefit to a minority, perhaps 13% to 20%, of gallstone victims, but it is these early and oft~en younger patients who may benefit most. The etiology of gallstones is now better understood, but the basic epidemiology is poorly documented. Even so, there is at present no clear target for closing the gap. The best data on - B108 -

a in In  14 In me 94  ~ 4 .  . prevalence (HHANES) 1985. Hispanic per-sons. standard history These is -just now being collect by the Hispanic HANES study which will conclude data collection in January of This part of the HANES activity is surveying 50% of the HANES population, totalling approximately 30,000 These patients will undergo weight measurement, blood chemistries, detailed dietary history, detailed of oral contraceptive usage and abdominal ultra-sound. data prevalence southwest, an effort Hispanic fifth among overall causes of death. It follows only cardiovascular disease, malignant neoplasms of the lung surrounding to 85% to 90%. As asymptomatic patient population provides will provide the best available information on in a population. The survey included areas in the the Dade county area in Florida and New York city in to encompass the Mexican, communities. The resources of the follow-up study. management issue to surgical procedures would be a longitudinal follow-up of this population in an effort to define the proper role for surgery. Cirrhosis of the Liver Cirrhosis is a major cause of mortality nationwide. It ranks major and gastrointestinal has been shown that will require complex care during these Presently, the gallbladder disease discovered an excellent to Cuban, and Puerto Rican most pressing question is what to do with an be harboring stones. This group for continued follow-up. HANES study will not permit such a place to close the gap on an important accounts for millions of dollars in tract, and COPD as a causes of death. It in the last year of life, these patients an average of 5 hospitalizations. Because of the and often extensive transfusion requirements needed hospital stays, the cost of treating this illness is very high. Dr. Mendeloff has contributed the first concrete data on incidence and prevalence of this illness in nearly 20 years. The magnitude of the problem has not changed much over this time interval and neither has the overwhelmingly most common cause -- alcohol. proportion of cirrhosis follow, is of the order of 60% and most liver experts and Dr. Mendeloff would place the proportion of cirrhosis which is alcohol related closer factors considered by the close the gap. Since population cumulative been hard to obtain good data on The best data on the subject is that an average intake of 180 it The most conservative estimates of the caused by alcohol in the United States alcohol control may well be one of the Carter Center, here is a good place to chronic alcoholics are a difficult has risk from alcohol. One which from Germany where it appears grams per cirrhotogenic day for a period of 20 years is the median dose. Whether nutritional status plays a role in susceptibility is studies does not data in finding cause a leading question. The data from animal suggest nutrition will be a major factor, but man is largely lacking. The only other interesting regarding risk is the reduced alcohol dose needed to cirrhosis in women. A explanation for this notable sex difference is - not available at this time. As hepatic transplantation comes into routine clinical practice, its role - B109 -

I in the treatment of the alcoholic cirrhotic may have pronounced economic importance to medicine. Peptic Ulcer Disease Peptic ulcer di_sease is perhaps one of the oldest gastro- intestinal illnesses. It has always seemed to show bumps in its frequency. The role of stress is always mentioned, primarily due to the marked increase seen in London during the period of the bombings during World War II. However, recent work on the frequency of the illness in varied socio-economic groups has lead to an open question on the role of stress. At present, it seems the illness is at least as common if not more common in lower rather than higher economic group. It is very common. This becomes evident- in a listing of hospital days or hospital admissions. It is -not now a leading cause of death in gastroenterology, and the death rate has been progressively decreasing since 1950. The epidemiology of this illness is confused by the fact that just at a time when the demographer of the illness was in -a state of flux, the classification in the ICD codes changed and the use of endoscopy as a means of obtaining accurate diagnostic information was introduced into routine clinical care. As well, very effective oral medications over and above the traditional use of antacids are now available. The introduction of the H2 receptor antagonists and • there movement to market in 1979 has changed the face of peptic ulcer disease dramatically. To make the point, Cimetidine was the largest selling pharmaceutical agent last year with total sales in excess of on billion dollars. There are no known ways to identify patients at risk for the primary development of peptic ulcer. Genetic influence and smoking appear to be the major demonstrable risks. The influence of smoking has been demonstrated on the illness' course not on its incidence. Smoking is known to adversely effect the healing rate of ulcer and adversely influence the mortality due to the disease. Up to 50% of the attributable risk from mortality in peptic ulcer is related to smoking. Despite the commonly held view of dietary influence, no such risk has been shown for any food including alcohol. There are drugs which seem to promote ulcer, but they account only for a small proportion of ulcer patients. These facts are well known in both the medical and lay community and are unlikely candidates for a place to effect the over magnitude of the ulcer load. Smoking and its role in worsening outcome and possibly in increasing incidence risk is the leading candidate for a closing of the gap in this illness. Inflamatory Bowel Disease No compilation of disease magnitude in digestive disease would be complete without mention of inflamatory bowel disease. The illness can only be traced for the last 25 years as the distinction between ulcerative colitis and Crohn's disease - B110 -

r a   a  U    occurred in the 1960's. Much is known about inflamatory bowel disease (IBD)_ but unfortunately none of these facts lend themselves well to a closing the gap strategy. The illness is not a major -cause of mortality, but as can be seen in hospitalization rates, it is a major cause of morbidity. In fact, many gastroenterologists would consider IBD to be the discipline's worst illness. Despite intensive research, we still have no clear understanding of its cause. We also lack an understanding of risk factors and there are no guaranteed therapeutic approaches. Perhaps the one place where a closing of the gap could occur is in those patients with chronic ulcerative colitis of greater than 10 years duration. These patients have cancer risks in excess of over 10 times the normal population. The colorectal cancer. cancers they develop are not typical of Careful surveillance of this popu),ation should reduce the cancer rate in chronic The lessons learned from such an experience to the larger problem of colorectal cancer in ulcerative colitis. may be transferable general. B111

Increase in Life Expectancy from Alternative Screening Strategies FOBT1/CN5 e FOBT1 /FX5(60 e i U = 40-~ 20- 0 250 8 FOBT1 /FX 0 -----+~' Ka 1 500 700 1000 2250 Cost in Dollars per Person 11 Females + Males FOBT1 /R FUBT'1 ® /CN3 3500 LtozhoszQz

asa at.tttaassa sa sa er~ Decrease in Mortality Resulting from Alternative Screening Strategies Cost In Dollars per Person $ 1BZhOSZQZ

150 140 130 n 120 A v 0 110 I ~ U C v .- 100 90 U • a 80 I ~ x W 70 ~ © ~ r- J 60 n 50 0 0 ~ 40 U C 30 20 10-I Increased Life Expectancy by Starting Screen at Various Ages 52 49 46 43 1 4 0 0 1 I 18 43 75 115 165 250 Cost per Person 6 tBZhDSZ0Z a~, a

500 450 in >~ 400 - a sr~ t~ ~ 350 ~ v ~ m 300 a , X ~, w ~ m 250 Increased Life Expectancy as a Function of Different Risks 200 0 m ~ . s ~ 150 `~ 100-I 50 , 250 500 1000 1500 2000 2500 3000 Cost In Dollars per Person o RR = 6 + RR = 4 o RR = 2 e RR = 1 OZgzfiOSzOZ

a a a a a  11 a a 0 a w     M SECTION C. ANALYSIS AND DISCUSSION * *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 r I I I I I I I I r I I The Carter Center of Emory University Health Policy Consultation Atlanta, November 26-28, 1984 CLOSING THE GAP: Cross-Sectional Analysis of Unnecessary Morbidity and Mortality in the United States* Robert W. Amler, M.D.,1 Craig C. White, M.D.,1 Michael K. Berry,l Donald L. Eddins,' Nancy N. Fajman, M.M.Sc.,2 Daniel McGee, Jr.1 1. Centers for Disease Control 2. F.mory University School of Medicine 9

Presented November 26, 1984 We wish to acknowledge the technical assistance of Nancy Pearce, Ronald W. Wilson (National Center for Health Statistics), Judith Biamey (Emory University), William H. Foege, and James S. Marks (Centers for Disease Control). _ The consultants' reports have covered most deaths, or mortality, and most significant illnesses, or morbidity, in the United States. Each year, these 13 health problems account for about about 70% of hospitalizations, 80% of all deaths, and 85% of direct personal health-care expenditures. For each health problem, we have been told what is currently known about the size of the problem, generic causes or reasons for the problem, and the potential prevention of death, suffering, and cost that is projected if those generic factors could be eliminated. Certain factors are especially important because they affect multiple health problems. Often the seriousness of such factors is not immediately obvious. A risk factor normally is viewed as affecting only one or two health problems at a time. But the true impact of a factor may not be recognized unless viewed with respect to multiple health problems in a cross-sectional analysis. For example, the health impact of alcohol cannot be fully measured by looking only at deaths from liver disease, or drunk driving, or the cost of detoxification units. For this reason, emphasis was placed on generic risk factors as they pertained to multiple health problems, to identify those factors most responsible for the gap. MAJOR HEALTH PROBLEMS Unintentional injuries. Dr. Smith and colleagues identified specific injury risks, as well as alcohol, tobacco, and socio-economic position. Diabetes mellitus. Serious complications -- blindness, amputation, kidney failure, and stroke -- could be-reduced substantially by specific preventive health care. The role of tobacco as a cause of vascular disease must also be considered, although difficult to quantify precisely. Digestive diseases. Generic factors include preventive health care (for cancer of the rectum and colon), tobacco (for ulcers) and alcohol (for liver diseases). Cancer. Many Americans fear cancer because it seems mysterious and uncontrollable, yet at least one-quarter of all cancer deaths are caused by ~ known external factors: tobacco, alcohol, improper nutrition, and Q occupational exposures. Other respected estimates suggest one-quarter of all N cancer deaths are due to tobacco-_alone. LrI ~ .~ CG N W - C2 -

I I I I I r I r I I r I I I I I 0 Violence. Many homicides and__suicid_e_s are_rel_ate_d to hand guns and use of alcohol. In addition, there is a complex interaction of substance abuse, cultu rl beliefs, and socioeconomic factors that may be partly amenable to specific prevention services and to improved community supports for youth and for early drug users. Infectious diseases. These deaths are largely preventable through services such as immunization, early diagnosis and treatment, and surveillance. Although tobacco and alcohol probably exacerbate many respiratory infections, the precise effect is difficult to quantify. Dental diseases. The most important dental_diseases -- tooth decay and periodontal disease -- are amenable to preventive health care in the form of fluoridation and specific programs of early diagnosis and treatment. Res irator diseases. Most chronic lung disease is caused by tobacco. Virtually all cases and deaths could be eliminated if tobacco use and certain occupational exposures were eliminated. In addition, specific prevention services can reduce the impact of asthma, tuberculosis, influenza, and pneumonia. Arthritis. The health impact of arthritis and other musculoskeletal diseases is substantial, yet reducible by specific prevention services such as calcium supplementation to prevent osteoporosis. Depression and alcoholism are complex problems that may partially be addressed by early detection and by specific prevention services. Infant mortality and morbidity. Several factors contribute to these problems, including unintended pregnancy, tobacco, alcohol, improper nutrition, preventive health care, and socioeconomic position. Cardiovascular disease. A_s many as two-thirds of these deaths are preventable. These are largely attributable to tobacco, high blood pressure, diet, and lack of exercise. GENERIC RISK FACTORS The goal of this project was to look at risk factors cross-sectionally over multiple health problems. Tobacco is a risk factor for morbidity and mortality resulting from cardiovascular disease and diabetes, cancer, respiratory diseases, digestive diseases, injuries and, perhaps, infections. Alcohol is responsible for__uninten_tional injuries, cancer, violence, infant morbidity and mortality, depression and alcoholism, and infections. -C3-

Injury risks. There_a_re generic risks associated with both unintentional and intentional injuries. Unintended pregnancy is associated with infant morbidity and mortality, and, though difficult to quantify, must impact on maternal health, violence, and depression. Prevention services, though diverse in type and application, clearly are of major importance in reducing morbidity and mortality for almost all of the health problems discussed. Violence, depression, and substance abuse are in fact generic problems which impact broadly not only on the physical and mental health of the individual and the family, but on the health of society as well. ANALYSIS We began this study with a cross-sectional review of the 13 high-priority health problems as reported by the consultants. We standardized definitions of the criteria that were measured to enhance comparability of the data, and made adjustments to minimize duplication between different health problems. Where risk factors overlapped, a "cascade" priority system was used to assign attributable proportions of morbidity and mortality. This model was used with the recognition that it tends to underestimate the impact of factors that are lower in the cascade because it assigns a single underlying cause for each death or event. Although the analysis was driven primarily by mortality data, morbidity was felt to be roughly parallel in most instances. Exceptions to this were arthritis, dental disease, depression and violence. The relative importance of these conditions was substantial when morbidity measures were applied. FINDINGS In 1980, the base-year used in the analysis, the US resident population was just over 227 million. There were 3.6 million births and 2 million deaths, including nearly 47,000 deaths among infants under 1 year old, for an infant mortality rate of 12.6 per 1,000 live births. Premature deaths in 1980 accounted for an estimated 12 million potential years of life lost before age 65. This estimate -- years of_potential life lost before age 65 -- is commonly used to measure premature death, and is derived from the number of deaths that occured in each age group during the year. In 1980, patients received approximately 277 million days of in-patient hospitalization in non-Federal, non-psychiatric, short-stay hospitals. The total national health expenditure was $249 billion. Of this total, $173 billion was expended for direct personal health care: defined as short-term -C4-

I I I I I I I I I I I I I I I I I hospitalization ($92 billion), physician, ($63 bitlion),and drugs ($18 billion). dentist, and other professional care Fil;ure I represents all deaths due to the 13 priority health problems. Sixty-six percent of these deaths are potentially preventable. The risk factors associated with these deaths include: Tobacco, high blood pressure, nutrition, screening, alcohol, injury risks, and others (including prevention services, hand guns, unintended pregnancy, occupational risks). Looking at premature death, as measured by years of potential life lost before age 65, 64.7% of the total is potentially preventable (Figure 2). Either way, about two-thirds of mortality is unnecessary. The distribution of risk fnctors associated with these deaths is somewhat different: Tobacco, alcohol, injury risks, prevention services, screening, unintended pregnancy, high blood pressure, and others (including hand guns, nutrition, occupational risks). The totals are so large -- 1.2 million deaths and 8.4 million years of life -- that minor variations in disease occurrence or in the model used for analysis have little impact on these distributions. Tobacco, high blood pressure, improper nutrition, and screening are important factors where death numbers are concerned. Other factors, such as alcohol, injury risks, prevention services and unintended pregnancy, are equally important because they affect the survival of young people. Impact of tobacco. Tobacco -is the leading cause of death in the United States. Tobacco causes approximately 360,000 deaths each year according to the Surgeon General's reportz or nearly 1,000 unnecessary deaths every day. Most of these deaths occur as heart attacks, strokes, and diabetes, cancer, and chronic lung disease. Note that tobacco causes more deaths by cardiovascular diseases than by cancer. Still, the cancer problem is large. Tobacco leads all other substances as the greatest carcinogen known to man (and to woman) and is responsible for the fact that more women will now die of lung cancer than breast cancer. Furthermore, tobacco causes almost all chronic lung disease -- more than asbestos and coal dust, even among workers who are regularly exposed to those substances. Nearly one-third of Americans who die of heart disease and stroke are less than 65 years old, and one-quarter of these deaths are attributable to tobacco (Figure 3). At least two additional health problems are important causes of premature mortality: Infant_mortality (resulting from low birth weight), and fires/burns. In fact, cigarettes are the leading cause of deaths from house fires -- over 2,000 killed every year, mostly children. And tobacco has other serious effects, such as ulcers and vascular disease. Though seldom resulting in death, these conditions are disabling and often necessitate surgery or amputation of a limb. Impact of alcohol. Alcohol is_the second leading cause of premature death, about I arrd a half million years of potential life lost before age 65 (Figure 4). The most commonly associated conditions are injuries (mostly car -C5- i

 crashes), liver diseases (mostly cirrhosis), alcohol-related violence (homicide and suicide), and cancer (mostly mouth, larynx, and esophagus). All of these conditions -- including cirrhosis -- are particularly tragic because they primarily kill young people. When used excessively alcohol also has serious effects on the heart and nervous systems and on the fetus. Impact of prevention services._ Much unnecessary, premature death is preventable through appropriate prevention services. Specific prevention services include prenatal care and appropriate newborn care, to reduce infant mortality; immunizations, rapid diagnosis and treatment, and surveillance, to reduce infectious diseases; targeted interventions to prevent homicides and suicides; and specific programs to maintain cardiovascular fitness and prevent complications of diabetes. Other appropriate services may prevent or reduce arthritis and osteoporosis, dental diseases, depression, alcoholism, drug abuse, and respiratory diseases. In addition, screening is of considerable importance in preventing deaths from cancer of the breast, cervix, and colon. Beyond preventing unnecessary death and suffering, many of these services have proven cost-benefit, but are not universally available to all Americans, hence, we pay more. Impact of unintended pregnancy is serious, particularly for teenagers. Teenage mothers earn half the income of those who first give birth in their 20's, and teenage fathers are less likely to complete high school than other men. Families in which the mother gave birth as a teenager account for about half of the 9.4 billion dollars paid by AFDC, or Aid to Families with Dependent Children. ,Impact of violence, depression, and substance abuse is substantial, though difficult to gauge from mortality statistics alone. The predilection of these problems for the young and for minority groups has important social implications beyond what statistics can show. Impact of socioeconomic level_has been alluded to repeatedly. Dr. Kaplan has provided some examples of the cross-cutting effect of socioeconomic position on multiple health problems. Each working group may find it useful to consider the role of socioeconomic position when considering specific recommendations. S U24MARY We have defined the gap; it is large and largely closeable. The data presented by the consultants__ clearly indicate that we already know the factors responsible for more than half of all deaths and major illnesses in this country, and those factors are within the realm of existing technology. The challenge now is to use our diverse talents to close the gap. 0 N    N a N   r a U -C6-

a a a a a a K a a a a K a a a a Figure I D EAT H~ ! f',\! U.~. P 0 P U LAT 0 [",T, 1980 1 3 LEADI NG' CAUSES BL.rL.!ZhL.lJSsS.lZ

Figure 2 `1'E,A,R,S) Cj'E hi FE: L(-DST BEEOP E(C-)5 1 ;.~ LEADING CAUSES, U.S., 1980 6ZSZf,OSZQZ I

a a a a a a a a A m m m m m m m m Figure 3 SMO KING - LOSS OF LIFE YEARS LOST BEFORE AGE 65 CIRCUL: (4-1.8%) oE8zhoSzOz

Figure 4 ALCOHOL - LOSS OF LIFE YEARS LOST BEFORE AGE 65 CANCER: (1 .9%) ALCOHOLISM: (12.H%) CIRRHOSIS: (16.9%) [EazfiaszOz

I I I I I I I I I I I I I I I Discussion of Fi.ndings and Selection of Priority Risk Factors Members of the Small Working Group Pre-Consultation Meeting August 29, 1984 Chairman: William H. Foege, M.D. Assistant Surgeon General Special Assistant for Policy Development Centers for Disease Control American Public Health Association (APHA): Susan S. Addiss, M.P.H. Chief Bureau of Health Planning and Resource Allocation Connecticut State Department of Health Hartford, Connecticut American Medical Association (AMA): Theodore C. Doege, M.D. Director Department of Environmental, Public, and Occupational Health Chicago, Illinois Association of State and Territorial Health Officers (ASTHO): Kristine Gebbie, R.N. Administrator Oregon Department of Human Resources State Health Division Portland, Oregon National Academy of Sciences (NAS): Frederick C. Robbins, M.D. President, Institute of Medicine Washington, D.C. Association of Schools of Public Health (ASPH): William F. Bridgers, M.D. Dean School of Public Health University of Alabama - Birmingham I~ Birmingham, Alabama ~ ~ GJ9 continued ~ ~ ~ ~ I

Members of Small Working Group, continued Association of American Medical Colleges (AAMC): Arnold Brown, M.D. Dean University of Wisconsin Medical School Madison, Wisconsin American College of Preventive Medicine (ACPM): M. Alfred Haynes, M.D. Dean Charles R. Drew Postgraduate School of Medicine Los Angeles, California Emory University: Donald 0. Nutter, M.D. Professor of Medicine School of Medicine Atlanta, Georgia Emory University: Eugene J. Gangarosa, M.D. Professor and Director Master of Public Health Program Department of Community Health School of Medicine Atlanta, Georgia University of Michigan Kenneth E. Warner, Ph.D. Professor and Chairman Department of Health Planning and Administration Ann Arbor, Michigan U.S. Department of Health and Human Services (DHHS) Glenna M. Crooks, Ph.D. Deputy Assistant Secretary for Health Washington, D.C. Centers for Disease Control (CDC) Donald A. Berreth Director Office of Public Affairs Atlanta, Georgia Centers for Diseasea Control (CDC) Jeffrey P. Koplan, M.D. Assistant Director for Public Health Practice Atlanta, Georgia -C12-

I I  I I I I I I I I r I I Discussion of Findings and Selection of Priority Risk Factors Initial group discussion of the paper presented by Dr. Amler emphasized the purpose of "potential years of life lost before age 65" as a summary field. This is an accepted measure of age-specific mortality and is reported regularly by the Centers for Disease Control (CDC) in the Morbidity and Mortality Weekly Report (MMWR). Use of this field was not meant to indicate a lack of concern for older individuals, or to imply a judgement that productive life ends at age 65. On the contrary, this measure makes it possible to distinguish conditions that primarily kill younger vs older individuals by contrasting the crude mortality rate for a given health problem, with the calculated potential years of life lost before age 65. A health problem that has a high crude mortality rate and relatively few years of life lost before age 65 generally causes death after 65. Conversely, a health problem that has a low crude mortality, rate and relatively many years of life lost before age 65 generally causes death at very young ages. This distinction is expected to become most important when the Carter Center subsequently considers international health problems. In any case, neither measure of mortality adequately addresses the issue of quality of life. Additional discussion centered on methods used to correct for duplication of cases and overlap of data. Substantial duplication was found for reporting of colorectal cancer h s it l i f ti di b d i l ~ , p o a ec ons, n a etes, epress on, a coholism, and ~ O infections in the first year of life. This overlap, if left uncorrected, LJ1 ~ ~ would have tended to overestimate the impact of certain diseases and certain ,~ ~ - C13 - co W ~ ~ -

risk factors. On the other hand, some bias was inevitable when correcting such different disease groups and data sets. Nevertheless, comparisons of study totals with published national totals allowed reasonable assurance that little significant duplication remained after the authors' correction. For example, the corrected total of deaths from all 13 broad disease groups did not exceed the 1980 U.S. total of two million deaths and was consistent with other published data. Group members listed all risk factors identified by the 13 position papers and the cross-sectional review paper. Additional "quality of life" issues (e.g., socio-economic status, depression, violence, and chronic diseases) were identified by group members and included in the List. After considerable discussion, a total of 18 risk factors were listed (Table 1). These were then ranked as "high," "middle," and "low" priority by each member, considering the negative impact, the availability of interventions, and the likelihood of successful intervention. The composite ranks were used to reduce the list to the nine highest ranked risk factors. Two factors, tobacco and alcohol, were unanimously ranked "high" (Table 2). The group was asked to review the nine factors and add any important factors that were important but omitted or not ranked high enough. One such factor was unintended pregnancy. Unintended pregnancy (which includes unwanted and mis-timed pregnancy and accounts for 55% of all pregnancies) seemed particularly significant considering its documented impact on infant mortality and its uncounted toll in domestic violence, homicide and suicide, mental illness, and socio-econoroic status. - C14 -

I I I I i I I I I I I I I I I I The ¢roup was asked to consider specific intervention stratPaies that addressed the listed Qeneric risk factors and whether the Carter Center was in an appropriate position to intervene. The factors were then ranked as "hiehest," "middle," or "lowest" prioritv for the Carter Center and for the U.S. Government. Four eeneric risk factors were identified as hiQhest priority for the Carter Center -- tobacco, alcohol, iniury risks, and unintencled prP¢nancv. Three additional factors were hitthlv ranked -- and improper nutrition, hand QunR, and dental risks (Table 3). ohecitv The Qrnup concluded itR session by enroura¢in2 the Carter Center, in its unique poFirion, to take hold steps aimed at closine the Gap. Stratejzies developed by the Health Policy Consultation in November should address the Re.lPctefi hieh priority risk factors as well as other qeneric health issues, Fuch as preventive health acr.ivitieR, mental health, and violPnce. -C15- l

TABLE 1. Eighteen Generic Risk Factors Initially Listed by Small Working Group of Health Professionals ------------------------------------------------------------------------------- Tobacco High blood pressure Obesity and improper nutrition *Screening Alcohol Injury risks *Access to treatment *Preventive health services Occupational exposures *Health education Firearms Unintended pregnancy Substance abuse (non-alcohol) Depression Infant mortality Dental risks "Chronic" diseases Violence * Inadequate availability or utilization

r I I I I I I I I I I I I I Table 2. Nine Priority Risk Factors Selected by Small Working Group of Health Professionals ------------------------------------------------------------------------------- Tobacco Alcohol Obesity and improper nutrition Injury risks Unintended pregnancy and infant mortality Hand guns High blood pressure Violence Dental risks ------------------------------------------------------------------------------- Table 3. - Highest Priority Risk Factors -------------------- --- ----------------------------------------------- Tobacco Alcohol Injury risks Unintended pregnancy Obesity and improper nutrition Hand guns Dental risks . ~ ---------------------------------- -------------------------------------------- ~ ~ N -C17- ~ ~ I r

SOCIOECONOMIC POSITION AND HEALTH George A. Kaplan Mary N. Haan S. Leonard Syme Meredith Minkler Marilyn Miszcynski Invited paper. Closing the Cap: Health Policy Project. The Carter Center, Emory University, Atlanta, CA. 26-28 November 1984.

I I I I I I I I I As early as the 12th century, it was recognized that people at the lowest socioeconomic levels in the community have higher death and illness rates. This pattern has been observed throughout the world regardless of whether the major causes of death and disability were from infectious or noninfectious diseases and regardless of how socioeconomic position is measured. Certainly, the overwhelming majority of diseases addressed by the Carter Center fit this pattern. A study we conducted in Alameda County, California, demonstrated that improved survival over an 18-year period was associated with higher socioeconomic position. Vital statistics data for the United States show similar results. For example, in one analysis, it was found that white males with incomes below $2,000 had mortality rates approximately 50% higher than all other males in that age group. The prevalence of specific diseases among the lower socioeconomic population is also higher. For example, in 1972 people with incomes less than $3,000 had three times the rate of heart disease as those with incomes greater than $15,000. The burden of diabetes was almost 3.5 times greater in the poorest group. Similarly, rates of anemia and arthritis were 2.5 times higher for the poor. Table I lists other health problems that are more severe in the lower socioeconomic levels. Although most obvious explanations for these differences are inadequate raedical care, low income, poor nutrition, unemployment, race, and hazardous living circumstances, the weight of evidence indicates these proposed explanations are inadequate. We believe that persons at low socioeconomic levels face greater environmental demands, both physical and social, and have fewer resources (financial and interpersonal) to deal with these demands. This conceptualization, combining demands and resources, may help to explain -C19-

why all persons of low socioeconomic position do not become ill. A person living in a high crime area on a fixed income may have better health if she or he has friends and neighbors on whom to rely for help than another person living in the same circumstances but benefiting from fewer social connections. Furthermore, the balance between demands and resources changes as one moves up the socioeconomic ladder. Although demands may increase, resources increase even faster. This view suggests that changes in demands and resources may help to alleviate the burden of illness associated with lower socioeconomic status. For example, high physical and psychological demands such as monotonous and repetitive work lead to higher rates of cardiovascular disease, especially in workers who have few resources such as control over the pace and timing of work or contact with coworkers. Job-design interventions (such as flex-time or autonomous work units) change the balance of demands and resources, and appear to lower rates of disease. High demands and low resources in the work environment have also been shown to be associated with risk behaviors such as smoking. Because of this, workplace smoking cessation programs are unlikely to be effective unless they also direct attention to reduction of demands and__increase of resources. There are other important examples. Indirect and direct-costs associated with cardiovascular diseases accounted for over $25 billion in 1977. If the bottom 25% of the socioeconomic distribution had had the same disease rates as the median income category, there would have been a quarter of a million fewer cases of heart disease in 1972, a savings of $3.3 billion. Similarly, if white males and females with 1970 incomes less than $6,000 had had the same rates of lung cancer as those with incomes of $8,000-13,000, there would have been approximately 12,000 fewer cases of lung cancer, a reduction of approximately 13%, a savings of $661 million in 1977 dollars. -C20- M . . M W . . n up w ~ tJl O ~ .~ ..+ N

0  a a  ~  a a a  a In summary, we believe that socioeconomic position represents a true generic risk factor worthy of consideration associated with a substantial burden of illness and also with acquisition of other generic risk factors. iiterventions that focus on demands and resources can reduce this toll in terms of medical costs, lost productivity, and human suffering. - C21 - a

Table 1. Health problems that are more frequent at the lower r socioeconomic levels Total mortality Heart disease Arthritis Diabetes Hypertension Angina _ Epilepsy Rheumatic fever Respiratory infections Anemia Lung cancer Esophageal cancer Sino-nasal cancer Infant and child mortality Neural tube defects Tuberculosis Unintentional injury Low birth weight Decreased survival from cancer Decreased survival from heart attack Restricted activity and bed days Days in short-term hospitals Number of hospital discharges - C22 -

al on N a a IN   U U  a r a   U SECTION D. DRAFT RECOMMENDATIONS OF THE WORKING GROUPS 

a a a a  a a a a a a   I   a I STUDIED HEALTH PROBLEMS AND ASSOCIATED GENERIC RISK FACTORS HEALTH PROBLEM INJURIES DIABETES DICESTIVE DISEASES CANCER VIOLENCE DRUG ABUSE INFECTIOUS DISEASE DENTAL DISEASE RESPIRATORY DISEASE ARTHRITIS DEPRF.SSION INFANT MORTALITY CARDIOVASCULAR DISEASE GENERIC RISK FACTORS Injury risks, Alcohol, Tobacco, Socio-economic level Lack of preventive services, Improper nutrition, Tobacco Lack of preventive services, Tobacco Alcohol Tobacco, Alcohol, Improper nutrition, Lack of preventive services Handguns, Alcohol, Lack of preventive/ social services, Socio-economic level Lack of preventive/social services, Socio-economic level Lack of preventive services, (Tobacco, Alcohol) Lack of preventive services Tobacco, Lack of preventive serivces, (Alcohol) Lack of preventive services Alcohol, Lack of preventive services Unintended pregnancy, Tobacco, Alcohol, Improper nutrition, Lack of preventive services, Socio-economic level Tobacco, High blood pressure, Improper nutrition, Lack of exercise 0

Working Groups on Intervention Strategies Selected Generic Risk Factors and Generic Problems Generic Risk Factors Tobacco Use Injury Risks Overuse of Alcohol Unintended Pregnancy Generic Problems Lack of Preventive Services Violence, Depression, and Substance Abuse

D ^ ^ I@ E~] ^ ^ ^ E ^ 7 ^ 0 E ^ ^ D ^ Recommendations of the Working Group On Tobacco Jesse Steinfeld, M.D. President, Medical College of Georgia Augusta, Georgia CHAIRPERSON Craig White, M.D. RAPPORTEUR -D3-

In 1964, a group of consultants, all considered impartial by the tobacco industry and many of whom were heavy smokers, submitted a report to the Surgeon General which indicated that cigarette smoking was a causative or social factor for many diseases including many cancers and cardiovascular and lung diseases. The tobacco industry laughed and said, "You have mad a terrible mistake! Cigarettes cannot cause cance...This is ridiculous." Since then, literally hundreds of thousands of reports, citing statistical, epidemiological and pathological evidence, have shown that the Surgeon General's report was right: cigarette smoking is the single greatest public health hazard in this country. And, it is not surprising when you consider that the human body is not equipped either immunologically or biochemically to handle the more than 6,000 chemicals - many of which are poisonous - in cigarette smoke. Approximately 53 million Americans smoke. Anyway you look at it, that is a devastating number, but it is encouraging to note that cigarette consumption is declining - in the developed nations. However, we express great concern over the rapid increase in the use of tobacco and tobacco - associated diseases in the deveLoping countries. Currently, it is accurate to say that tobacco is one of the most significant health problems in the world today. We must make nonsmoking the social norm. We must through every avenue available, make smoking socially unacceptable. 0 - D4 -

I I I I I I I I I I I I I r I I I Recent surveys reveall that although most people know tobacco is harmful, well over half to three-quarters do not associate smoking with heart disease. They may associate smoking with cancer, but many do not realize that the cancer it causes may be deadly and largely incurable. Everyday, approximately 1,000 people die prematurely from cigarette smoking. 'Chat is equivalent to four jumbo jets crashing each day with no survivors. Can you imagine the outcry in this country if New York, Atlanta, Chicago and Los Angeles had a 747 crash everyday? We would not tolerate it, yet, we have come to accept tobacco, with its monumental risks, as a pervasive element in our society. It is a social norm. We have developed many recommendations that could assist in making nonsmoking the social norm. These recommendations involve increasing the public's knowledge of tobacco, restricting the promotion of tobacco products, increasing litigation against tobacco manufacturers and instigating active economic and public policies. (Please consult the list of intervention strategies which accompany this summary.) We need to work with the media to increase the coverage of smoking, tobacco and health issues and request equal space/time to counteract the effect of advertisements. Maybe we should list all tobacco - related deaths in a separate section in the obituary pages and report tobacco on death certificates as we do the heavy use of alcohol. 19

Recently, the U.S. District Court in New Jersey, gave us a powerful tool in combatting tobacco use: litigation. The judge ruled that people injured from tobacco and who claim the warnings on cigarette packs are not adequate are entitled to the right to present their claims for adjudication. Although highly controversial, this tool could be highly successful. If a number of lawsuits are successful, the cigarette industry could follow the abestos industry and find they cannot afford to manufacture cigarettes because the price is too high. We should restrict the promotion of tobacco products, including smokeless tobacco, by either banning the promotion of all tobacco products or requiring the industry to conform to their own advertising standards which prohibit ads that suggest smoking is essential to social prominence or attraction or portray smokers participating in strenuous physical activity. We must solve the dilemma of the small tobacco farmer and work with insurance companies to establish and expand non-smoker differentials for insurance policies. We could increase the federal excise tax on cigarettes and eliminate the price support and allotment programs for tobacco. And, we should restrict the sale of cigarettes to retail outlets only, and prohibit their sale at all health - care institutions. We should better train our physicians on the hazards to tobacco and encourage them to refer patients to smoking cessation programs. Our efforts to curtail smoking during the last twoj decades have been somewhat successful: some 33 million Americans have quit. Without the programs and public education that have been implemented, we would be a population of 90 million smokers, smoking non-filtered, high-nicotine, high-tar cigarettes. -D6-

no 14 0 U U  U   N N r N N N N N Intervention Strategies to Reduce the Prevalence of Smoking and Tobacco Use Since the first Surgeon General's report on the hazards of smoking was released in 1964, many methods to reduce the prevalence of smoking have been studied and advocated. While slow but steady progress has been made by smoking cessation efforts, more than 350,000 individuals still die every year from smoking-related diseases. Further, although the overall prevalence of smoking has declined, with the nation's increasing total population and higher smoking rates among youth, the actual number of smokers in the U.S. has essentially remained the same. Of those still smoking, the proportion smoking 25 or more cigarettes per day has increased markedly. Tragically, this unnecessary morbidity and mortality is more immediately preventable than current rates indicate. Current attempts to reduce smoking prevalence focus on the individual almost exclusively, rather than on society as a whole, or on groups of individuals at particular risk for smoking uptake or smoking-related morbidity. In an effort to consider both societal as well as individual approaches, strategies to reduce smoking prevalence have been grouped on the following pages into 4 basic categories: Education and Information, Economic Incentives, Restrictive Policies, and System Interventions. The categories themselves are not particularly important; they simply provide a general framework within which intervention strategies can readily be grouped for the purpose of discussion. Specific interventions and efforts appropriate to each category may utilize existing knowledge and resources, and link efforts of health professionals, educators, legislators, and professional organizations. -D7- r

Intervention Strategies to Reduce the Prevalence of Smoking and Tobacco Use OUTLINE I. Education and Information A. Mass Media Efforts 1. Increase knowledge of smoking and tobacco hazards. 2. Encourage and promote smoking cessation. 3. Provide incentives for non-smokers (esp. youth) not to start. 4. Coordinate efforts between multiple agencies and organizations involved in anti-smoking activities. 5. Stimulate public participation in programs to reduce smoking. B. National Health Education Efforts 1. Promote educational activities in primary and secondary schools. 2. Promote educational activities in the community. C. Labeling 1. Develop'index of mutagenicity and include index on all cigarette package labels. II. Economic Incentives/Disincentives A. Subsidies 1. Eliminate the federal price support programs for tobacco. 2. Provide subsidies/low interest loans for farmers (small and large?) growing crops other than tobacco. B. Insurance 1. Expand discounts/rebates/benefits on health and life insurance to non-smokers. 2. Consider reductions in home/property and auto insurance for non-smokers. C. Federal Excise Tax on Cigarettes 1. Continue current tax authorization (expires in 1985), and make tax "ad valorem" so that it will reflect inflation. 2. Increase tax amounts to be commensurate with the direct health care costs attributable to tobacco (on the order of $1.00/pack). Target these revenues for Medicare/Medicaid to offset smokers' higher medical care expenses. III. Restrictive policies on the marketing, promotion, and use of tobacco A. Restrict marketing of tobacco products. 1. Approve sale only at licensed retail outlets. 2. Prohibit sale of cigarettes from vending machines (to make cigarettes less easily available to minors). 3. Prohibit sale of cigarettes in hospitals, nursing homes, other health care facilities, and pharmacies. - D8 -

I I I I I I I I I I I I I r r r I I B. Restrict promotion of tobacco products. 1. Ban all advertising of tobacco products if possible. 2. At the least, prohibit the use of models in advertising. This recommendation was made by the National Commission of Smoking and Public Policy in 1978. This is in keeping with the tobacco companies' voluntary advertising codes which prohibit advertising suggesting that cigarette smoking is essential to social prominence or social attraction, or portraying smokers participating in physical activity requiring stamina or athletic conditioning beyond normal recreation.. 3. If advertising is to continue, require compensatory time and space for health education messages regarding smoking. 4. Require that advertising of tobacco products strictly complies with "truth in advertising" ethics/codes. C. Prohibit smoking in health care institutions and all elementary, junior, and senior high schools. D. Appropriately restrict smoking in alil public areas and the workplace. IV. Integrate intervention activities into existing social systems. A. Health Care System 1. Prohibit smoking in all health care institutions. 2. Take responsibility for providing either direct aid for smoking cessation or appropriate referral to persons/programs which offer such aid. 3. Stress the health hazards of smoking in the education of health professionals and provide complete information regarding the health consequences of smoking and methods for smoking cessation. 4. Stress the importance of professionals serving as appropriate role models by refraining from using tobacco. B. Workplace 1. Provide appropriate guidelines which discourage smoking in the workplace and support non-smokers' rights. 2. Make smoking cessation and education programs available to all employees. 3. Provide incentives for non-smoking in the workplace (bonuses, vacations, dinners, etc.). 4. Generate support for anti-smoking policies and efforts. C. Educational System 1. Prohibit tobacco use in schools. 2. Stress the importance of teachers serving as role models by refraining from using tobacco. 3. Make cessation aid available for faculty, staff, and students. D. Voluntary Agencies 1. Coordinate education efforts on the health hazards of smoking and tobacco use. 2. Coordinate a professional media campaign to discourage smoking. 3. Coordinate cessation activities in appropriate sites. 4. Act as a referral network for professionals and the public regarding cessation programs, and establish guidelines and standards for programs. -D9-

PRIORITIES FOR THE NATION (summary) DRAFT RECOMMENDATIONS provided by the working group on Tobacco Use. Intervention Strategies to Reduce the Prevalence of Smoking and Tobacco Use I. Education and Information A. Mass media efforts B. Health education efforts nationwide II. Economic Incentives/Disincentives A. Subsidies B. Federal excise tax and allotment programs C. Insurance III. Restrictive policies on the marketing, promotion, and use of tobacco A. Restrict marketing practices B. Restrict the promotion of tobacco products C. Restrict smoking to designated areas in schools, health care institutions, the workplace and public places. IV. Integrate Intervention Activities into Existing Social Systems A. Health care systems B. Workplace C. Educational system V. Specifically Target Intervention Activities at High Risk Groups Including Minorities, Pregnant Women, and the Poor

4 4 I 4 I 4 4 4 I I    a  I  PRIORITIES FOR THE CARTER CENTER DRAFT RECOMMFNDATIONS provided by the working group on Tobacco Use. Intervention Strateqies to Reduce the Prevalence of Smoking and Tobacco Use - MAKE NON-SMOKING THE SOCIAL NORM I. MEDIA AND THE TOBACCO/HEALTH MESSAGE A. Work with the media to accurately and appropriately increase the public's knowledge of the hazards of tobacco. 1. Improve communication between: science/health professionals and the media, media and the public, and health professionals and the public. 2. Work with the media to increase coverage of smoking/tobacco and health issues, recognizing that any attempt must deal with the issue of advertising revenues and their influence on publishing practices. B. Restrict the promotion of tobacco products. OR 1. Develop feasible and appropriate methods to accomplish this including either: • The implementation of a total ban on the promotion of all tobacco products (media advertising, sponsorship of sporting and cultural events, complimentary cigarettes). • The requirement that advertising conform to the industry's own standards (e.g., the tobacco companies' voluntary advertising codes which prohibit advertising suggesting that cigarette smoking is essential to social prominence or social attraction, or portraying smokers participating in physical activity requiring stamina or athletic conditioning beyond normal recreation.) Further, require that compensatory space for counter advertising be made available. 2. Immediately require that the promotion of smokeless tobacco products conform to the standards for advertising and promotion of cigarettes. II. TORT LAW: COMPENSATING THE VICTIMS OF SMOKING • Develop a repository of resource material and legal data for use in litigation by victims of tobacco-related disease and death. III. THE MORAL DILEMMA • There is a clear dilemma in several of the southeastern states between the cultivation of tobacco and the health toll exacted by tobacco products. 9

• In North Carolina a group of church leaders raised this issue as a central dilemma facing their state. As this applies to numerous states in the southeast region, the Carter Center should convene a group of church leaders of all denominations to examine these issues and to make recommendations. IV. ECONOMIC AND PUBLIC POLICIES A. Work with the small tobacco farmer to develop means to assist in the transition from tobacco to non-tobacco crops. B. Work with insurance companies to establish and expand non-smoker differentials for insurance policies (e.g., health, life, home, property, auto) C. Lend the moral support of the Carter Center to efforts to maintain or increase the federal excise tax on cigarettes, and to eliminate the price support and allotment programs for tobacco. D. Restrict the sale of cigarettes to licensed retail outlets, and prohibit any sale from vending machines. E. Lend the moral support of the Carter Center to efforts to promote non-smokers' rights. V. ASSIST IN THE PROMOTION OF THE NON-SMOKING NORM BY WORKING WITH LEADERS IN THE FOLLOWING FIELDS TO ACHIEVE THE ENUMERATED OBJECTIVES. A. Health Professionals and Institutions 1. Restrict smoking in all health care institutions to designated areas. 2. Prohibit the sale of cigarettes in hospitals, nursing homes, other health care facilities, and pharmacies. 3. Encourage health professionals to provide either direct aid to patients for smoking cessation or to refer patients to persons/programs which offer such aid. 4. Stress the health hazards of smoking in the education of health professionals and provide complete information regarding the health consequences of smoking and methods for smoking cessation. 5. Stress the importance of professionals serving as appropriate role models by refraining from using tobacco. B. Educators and Schools ~ C 1. Prohibit tobacco use in schools. ~ L.r'I ~ 2. Stress the importance of teachers serving as role models by ~ refraining from using tobacco. ~ ~ 3. Make cessation aid available for faculty staff and students iJl 4. , , . Promote educational activities in primary and secondary schools. M . - D12 -

4 4 4 4 4 I I 4 4 I I I C. Business, Management, Labor, and the Workplace 1. Restrict smoking in the workplace to designated areas. 2. Make cessation and education programs available to all employees. 3. Provide incentives for non-smokers in the workplace (e.g., bonuses, prizes, etc.) NOTE: The group expressed great concern that the rapidly increasing use of tobacco and the occurance of tobacco-associated diseases in developing countries constitutes a significant health problem for the world today. ~ ~ ~ ~ W1 ~ ~ ~ CJ'I I ~ ~j 4 -D13- 9

Recommendations of the Working Group On Unintended Injuries Susan Baker, M.P.H. Professor, Department of Health Policy and Management Johns Hopkins School of Public Health Baltimore, Maryland CHAIRPERSON Dan Horth RAPPORTEUR N Q ~ ~ ~ fV CJ'I - D14 - C~ P P P w  a a ~. w

4 I I I I I I I I I I I Injuries impose a greater burden on modern societies than any disease and this is not shared equally. Rather, it rests heavily on the poor, on teenagers, young children and the elderly. Unlike many other major health problems, a variety of effective preventive measures are available and inexpensive in relationship to their benefits, yet tragically not applied. The task force on injuries chose those measures for prevention with the greatest promise for preventing significant numbers of serious injuries and deaths. Injuries from motor vehicles are the leading cause of death for almost half of our expected span of life. Measures to prevent these injuries exist today but are not being applied. In particular, safer vehicle designs with automatic restraints represent the single - largest opportunity to close the gap that represents preventable injuries and deaths. In addition, seatbelt use is vitally important. Seatbelt laws shouold be promoted in all states in a form that will not jeopardize or delay passive restraint standards. Because of the extremely high death and injury rates involving teenage drivers and occupants, states should develop strategies to reduce teenagers' exposure I I to high - risk driving situations such as night driving and alcohol - impaired driving. Measures include increasing the driving age and restricting driving privileges to daylight hours. ~ ..G Lrl - D15 - LZ I

Alcohol contributes to at least half of all motor vehicle - relared deaths. We recommend that current drunk driving laws and their enforcement be evaluated to identify gaps and loopholes and develop model state legislation. Such evaluation should_include consideration of liability on the part of purveyors of alcohol for injuries caused by drunk drivers. Similarly, liability for other alcohol - related injuries such as fires and shootings should be explored. Home injuries are a serious risk to young children and the elderly in particular. Falls, fires and drownings at home cause about 20,000 deaths each year. Injury control_programs should be developed that focus on the home and that tie together in a cost - effective manner the diverse intervention strategies needed to deal with the many sources of injuries in the home. High priority should be given to building codes that require smoke detectors in all dwellings and childproof swimming enclosures as well as automatic fire extinguishment systems, hot water systems that cannot discharge water hotter than.120 degrees and designs that reduce falls. Injuries from firearms kill 34,000 Americans every year. For ages 15 to 34, they are the second leading cause of death in this country. For young adult blacks, they are the number one cause of death. The poor of all races bear a disproportionate share of the burden of firearm - related deaths and disability. The volatile issue of gun control has drawn attention away from the variety of approaches that might reduce firearm injuries ranging from ~ reducing the importation of easily concealed handguns to designing guns so ~ N U1 - D16 -

a a a   11  0 0 0  that they cannot easily be fired by young children. Occupational injuries kill 13,000 workers each year and permanently disable many times that number. Certain groups of workers are at especially high risk of severe injury. Many job hazards have not been adequately addressed. A few examples are workers on farms with fewer than eleven employees who are not protected under the OSHA laws, pilots of light aircraft for which occupant protection standards are more than 30 years out of date, loggers, train operators and firemen. In conclusion, let me emphasize that the full report includes many recommendations for specific intervention strategies including the 55 mile hour speed limit, motorcycle helmet laws, improved road design, childproof packaging for household chemicals, reduction in work - related noise levels and many others. - D17 - ~

Intervention Strategies to Reduce Injury Risk The unnecessary morbidity and mortality resulting from unintentional injuries places a staggering burden on the individual, the family, and society. Because injury mortality occurs disproportionately among the young, it is a leading cause of years of life lost prematurely. When injuries are not fatal, they can result. in serious and permanent morbidity and disability. Unintentional injuries are of major concern for every facet of society. While for analytic purposes, the "Closing the Gap" Health Policy Project chose to consider intentional and unintentional injuries separately, general injury prevention strategies suggested by the following outline are applicable to both. This outline groups intervention strategies into categories to facilitate their contiitleration and discussion. Regardless of the categories, it is worth noting the experience of experts in the fields of injury control (both intentional and unintentional), health education, and public health who caution regarding the hazards of strategies applied to the individual instead of to groups, communities, or society as a whole. Tnterventions are most successful when they intervene at the community level rather than at the individual level; when they concentrate on modifying environmental factors rather than altering human behavior; and when they require little or no individuall effort. Although these suggested strategies i,iay appear simplistic, the logic and effectiveness of their application requires their statement.

I 4 I I I I I I I I I I I I I I I Intervention Strategies to Reduce Injury Risks I. Industry Efforts A. Vehicular Design 1. Incorporate proven safety features in the design and manufacture of automobiles, including, but not limited to: a. a single, centered rear brakelight at eye level; b. a device which limits an automobile's maximum speed to that commensurate with the automobile's ability to protect occupants from fatal frontal crashes; c. passive restraints including air bags and automatic seat belts; d. bumper height under 21" (to reduce injuries to adults); e. improved exhaust systems which do not allow toxic gases to leak into vehicle; f. warning devices that detect high carbon monoxide concentrations and automatically turn off the engine. 2. Build/modify boats to ensure stability, adequate lighting and availability of flotation devices. 3. Incorporate "rollover" protection design into tractors, powered industrial trucks, and construction equipment (e.g., fork lifts, skip loaders). B. Design of Other Equipment and Products 1. Reduce water heater temperatures at least to less than 1300 F (preferably to less than 1200 F). 2. Require the manufacture of cigarettes that extinguish within 4 minutes. 3. Promote manufacture and use of matches that burn at a lower temperature, self-extinguish when dropped, and are difficult for children to light. 4. Increase the use of flame retardants in household furnishings. 5. Reduce or eliminate manufacture or sale of hazardous chemicals (e.g., change chemical formulation, as in formerly leaded paints). 6. Limit amount of dangerous drug or product per package, (e.g., number of baby aspirin/bottle to less than a fatal dose; single dose units of dangerous household products). 7. Encourage increased corporate responsibility for designing safe products for children. 8. Encourage increased corporate responsibility for providing safe food products for children; label foods that are hazardous for young children. -D19- J

9.. Place air holes in garment bags. 10. Design guns_to reduce incidence of inadvertent discharge; make it difficult for a child or inebriated individual to fire guns. C. Worker Safety 1. Improve ventilation in high risk areas to prevent build-up of dangerous gases. 2. Eliminate wage incentives that lead to increased risk-taking behaviors. 3. Increase the use of robots for dangerous jobs. 4. Limit noise levels so as not to obscure sounds from warning devices. 5. Design worksite layouts that increase visibility by operator of hazardous portions of machinery. 6. Provide and require use of protective clothing and equipment. 7. Provide lifelines for workers near bodies of water. II. Environmental Design Strategies A. Roadways B. In 1. Incorporate modern roadway design and safety features in the development of new roads, and remove hazards from existing roads. a. Remove roadside structures or use only those that decrease crash forces. b. Increase duration of yellow phase of traffic light sequence. c. Separate pedestrians from vehicles by physical barriers. the Home and Community 1. Promote the use of: increased illumination, handrails, childproof barriers, walkways, window guards, and non-skid surfaces on stairs and tubs. Promote the rapid removal of ice and snow from sidewalks. Sand surfaces for playgrounds. 2. Install smoke detectors and sprinklers, especially In high risk buildings. 3. Develop and implement standards for safe swimming pool use and design, including: a. high fences with self-latching gates; b. ready availability of rescue and resuscitation equipment; c. adequate lighting within and around the pool; d. slip-resistant surfaces around the pool. -D20-

I I I I I I I I I I I I I I I I I I 4. Post siyns idNntifying depth, undertow or slippery bank where warranted. 5. If guns must be kept in the home, keep all guns and ammunition locked and inaccessible to children. III. Education A. General Public 1. Broaden the availability arrd use of cardiopulmonary resuscit.ation (CPR) training. 2. Teach and publicize the proper treatment for burns and common injuries. 3. Communicate the nature of imminent hazards with minimal confusion and a minimum of false alarms. 4. Combine educational efforts with other strategies, including community organization and involvement. B. Targeted Groups/Individuals 1. Instruct high-risk groups, or individuals responsible, of their increased risks (e.g., advise epileptics to shower rather than bathe t.o prevent drowning; advise parents of the potential of children choking from common foods). 2. Teach the "Heimlich Maneuver" to parents, child care providers and restaurant workers. 3. Provide trial lawyers with the epidPmiological data on which to base litigation against automakers who fail to provide the most effective methods to reduce motor vehicle injuries and death; apply this strategy for other industries or manufacturers. IV. Health Intervention Strategies A. Health Professionals 1. Encourage health professionals to discourage misuse/abuse of alcohol. 2. Restrict anti-depressant prescriptions. B. Health Care System i. Implement/expand alcohol rehabilitation programs; widen their availability. 2. Support poison control centers. - D21 -

3. Increase the availability of emergency medical services and pre-planned protocols for emergency situations. V. Economic Measures to Reduce Injuries A. Public Programs 1. Fund and provide safe, convenient public transportation. 2. Help low-income persons pay winter heating costs. 3. Provide air-conditioned shelters for individuals at risk for heat-related morbidity/mortality, and provide transportation to these shelters. B. Incentives/Disincentives 1. Encourage insurance companies to cancel liability coverage for manufacturers of faulty or dangerous goods. 2. Provide tax incentives for implementation of new safety designs. 3. Base the tax on wine, beer and liquor on alcohol content. 4. Increase and index the price of alcoholic beverages to inflation. VI. Restrictive Policies and Their Enforcement A. Vehicular Use 1. Enforce motorcycle headlight Laws. 2. Enforce child restraint laws. 3. Require helmet use for motorcyclists, bicyclists and horseback riders. 4. Raise the minimum driving age. 5. Strictly enforce speed laws and lower the speed limit in high-risk areas. 6. Require a physical exam for the elderly prior to their receipt of a driver's license. B. Alcohol Use ~ 1. Raise alcohol purchase age to 21. ~ 2. Restrict advertising of alcohol as socially desirable and Ln harmless. ~ ~ ~ ~ - D22 - CN

I I I I I I I I I I I I I I I I I I 3. Restrict sale and consumption of alcoholic beverages in boating, pool, harbor, marina and beach areas. Impose penalties for operating a boat while intoxicated. 4. Prohibit the sale of beer/wine at convenience stores, gas stations, and fast-food outlets. 5. Encourage/enforce provider liability for damages resulting from serving alcohol to a driver who subsequently sustains/causes injury or death while intoxicated. C. Building Design and Upkeep 1. stringently enforce heat and electrical standards for old and new homes. 2. Enforce building codes for fire doors, fire walls, clearly marked exits, fire extinguishers, and required sprinkler systems. D. Firearms 1. Reduce the availability of guns, especially easily concealed handguns. 2. Reduce the availability of ammunition and/or make it less lethal. 3. Require hunters to wear helmets and bullet-proof vests. - D23 - 9

SPECIFIC RECOMMENDATIONS FOR INTERVENTIONS TO REDUCE INJURIES INITIAL LIST Motor Vehicle Injuries Seatbelt laws that will not delay implementation of the passive restraint standard; Helmet Laws for users of motorcycles, bicycles, mopeds; Reduce exposure of teenage drivers to high-risk situations through curfews, increased driving age, etc.; Speed reduction through 55 mph enforcement-'and changes in top speeds of vehicles; Removal or separation of roadside hazards (unyielding posts, ditches that cause rollover, etc.); Improved public transport. Home Injuries Smoke detectors in all homes; Automatic sprinkler systems in all new homes; ChildprooE enclosures around swimming pools; Housing codes to reduce falls from windows; Firesafe cigarettes. - Occupational Injuries Rollover protection devices on all farm tractors; Reduction of specific hazards for high-risk groups (e.g., crane designs that prevent electrocution of workers); State-of-the-art designs for all new small airplanes that reduce crash injuries. Firearm Injuries Reduced availability of handguns ? Consumer products ? Alcohol - D24 -

I I I I I I I I I r I I I I UNINTENTIONAL INJURIES DRAFT RF.COMME:NDATIONS provided by the working group on Unintentional Injuries National Intervention Priorities I. Motor Vehicle-Related Injuries A. Safe vehicle designs (2)* B. State seat belt laws that will not delay the implementation of the passive restraint standard (3) C. Reductions in exposure of teenagers to high-risk driving situations D. Reductions in driving under the influence, through identification and elimination of loopholes in laws and enforcement, and application of liability laws (4) E. Accurate portrayal of injury risks in the media and provision of role models for injury prevention II. Home Injuries A. Housing codes requiring smoke detectors and childproof swimming pool enclosures for all homes B. Automatic fire extinguishment systems and designs that reduce falls (e.g_, non--skid surfaces, handrails) in all new homes C. Support for reauthorization of Consumer Product Safety Commission and increased funding authorization D. Further the efforts for self-extinguishing cigarettes (5) III. Firearm Injuries - Carter Center Conference (6) IV. occupational Injuries A. Protect workers not currently covered by OSHA (7) B. Address serious work hazards that are not currently being prevented (7) V. General Increase knowledge of injury control in the community, including IN courses in public health, medical, and law schools, and as part of high school and college science curricula CD Lil if N G ~ ~ * numbers refer to items on list for Carter Center ~ ~0 I - D25 - IN

UNINTENTIONAL INJURIES DRAFT RECOMMENDATIONS provided by the working group on Unintentional Injuries. Carter Center Intervention Priorities 1. Designate a Carter Center fellow to take responsibility for injury prevention - 2. Encourage car manufacturers to mass produce a car that incorporates occupant protection features of the research safety vehicle, including airbags. Encourage purchase of such cars by the public, governmental agencies, and industry. 3. Explore with DOT the possibility of reopening the passive restraint rule to remedy the conflict with seatbelt laws. 4. Evaluate current drunk driving laws and their enforcement, and develop model laws 5. Support and promote current activities involving the office of the Assistant Secretary of Health directed toward development of self-extinguishing cigarettes 6. Sponsor a conference and workshops on firearm injuries between health professionals, legislators, manufacturers, and citizens' groups to explore innovative approaches to the problem 7. Identify workers and injury risks that are not being addressed adequately

4 I I I I I I I I I I Recommendations of the Working Group On Preventive Health Care Lester Breslow, M.D., M.P.H. Co-director, Division of Cancer Control Johnson Comprehensive Cancer Center, UCLA Los Angeles, California CHAIRPERSON William Herman, M.D. ~ RAPPORTEUR N ~ L~1 -D27- ~ .~ ~ I I

The American people are on the move toward health maintence, particularly through prevention. Cigarette smoking is declining, cholesterol levels are lower, high blood pressure is coming under control and we see these things reflecting in improved health. For example, heart disease is decreasing at the rate of 2 1/2 percent a year and, except for lung cancer, total mortality from cancer is declining. Life expectancy is increasing, particularly among those beyond 65 years of age. We see our job as helping to accelerate and magnify these favorable trends in health. Our goal is a comprehensive, community - oriented set of services for health promotion and disease prevention that will be available to all Americans. The ultimate decisions affecting prevention are, in many instances a personal matter taken by individuals or families. But these decisions are not made in a vacuum--they are always made in a social context to which attention should be directed. These decisions should encompass those things we ordinarily calt medical care as well as the whole array of personal health practices. We believe that prevention should include not only the avoidance of disease where possible, but also the detection of pathological processes early enough so that corrective action can be taken. Finally, prevention requires action through the entire social system--not just the health field but the educational system, industry and local governments. We propose several strategies to reach our goal. We seek a concensus on standards for personal and environmental health services and for education - D28 -

4 4 I I I I I I I I I I I I I directed towards health maintenance and disease prevention. For each age period in life it is possible to define specific sets of services which are appropriate for health promotion. We should extend present preventive efforts (for example, immunization programs and fluoridation) and extend the coverage of health matters in the mass media to incJ.ude prevention. We need to achieve adequate public and private funding for effective preventive health services with particular attention to universal coverage for specified services. We also must develop and implement prevention - oriented school health services with special attention to food service and physical education. It seems a little untidy of us to teach youngsters about nutrition in the classroom and then send them at 11:45 to a cafeteria where they are presented mainly with various kinds of junk foods. Let us seek new incentives for health professionals to provide preventive services and offer financial incentives to individuals and groups for undertaking preventive activities, for example, through insurance deductibles. - D29 - W ~

Strategies to Improve Preventive Health Care The goal of the "Closing the Gap" Health Policy Project is to identify and implement intervention strategies that address generic factors underlying seemingly unrelated health problems. Data reported by consultants in 13 high priority health problem areas have demonstrated the importance of preventive health care as a significant generic factor in reducing the "gap." Preventive health care is of major importance in reducing the burden of unnecessary illness and premature death due to such diverse health problems as infectious diseases, dental disease, and cancer. It also contributes to the control of diseases and health problems such as diabetes, arthritis, and infant mortality. Preventive health care includes services and programs organized to prevent illness, complications, and/or death. Prevention may be primary in that the disease itself is entirely prevented (e.g., through immunization, flouridation); or secondary in that the disease, while not prevented, is detected early enough to prevent or modify serious health consequences (e.g., from diabetes, sexually transmitted diseases, cervical cancer). In addition, surveillance is an essential component of prevention in that it provides information on changing trends in disease incidence so that appropriate responses may be initiated (e.g., for hospital-acquired infections). The following outline is provided as a basis for discussion of possible strategies to improve preventive health care.

I I I I I I I I I I I I I I r r r r Strategies to Improve Preventive Health Care OUTLINE I. Availability, Accessibility and Utilization of Preventive Health Services A. Availability and Access to Care 1. Ensure the adequate provision of public funds for health services known to be cost-beneficial (e.g., immunizations, flouridation). Provide entitlement funding for these services. 2. Develop new approaches to the funding of preventive health services. 3. Increase and improve the range of preventive health services available (e.g., preventive dental care; screening and early detection of diabetes, cancer, and hypertension; care for patients with arthritis or back pain; care for the diabetic patient). 4. Improve.the distribution of providers of preventive health services. 5. Provide preventive services during hours convenient to individuals requiring necessary services. 6. Provide incentives that reward health professionals for utilizing appropriate preventive health services. 7. Provide transportation for individuals requiring assistance. B. Utilization 1. Provide reimbursement by health insurance plans for essential preventive health services (e.g., screening/early detection programs, preventive dental care, calcium supplementation to prevent osteoporosis). 2. Educate the public as to the benefits of preventive health services. 3. Promote awareness in the community of available preventive health services. 4. Encourage greater public utilization of preventive services. 5. Encourage community sponsorship of preventive health activities. 6. Increase utilization of services by individuals at high risk for preventable health problems by linking social support programs to preventive health services. II. Improving the Quality of Preventive Health Services A. Develop Standardized Recommendations for Preventive Health Services B. Professional Education 1. Ensure that professional schools educate health professionals to deliver comprehensive preventive services which reflect known interventions for preventable morbidity and mortality (e.g., incorporate essential information into medical school curriculum). 2. Stress the health consequences of lifestyle/behavioral factors known to be associated with preventable morbidity and mortality in the education of health professionals. 3. Encourage health professionals to utilize available, standardized recommendations for preventive health care. - D31 -

III. Preventive Health Programs A. Primary and Secondary Prevention 1. Expand and/or maintain programs requisite to the delivery of quality preventive health services (e.g., immunization, flouridation, diabetes control program). 2. Ensure the provision of adequate public funds for programs known to be cost-beneficial (e.g., immunization, flouridation). B. Surveillance 1. Expand and/or maintain surveillance activities to identify and evaluate preventable health problems (e.g., hospital-acquired infections, tuberculosis, sexually transmitted diseases). 2. Expand current surveillance activities to ensure an ability to identify new and unusual problems of public health significance.

4 4 PREVENTIVE SERVICES 4 4 4 4 I 4 NATIONAL PRIORITIES DRAFT RECOMMENDATIONS provided by the working group on Preventive Services. For closing the gap with respect to preventive services we envision a comprehensive community-oriented set of services for health promotion and disease prevention that will be available to all Americans. I. Services should: A. Take into account the ultimate decisions on many preventive services by individuals and families in the context of their social environment; B. Encompass personal health, environmental and educational components; C. Include both primary and secondary prevention; I I 4 I I D. Enlist the health care system with its individuals served, health professionals and third parties; the educational system: elementary schools; high schools, colleges and adult education; the industrial system, including management and labor; and other community organizations such as health departments, voluntary and professional associations. Ii. Strategies recommended for reaching that ideal in health promotion and disease prevention. A. Seek consensus on standards for personal health services, for environmental health services and for educations directed toward health maintenance and disease prevention, specifically: ~ r„ ~ ~ B. ~ I C. ~ 1. Extend what has been accomplished regarding standards in the care of pregnant women and infants to the rest of the age periods throughout life; 2. Extend what has been accomplished in regard to standards for flouridation to the entire physical environment, including the work place; 3. Extend present efforts to define health considerations in fV broadcasting and other mass media as well as in schools and ~ adult education, generally. r%j C.r1 ~ Obtain comprehensive implementation of such standards, for example, ~ in all work places not just the larger ones. ~ ~.I Develop and implement disincentives for unhealthful decisions in addition to incentives for healthful ones. - D33 - - ~

D. Achieve adequate, appropriate public and private funding for effective preventive health services, with particular attention to universal coverage for specified services. 1. Develop and incorporate into "third-party packages" - sets of preventive services that meet people's needs. 2. Encourage organization and funding of preventive services through industry (e.g., employer-sponsored programs and labor-management negotiated programs). 3. Develop arid implement preventive-oriented school health services, with attention to curriculum. 4. Continue and, where necessary, expand public funding of preventive services for needy segments of the populations. 5. Seek new incentives for health professionals to provide preventive services. 6. Offer financial incentives to individuals and groups for undertaking preventive activities. 7. Develop alternate methods of covering individuals for preventive services, including opt.ions for election by people. 8. Support health departments, both legislatively and financially, in training of personnel and redirection of services as a key resource for prevention. E. Explore new ways of providing preventive services (e.g., utilizing new and para-professionals as well as traditional professionals). F. Promote the incorporation of a preventive orientation into medic3l and other health professional education. G. Establish and periodically revise objectives regarding bodily, behavioral, and environmental risk factors for health. 1. Involve people in telling what they need. 2. Provide epidemiological expertise. 3. Popularize the objectives. ti. Develop and maintain surveillance of all phenomena pertinent to (G) above. I. Link appropriately Carter Center activities in prevention to other movements in the field (e.g., to Health Promotion Disease Prevention/Objectives for the Nation, the U.S. Preventive Services Task Force, and the Institute of Medicine). - D34 - W W W r

I I I I I I I I I I I I PREVENTIVE: SERVICES CARTER CENTER PRIORITIES [)RAF'I' RECOMMENDRTION-S-provided by the working group on Preventive Services. To help close the gap in preventive services, we recommend that the Carter Center use its special capacity for assembling coalitions to: 1. Develop and promote a set of personal health services directed toward health promotion and disease prevention that,will be made universally available to the American people; 2. Define and attain the universal availability of community services for education regarding prevention, for environmental health protection and for surveillance of progress toward community health goals; 3. Assure the appropriate training of all types of health professionals in preventive services; and that the Carter Center disseminate widely the work and results of these coalition endeavors. - D35 - I I

Intervention_ Strategies to Reduce the Prevalence of Alcohol Misuse and Associated Complications Frederick C. Robbins, M.D. President, Institute of Medicine National Acadamy of Sciences CHAIRPERSON Patricia Ramia RAPPORTEUR - D36 -

I I I I I I I I I I I I I I ~ Alc•chol accounts for as many deaths each year as the entire Vietnam War. Half of these deaths are the result of alcohol - related accidents, particularly automobile accidents. Many of these deaths are among youth, awarding alcohol the number two spot in the ranking of risk factors leading to the loss of productive years of life. Five key assumptions guided us in our examination of the use and abuse of alcohol. First of all, we have to recognize that our society accepts the moderate consumption of alcohol in low - risk populations. Unlike cigarettes where we can say one cigarette is bad and two are worse, our culture and indeed almost every culture accepts some use of alcohol. Secondly, we felt that any consumption in high - risk groups is to be discouraged. Thirdly, the option of not drinking should be socially acceptable. Fourth, heavy use in all situations is to be discouraged. And lastly, safety and health protection measures that apply across our entire population should be a high priority. Our recommendations to decrease the abuse of alcohol centered on three broad goals: alter the individual and public perception of alcohol use, align public policy with health priorities and provide appropriate prevention and treatment measures. It is important to note that in order to reduce alcohol - related death and disease we must work closely with two high - risk populations: young people who drink to excess and account for many vehicular accidents and pathological drinkers who are dependent are addicted. In the past, education has been seen as necessary and sufficient to deal with ~ alcohol problems. We know that it is necessary but not at all sufficient. [11 -~ N ~ ~ - D37 - I

There are actually three educational approaches to be considered. The first approach teaches that alcoholism is a disease and that alcohol is a major drug. Alcoholism is treatable and it is socially acceptable to seek treatment. The second message is that alcohol problems are linked to other social problems such as unemployment, economic conditions and consumer product safety issues for example. Finally, we need to educate special populations about alcohol abuse. We need to educate those people who make decisions that affect the lives of others: family members, state and local politicians, appointed officials, etc. Our specific recommendations for aligning public policy so as to promote health, which in this instance means discouraging alcohol consumption, include increasing the price of alcohol through tax policy, especially by increasing the federal excise tax on beer and wine. Currently, alcoholic beverages are priced competitevely with soft drinks. This makes the symbolic statement that alcohol is a legitimate alternative in any situation where soft drinks are used. Additionally, we recommend removing the tax deductions for alcohol as a business expense. Corporations now purchase 12% of all alcohol in the U.S. That amounts to $5.6 billion dollars that they are allowed to write off on theirr taxes through expense accounts, gifts and at conventions. And, the alcohol industry legally deducts their advertising costs which total some $1.5 billion a year! - D38 -

4 4 4   U I  I I I I I I I I I I We strongly encourage the development of server - intervention programs. By this, we mean not only the Dram Shop Third Part Liability laws which place the responsibility and liability for providing alcohol to an intoxicated person on the server, but also the proper education of servers and the improvement of the envirnment in which alcohol is served. We need to provide training for servers. They are handling a dangerous drug and sometimes they are giving it to very young people or those who may have been using medication. These servers need to know a lot more information about dispensing this drug. And, we need to design bars that create an environment that is conducive to lower levels of consumption and safer kinds of drinking behavior. We urge the Carter Center to bring together people from the retail industry, the alcoholic beverage industry and community representatives to discuss ways that server - intervention and other approaches to more sensible use of alcohol can be promoted. The Center might adopt a similar approach with representatives of the media in order to encourage the proper portrayal of alcohol use and abuse in the various media, most particularly the mass media such as T.V. - D39 -

Intervention Strategies to Reduce the Prevalence of Alcohol Misuse and Associated Complications Misuse of alcohol has severe adverse health and social consequences on the individual, the family, and society. The health consequences of alcohol misuse/abuse may include intentional or unintentional injury to self, family, friends, or others. The morbidity and mortality resulting from injury in motor vehicle accidents, fires, drownings, falls, and violence is excessive. Other health consequences resulting from alcohol misuse or abuse include cancer, pregnancy-related disorders, diseases of the digestive system, and heart disease. Even when these health consequences are not fatal, there is often serious, permanent disability associated with alcohol misuse that significantly reduces the quality of life for the affected individual. Alcohol is a leading cause of illness and death and is a leading cause of years of life lost prematurely. The following outline attempts to categorize strategies to reduce the problem of alcohol misuse into a framework which allows meaningful discussion of potential intervention strategies and methods. The categories themselves are not important; they are provided only to help organize ideas and discussion. - D40 - NO W . No

a 9  I.    I U I I I I r r r r I I Intervention Strategies to Reduce the Prevalence of Alcohol Misuse and Associated Complications OUTLINE Education and Information A. Mass Media Efforts 1. Increase knowledge of the risks and hazards of alcohol misuse and abuse. 2. Alter public attitudes and awareness of problems associated with alcohol use. 3. Provide incentives for non-drinkers (esp. youth) not to start. 4. Coordinate efforts between multiple agencies and organizations involved in alcohol abuse activities. 5. Stimulate public participation in programs to reduce the prevalence of alcohol misuse. B. National Health Education Efforts 1. Promote educational activities in primary and secondary schools. 2. Promote educational activities in the community. 3. Institute educational programs which help to develop coping skills to resist peer pressure, utilizing community resources (e.g. schools, churches, community organizations). C. Server Education 1. Require adequate server education by licensing boards. D. Societal Norms 1. Establish acceptable social definitions of alcohol use and misuse. 2. Increase the social unacceptability of alcohol misuse. II. Economic Incentives/Disincentives A. Taxation 1. Equalize taxation on beer, wine, and distilled spirits. 2. Increase taxes on all alcoholic beverages. 3. Remove any tax advantages associated with entertaining with alcohol. III. Restrictive policies on the marketing, promotion, and use of alcohol A. Restrict marketing of alcoholic beverages. 1. Restrict hours of sale and serving of alcoholic beverages. 2. Increase the legal age limit for purchasing alcoholic beverages. B. Restrict promotion of alcoholic beverages. 1. Limit the advertising of alcoholic beverages. 2. Limit the extent and manner in which alcohol may be portrayed by the media, the entertainment industry, and in the sponsorship of public events. 3. If advertising is to continue, require compensatory time and space for health education messages regarding the risks associated with alcohol. 4. Restrict the promotion of alcohol consumption by establishments that serve alcoholic beverages (e.g. happy hours, consumption contests). - D41 -

C. Institute policies requiring the labeling of alcoholic beverages to include alcohol content, ingredients, and a warning regarding the hazards associated with alcohol misuse. D. Institute policies which place responsibility on the server/provider for serving/providing alcohol to individuals who subsequently sustain or cause injury or death as a result of their intoxication. E. Increase and consistently enforce existing laws and penalties for violations incurred while intoxicated. IV. Integrate intervention activities into existing social systems. A. Health Care System 1. Provide counseling or aid for alcohol abusers or, if more appropriate, referral to persons/programs which offer such aid. 2. Stress the health hazards of alcohol misuse in the education of health professionals. Provide complete information regarding the health consequences of alcohol misuse and methods for treating this problem. 3. Make health professionals aware that they are at particular risk for misusing alcohol. Educate health professionals regarding alternative coping skills and behaviors. B. Workplace 1. Make educational program3 available to all employees, and, if possible, provide financial support for treatment programs. C. Voluntary Agencies 1. Coordinate education efforts on the health hazards of alcohol misuse/abuse. 2. Coordinate a professional media campaign to discourage alcohol misuse. 3. Coordinate counseling and treatment programs in appropriate sites. 4. Act as a referral network for professionals and the public regarding counseling and treatment programs, and establish guidelines and standards for such programs. - D42 -

I I I 4 I 4 I I I I 4   I I I I I RECOMMF.NDATIONS TO PREVENT ALCOHOL MISUSE NATIONAL INTERVF.NTION PRTORITIES DRAFT RECOMMENDATIONS provided by the working group on Alcohol Misuse. The working group on alcohol misuse identified the following priority goals and activities for intervention. Goal 1 _ Change public and individual perceptions regarding alcohol use. Activity Increase general knowledge and skill development. Suggested topics include facts about alcohol, attitudes, and community action policies. Education should be provided through: 1. media a. b. c. public service messages program content advertisement 2. schools 3. workplace 4. general community Goa1 2 Bring public policy into accord with health priorities. Activity _ Examine and disseminate strategies for community action: 1. local level 2. server intervention Activity _ Modify government policy in the following areas to achieve health goals: 1. taxation 2. advertising 3. sales/distribution Goa1 3 Improve prevention and treatment services. Activity 1. Develop employee assistance programs in the workplace. 2. Encourage insurance companies to establish incentives for healthier lifestyles. 3. Improve curricula of health professionals and challenge them to be role models. - D43 -

RECOMMENDATIONS TO PREVENT ALCOE{OL MISUSE CARTER CENTER INTERVENTION PRIORITIES DRAFT RECOMMENDATIONS provided by the working group on Alcohol Misuse. It is recommended that the Carter Center devote its efforts in the following areas: 1. media 2. taxation policy 3. advertising policy In addition, the Carter Center could generate community action to assist in the above areas.

    I I I I I I I r I I r I r r Recommendations of the Working Group On Depression, Violence and Substance Abuse Thomas E. Bryant, M.D., J.D. Public Committee for Mental Health Washington, D.C. CHAIRPERSON Nancy Fajman, M.P.H. RAPPORTEUR - D45 - 1

DEPRESSION - We must first reduce the stigma associated with depression. Civen the nature of depression, one of the variables that seems most amenable to change is the public's perception of it. We need for people to see that depression is a treatable and understandable disease, and one for which they should not be ashamed_to seek treatment. We need to increase the recognition and treatment of depression by our primary care physicians. This can be accomplished in part by an active program in medical school curricula and continuing education. Plost people with serious or severe depression go to their family doctor rather than a psychiatrist or a psychologist. Therefore we need to train family doctors and their nurses to better recognize and treat this problem. We also need to promote a positive concept of mental health as a desirable quality of life and promote meaningful social roles in the community for ~ persons who are not able to work. VIOLENCE - We must limit the availability of lethal agents -- medication and firearms. This is particularly applicable to both suicides and domestic violence. We also feel it is important to research the epidemiology of firearm injuries. This is almost a completely neglected area. We can also undertake educational efforts to criminalize family or domestic violence. In the past, family violence has been somewhat ignored by the courts but this is changing. We would like to encourage this change and feel - D46 -

I I I I I I I I I I I I I I I I I I a number of positive changes will follow if we can criminalize family violence. An important recommendation is that we undertake efforts to empower women. For example, adequate safety and income opportunities are needed by women who are victims of family violence. We also should increase the availability of shelters for battered women and their children. SUBSTANCE ABUSE - Our primary recommendation is to increase the proportion of drug users in drug abuse programs. Furthermore, efforts should be made to identify users early in their drug careers with the expectation that intervention efforts are more effective at that stage. Efforts should be made to increase funding for youth programs, such as recreational programs that provide alternative activities for young people. We also feel that, because of the high incidence of bacterial and viral infections, we should decriminalize the "works" --syringes and needles. - D47 -

Intervention Strate ig es to Reduce Violence, Depression, and Substance Abuse The impact of violence, depression, and substance abuse on our society is staggering. Not only are these problems important causes of death, they are also major causes of years of life lost prematurely. The toil in terms of morbidity and cost are at least equally large. The predilection of these diseases for the young and t'or minority groups has important social implications beyond those which any measure of morbidity or mortality might portray. The following intervention strategies have been categorized into broad classes to facilitate consideration and discussion. These classes consider both general intervention strategies applicable to all three problems, as well as specific strategies applying to only a single problem. Regardless of the categories, it is worth noting the experience of experts in the fields of injury control (both intentional and unintentional), health education, and public health who caution regarding the hazards of strategies applied to the individual instead of to groups, communities, or society as a whole. Interventions are most successful when they intervene at the community-level rather than at the individual-level; when they concentrate on modifying environmental factors rather than altering human behavior, and when they require little or no individual effort. Although these suggested strategies may appear simplistic, the logic and effectiveness of their application requires their statement. - D48 -

4 4 Intervention Strategies to Reduce Violence, Depression, and Substance Abuse OUTLINE 4 Ll I LJ 7- a I. Education and Information A. General Public 1. Increase education regarding family life, family planning, and child rearing. 2. Promote education regarding the importance of parent-child bonding and family stability. 3. Educate parents and children to identify and acknowledge violent behaviors/impulses (e.g., suicide, domestic violence). 4. Teach appropriate coping/conflict resolution skills. 5. Enhance public education regarding the causes, manifestations, and treatment of violent behavior/impulses, depression, and substance abuse. 6. Integrate psychological education, including stress and stress management, into the public school curriculum. B. Professionals 1. Improve recognition of the victims of violence, depression, and substance abuse by health care professionals, teachers, and clergy. 2. Improve management and treatment of victims of violence, and cases of depression and substance abuse by health care professionals. D F7. ^ 9 ^ a r 14 II. Restrictive Policies and Societal Factors A. Handguns 1. Limit the availability of handguns and small arms ammunition. a. Sell handguns only to groups requiring their use (e.g., military, police). b. Mandate difficult and expensive registration or licensing of firearms. c. Sell ammunition only during hunting season or at approved target practice sites. Increase the price of ammunition significantly. d. Decrease production/manufacture/importation of firearms and ammunition. 2. Implement strategies to reduce the injury potential of handguns and small arms ammunition. a. Place safety guards on guns which require multiple steps to remove, making removal beyond the ability of children and intoxicated adults. b. Develop (and require the use of only) ammunition that is less likely to penetrate the skin, and requires less velocity to fire. c. At the least, require the use of only "fully-jacketed" bullets (as required by the Geneva Convention and used by the military). d. Sell only guns that require reloading for general use. e. Reduce the muzzle velocity of guns provided for general use. - D49 -

B. Mass Media 1. Decrease the portrayal of violence and the acceptance of violence as regular and reasonable elements of life. 2. Restrict programming which includes violent behavior to limit the exposure for youth. C. Social Changes 1. Decrease the cultural acceptance of violence. 2. Define high-risk settings and occupations for violence, depression, and substance abuse, and determine appropriate interventions. 3. Discourage the acceptance and portrayal of males as overly dominant and physically aggressive in societal roles. III. Economic Factors A. General 1. Increase funding for youth recreation programs. B. Violence - 1. Train high risk adolescents in job related skills, and make jobs available to them. C. Depression 1. Improve insurance coverage for psychological disorders. 2. Fund efforts to promote public education, research and treatment of depression. D. Substance Abuse 1. Improve insurance coverage and expand funding for employee assistance programs. IV. Health and Social Services A. General 1. Develop outreach/support organizations for groups at high risk for depression, suicide, and drug abuse (e.g., unemployed, recently bereaved, divorced, chronically ill, children of the mentally ill, children of alcoholics). 2. Reduce consumption of alcohol and other drugs. B. Violence 1. Develop and strengthen existing programs for the detection and treatment of child abuse. 2. Expand the number of shelters for battered women, and the scope of services offered. 3. Interact with police departments and schools to record, intervene in, and help prevent violent incidents. N O N tJ1 O ..~ ~ ~ ~ -D50- ..G

4 4 4 4 4 4 I 0 I I  I I  I I I I C. Depression 1. Improve screening and intervention efforts in primary medical care settings to promote prevention and recognition of depressed and otherwise emotionally disturbed individuals. D. Substance Abuse 1. Identify users early in their drug using careers. 2. Improve access to and increase utilization of substance abuse treatment programs. V. Criminal Justice System A. Violence 1. Have police, courts and laws treat family violence as criminal behavior. 2. Train police/citizen intervention teams. 3. Increase clearance rates for murders and robbers. 4. Improve linkages between police and social services in response to violence. 5. Initiate informal citizen surveillance and silence-witness programs. 6. Educate prosecutors, judges, and juries about woman battering and child abuse. 7. Facilitate access of victims to legal services. 8. Initiate victim- and witness-assistance programs. 9. Increase and consistently enforce penalties for the use of handguns in the commission of crimes. B. Substance Abuse 1. Decriminalize the possession of drug-related paraphernalia and allow over-the-counter sale of needles and syringes without prescription (to prevent the spread of infectious disease). - D51 -

DEPRESSION, VIOLENCE, AND SUBSTANCE ABUSE DRAFT RECOMMENDATIONS provided by the working group on Depression, Violence, and Substance Abuse. GENERAL RECOMMENDATIONS L Depression 1. Develop and promote a broad-based public education campaign designed to reduce the sti a associated with depression (and other mental disorders). This effort will require the active cooperation of those in the mental health field and experts from other fields (e.g., media, communications). 2. Promote efforts to increase the recognition and appropriate treatment of depression by primary care physicians through medical school curricula and continuing education. 3. Promote a positive concept of mental health as a desirable "quality of life." 4. Provide meaningful social roles in the community for persons, who by virtue of their disability (e.g., depression) are unable to work. Violence 1. Undertake efforts to limit the availability and use of potentially lethal agents (medications, firearms). (Suicide/Domestic Violence) 2. Increase research in the epidemiology of firearms injuries. 3. Undertake educational efforts designed to criminalize family (domestic) violence. 4. Undertake efforts to empower women (e.g., adequate safety and income opportunities) who are victims of family violence. 5. Increase the avai7ability of shelters for battered women, with emphasis on appropriate support services. 6. Create alternative assistance for perpetrators within the context of criminalizing the behavior. Substance Abuse 1. Efforts should be made to increase the number of individuals in various types of drug abuse treatment programs. 2. Efforts should be made to identify drug users earl in their drug using careers, with the expectation that intervention efforts can be more effective at that stage. _ D52 -

4 IN a a a  0 I I     I I I Substance Abuse (cont.) 3. Efforts should be made to improve and expand existing treatment services, especially to improve the quality of direct medical care available to those needing such assistance. 4. Efforts should be made to increase funding for youth programs (e.g., recreation) which provide alternative activities for young people. 5. Because of the high incidence of bacterial and viral infections associated with the use of contaminated needles and syringes by drug users, in those states where the possession of such articles is illegal, consideration should be given to decriminalizing their possession (i.e., selling steril equipment to dry users). - D53 - 

DEPRESSION, VIOLENCE, AND SUBSTANCE ABUSE DRAFT RECOMMENDATIONS provided by and Substance Abuse. the working group on Depression, Violence, CARTER CENTER RECOMMENDATIONS With particular regard to depression, violence, and substance abuse, The Carter Center should continue the comprehensive review of the literature regarding the efficacy of proposed health and socio-economic interventions, with the intention of identifying what is already known and not known about them. 1. Develop, apply and evaluate curricula stressing affective education in early school years. (Depression, Violence, and Substance Abuse) 2. Support the development of model protocols at the state and institutional level to train "gatekeepers" in the identification, assessment, and intervention in cases of suicidal and self-destructive behavior and in instances of domestic violence. 3. Convene a special conference enabling scientific research and policy experts to meet with spokespersons from various interest groups to develop strategies to reduce firearms-associated injuries. 4. Convene a special conference to facilitate a dialogue within the Black community regarding issues surrounding high rates of assaultive and violence behavior.

I 4 4 I I I I I I I I I I I 9 I I I Recommendations of the Working Group On Unintended Pregnancy Luella M. Klein, M.D. President, American College of Obstetrics and Gynecology Martin Smith, M.D. President Elect, American Acadamy of Pediatrics CHAIRPERSONS - D55 - i

Unintended pregnancy is a national problem and it requires national attention. In 1980, there were 6 million pregnancies in the U.S., 3.3 million of which were either unwanted or mis-timed--occuring before the woman wanted to have a child. Of these, 3.3 million unintended pregnancies, 1.5 million were terminated by legal abortion. Of the 55 million women in the U.S. of reproductive age, 36 million wish to prevent pregnancy each year. We need to understand that women spend most of their reproductive lives preventing pregnancy. And, as both health - care providers and as a public, we must be mindful of teenagers. There are more than 1 million pregnancies among teenage women each year, 80 percent of them unintended. Data show that a woman who has a child before she is 18 has only a.50 percent chance of completing high school. Without at least a high school education, she has less opportunities to have a productive job and be able to provide for herself and her children. She is usually unwed and often faces a life of public support, perhapssub.jecttng herself and her children to poverty for the rest of their lives. While it is true that unintended pregnancy is more frequent among adolescents and blacks and among lower socio - economic women, these groups do not constitute the largest groups of women who have unintended pregnancies. We can reduce unintended pregnancy. To do so requires the breaking down of myths that have prevailed in our society for decades. One such myth is that ~ contraception is more dangerous than pregnancy. In fact, oral contraceptives Q ~ ~ ~ N ~ ~ ~ - D56 - t M~

11 9 0    I I I  I I I r I r I or IUD's are safer--from a mortality point of view--than using no contraception, except in older smokers on the pill. We need to put these risks into perspective. Never have so many known so much about a drug but been unable to put its risks, its safety and its benefits into perspective. There are more than 3 million women who do not use effective contraception in the U.S. because of fear of complications--not complications but, fear of complications. We must also alter the media presentation of sexual issues. In this country, we sell everything with sex and every night we see instant intimacy with no discussion of the results of instant intimacy. There is almost a conspiracy of silence on television, radio and in printed media a out responsible sex and about pregnancy prevention. More important than simply the advertising of contraceptives are the words contraception, birth control, pregnancy prevention, and sexual responsibility--these things are never discussed on television. It is also important that the media show the male partner having more responsibility and taking an active role in family planning. It is very important for us to enunciate a reproductive health policy with the goals that all pregnancies are intended and cared for. Such a policy needs emphasis throughout society, especially among health - care providers. It iscommon for physicians not to know the mortality rate of various contraceptive methods nor the mortalityrate of pregnancy. The fact that unintended pregnancy is prevalent in our society and is preventable should be a subject for discussion within every professional health care association. ~ -D 57-

Additionally, life education, reproductive health information and sex information should he available in schools and information on these subjects should be presented to parents, teachers, counselors and local PTA's. One of the ways to decrease the risk of unintended pregnancy is to increase self - esteem among those with less education or lower socio - economic status. [de have found that if a woman feels she has few opportunities, that she cannot accomplish something in life or attain higher income and status,' she is likely to see little use in preventing pregnancy. Therefore, wemay need to improve the educational level of women and provide greater access to jobs if we wish to make women feel responsible for themselves and choose contraception or postpone sexual involvement. Some of us in the group were adamant that women should understand that control of their own lives and reproduction is within their reach today. We should not only maintain but improve access to contraceptive services and coordinate with other health services. We support voluntary, confidential contraceptive services for all sexually active persons of all ages. In this era of decreased funding for social programs, it is not popular to recommend moremoney for present programs and projects. But, we should examine these costs closely: the cost of one unintended pregnancy toa teenager for her support, medical care, AFDC, housing, etc., is $18,000, while the cost of comprehensive family planning services is $43.00.

4 4 4 4  I   I M r r r r Intervention Strategies to Reduce Unintended Pregnancy The problem of unintended pregnancy is large and its consequences are serious as indicated by the fact that 55 percent of all pregnancies are unintended. The recent decrease in federal and state funds for family planning services has led family planning programs to charge fees for their services. This charge has come at a time when unemployment and increased costs have made payment for such services difficult for many individuals. For teenagers, the consequences of unintended pregnancies are especially serious. Only 50 percent of women who give birth before age 18 ever complete high school, compared to 96 percent who do not have children before age 20. Seventy percent of men who become parents as teenagers complete high school, compared to 95 percent of those who do not become parents. Teenage mothers earn 50 percent of the income of those who first give birth in their 20's. Families headed by teenage mothers have incomes 80 percent less than the average income for all families. About 50 percent of women in families receiving Aid to Families with Dependent Children (AFDC) have given birth as teenagers. In 1975 about 50 percent of the 9.4 billion dollars in AFDC payments went to families in which the woman had given birth as a teenager. Social scientists who study population changes in different societies recognize four major ways in which childbearing is prevented: They are, 1) postponing marriage, cohabitation or age at first sexual intercourse; 2) contraception including traditional methods of barriers and withdrawal, and more modern methods such as the IUD, hormonal pills and injections, and sterilization; 3) induced abortion by illegal and unsafe means such as Coat han9crs and sticks, or by modern methods ranging from menstrual regulation to dilation and evacuation; and 4) frequent prolonged breast feeding to extend the interval between pregnancies. National and international forums have identified four key ethical rationales for national policies and programs supporting family planning. Consistent with basic American traditions is the right of individuals and couples to choose for themselves the number and timing of the children they have. The second is the health advantage to the mother, the infant, and the family resulting from limiting family size and spacing children. The third principle of distributive justice is the foundation of public health in the United States that promotes the reduction of differences in health problems between the affluent and the poor. This is the rationale supporting the national Title X family planning program and the family planning services received through Medicaid. The fourth principle is the intrinsic value of improving social and economic opportunities which, in developed industrialized nations, are facilitated by having smaller families and by delaying the age of childbearing beyond the teenage years. O ~ C.r'I ~ fV ~ - D59 - ~ ~ ~

Major constraints to preventing unintended pregnancy include the open marketing of sexual behavior outside of marriage. Another factor is the extraordinary lack of information provided about reproductive physiology, the risk of pregnancy, and the benefits and risks of different methods of contraception. European countries appear to have achieved low teen fertility through an acceptance of premarital sexual behavior but emphasize monogamy, sex education and widespread accessibility of contraception. The following is an outline of selected intervention strategies which might be considered in ameliorating the problem of unintended pregnancy in the United States. -

a a a 0  r N N N N N N r r N N N 11 UNINTENDED PREGNANCY INTERVENTIONS DRAFT RECOMMENDATIONS provided by the working group on Unintended Pregnancy. The goal of reproductive health is that all pregnancies in the countryy are intended and cared for so that women, men and their families experience minimum mortality and morbidity. GENERIC INTRRVENTION STRATEGIES I. Social Issues A. Enunciate a reproductive health policy to reduce unintended pregnancies 1. Professional associations 2. Family planning information via mass media 3. State education departments B. Decrease risk of unintended pregnancy 1. Provide jobs (males and females) 2. Increase self-esteem (males and females) C. Alter media presentation of sexual issues D. Emphasize the role/responsibility of the male partner E. Develop minority support for prevention of unintended pregnancy F. Increase the educational level of women II. Information and Education A. Increase public awareness of unintended pregnancy as a high national priority B. Use prototype successful teen programs 1. Encourage postponement of intercourse for both males and females 2. Use positive peer influences C. Stimulate the development of community-based initiatives D. Educate children, PTA, teachers, parents, and professionals (group - specific education) E. Educate women in the understanding that they control their lives and reproduction - D61 -

III. Contraceptive Services A. Increase access B. Coordinate contraceptive services with other health services (i.e., screening, referrals, counseling) and offer screening and counseling for areas of concern surrounding contraceptives (i.e., sexuality, abstinence) C. support confidential contraceptive services for all sexually active persons of all ages D. Provide alternatives/options for dealing with unintended pregnancy E. Prevent the recurrence of an unintended pregnancy by women who have already had one unintended pregnancy (i.e., target high risk groups) IV. Specific Interventions A. High Priority Interventions 1. Evaluate efficacy of family planning programs and develop proposals to meet 1990 objectives for the nation 2. Convene a meeting of media executives, writers, producers, sponsors, actors, etc. to promote responsible sexual portrayals in media 3. Convene meetings of all interested groups such as Right to Life, Pro Choice, ACOG, AAP, etc. to discuss areas of agreement 4. Mobilize minority support B. Other Interventions 1. Increase funding for existing projects 2. Establish a pilot project to determine effectiveness of specific interventions 3. Encourage alliance of ACOG, AAP and other interested organizations for leadership 4. Encourage and provide better teacher and professional education. ~ ~ ~ fJ1 G ~ ~ ~ ~ - D62 - r~"+

. w M r r M r About the Carter Center The Carter Center of Emory University represents a bold adventure in public service. Combining the intensity of academic inquiry with the experience of a former President of the United States, the Carter Center contributes to the capacity of leaders in this nation and throughout the world to study, design, and implement policy for human good. The purpose of the Carter Center is to address, within appropriate facilities and a contructive atmosphere, issues of domestic and interational policy through programs of intensive research, public forums, and consuLtations. In this regard, areas of policy research include environmental quality, economic issues, arms control, health policy, peace and civil and human rights. ~ ~ t•`J t.r9 ~ ..G ~ ~ Production Staff: O Sherry F. Carlin, B. S. N., AnnMarie Kasper, Mary Ellen Kates, J. D., Freida R. Quarles, Pamela Willoughby.