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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