HEALTH STATISTICS

CHRONIC DISEASE PREVENTION

Antiqua Medicina: From Homer to Vesalius

HEALTHFINDER

NAT'L INSTITUTE OF DIABETES AND DIGESTIVE AND KIDNEY DISEASES

"Dance of Death" of Bubonic Plague

Medical Progress Past, Present, and Future

Richard S. Hollis, MD, Clinical Professor of Obstetrics and Gynecology, University of Mississippi, 2500 N State St, Jackson, MS 39215
Southern Medical Journal, Vol. 93, No. 12: 1173-1176, 2000. 2000 Southern Medical Association This is an abridged version of the full text article.

To appreciate the advances that have been made in the last century, I have reviewed the status of health and knowledge that existed in the late 19th and early 20th centuries.
In 1876, when the English surgeon Baron Joseph Lister visited the United States, American surgeons were still consulting the weather to fix the day of an operation and were operating in frock coats. Some believed that a wind from the northeast carried the germ of erysipelas. It was not until then that the surgeons and their assistants began to clip their fingernails and scrub their hands and arms thoroughly with soap and water. They would also dip them into a solution of bichloride of mercury before operating. Also, during this same period, sea sponges were replaced with linen sponges that were boiled. In Europe, Dr. Joseph Plenck had recommended the use of gloves for obstetricians to protect them from venereal infection in the early 1800s. However, it was not until 1890 that Dr. Horatio Storer of the Boston Lying-In Hospital recommended boiled rubber gloves as an occupational safety practice for physicians in the United States. Dr. William Stewart Halsted is credited with introducing the hygienic use of rubber gloves in 1905.

Life expectancy for people born in the United States has changed dramatically. In 1900, life expectancy was influenced by the fact that yellow fever, typhus, and bubonic plague remained formidable foes, and their mode of transmission had not been discovered. Insulin, antitoxin for diphtheria, vitamins, antibacterial drugs, and safe techniques for blood transfusion did not exist. Radiographs were just coming into use in hospital practice. The only form of preventive medical therapy other than the sucking of lemons and limes by sailors to prevent scurvy were the smallpox vaccination. Only 58 organizations were engaged in public health nursing, employing 130 nurses for the entire United States.

The most common items in the billing records of a family physician for patient visits in the 1930s were:
Follow-up incision and drainage of abscess.
Diphtheria immunization.
Follow-up drainage for mastoiditis.
Scrotal tap for epididymitis.

Several important discoveries and significant occurrences in the 20th century brought about a healthier life for United States citizens:
The American Association for Cancer Research was founded in 1907.
Water was first chlorinated in 1908.
The American Society for the Control of Cancer was founded in 1914 (It was later renamed as the American Cancer Society.)
Dr. Jonas Salk introduced polio vaccine in 1953. He, his wife, and their three sons were in the first group to receive the injections. The last case of indigenously acquired poliovirus occurred in 1979.
The elimination of rickets, pellagra, and malaria, as well as a marked reduction of typhoid fever in the United States improved life expectancy.
Diphtheria toxoid was introduced in 1920.
Insulin was discovered by F. G. Banting and C. H. Best in 1922.
Penicillin was discovered by Alexander Fleming in 1928, though it was not studied as an antibacterial drug for 10 years.

Looking at these developments we can appreciate the statement, "Much of the health made in this past century has been the conquest of infectious diseases, often by environmental means of through the use of simple preventative or therapeutic measures such as vaccines and antibiotics."

An Italian physician recorded the first description of a blood transfusion in the 1600s. Later, blood transfusions were used in World War I. However, it was not until 1930 that Karl Landsteiner determined that there were four blood types.

Today, we accept education as essential and are constantly striving to improve on methodology and maintain quality. Undergraduate, graduate, postgraduate, and continuing medical education is foremost in our minds. This has not always been the case.

In the early 1900s, three types of medical schools existed as described by Dr. Flexner. The "first rank" (about 10% of total schools) required 1 year of college work, the "second division" (about 33%) required a high school diploma for entrance, and the remainder of the schools settled for entrants with a grammar school education or some unenforced equivalent. Flexner's report of 1910 was the stimulus for the development of American excellence in scientific medicine and the implementation of the full-time system in clinical as well as preclinical medical education. According to one count, 76 medical schools disappeared from existence between 1906 and 1920, either by ceasing to function or by merging with stronger institutions. Another account recorded the closing of 92 medical schools between 1904 and 1915.

The first specialty group to establish a means for certifying its members was ophthalmologists when they established the American Board for Ophthalmic Examinations in 1916. The American Board of Otolaryngology was incorporated in 1924, and the American Board of Obstetrics and Gynecology was established in 1930. A proposal was made in 1927, a certificate of incorporation was granted by the state of Delaware in 1930, and the first written examination for obstetricians and gynecologists was held on March 13, 1931. In 1951, 11 physicians founded the American College of Obstetricians and Gynecologists (ACOG). As of June 30, 1999, ACOG reported a membership of 39,162.

The formal residency system was developed by Dr. John W. Williams of Johns Hopkins. In 1931, there were 83 residency programs in obstetrics and gynecology approved by the Council on Medical Education and Hospitals of the American Medical Association and the Committee of Graduate Education of the American Board of Obstetrics and Gynecology. Today, 125 medical schools are accredited by the Liaison Committee on Medical Education with 66,000 medical students. More than 7,000 residency programs with 100,000 residents are recognized by the Accreditation Council of Graduate Medical Education, making medical education in the United States the envy of the world.
The development of anesthesia has played an important role in medical progress this century. In their book Control of Pain in Childbirth, Lull and Hingson described historical anesthetic practices. These ranged from relatively modern agents such as barbiturates, opiates, ether, and nitrous oxide, as well as techniques of conductive and general anesthesia, to more archaic agents and techniques, such as cocaine, chloroform, ethyl alcohol, heroin, Jamestown weed, Kane's cocktail, mesmerism (ie, hypnotism), morphine, opium, and rectal ether.

The introduction of analgesics and anesthetics occurred as follows:
Dr. Crawford Long of Jefferson, Ga, used ether in the 1840s and reported his experience in the Southern Medical and Surgical Journal in 1849.
Dr. Kreis first reported the use of spinal anesthesia in obstetrics in 1900.
Dr. Gauz of Freidburg first reported the use of scopolamine in 1906.
Dr. Webster of Chicago was the first to use nitrous oxide and oxygen in the US in 1909.
Dr. Erwin Zwiefel reported on 4,000 cases of caudal anesthesia collected from the literature in 1920.
Drs. Hamblen and Hamlin of Virginia first reported the use of barbiturates in the United States in 1921.
Dr. Pages of Spain first used peridural anesthesia in 1921. However, Drs. Graffagnino and Seyler of New Orleans were the first to successfully apply this procedure for the relief of pains of labor and delivery.
Drs. Meeker and Bonar were the first to use caudal anesthesia in the United States in 1923.
Dr. Gwathmey reported in 1931 the use of rectal ether in 20,000 cases.
Drs. Franken and O'Connor reported the first successful use of spinal anesthesia for a cesarean section in 1934.

Five essential parts of medical progress were developed this century:
An attempt to control infectious processes.
The ability to use blood/blood products safely.
Anesthesia.
Medical education.
Research.

Antibiotics and chemotherapeutics, together with the increasingly available immunizations, have benefited untold millions. Today, we have sophisticated blood and blood volume replacement with accurate scientific control of specific type and volume of blood products and electrolytes. Anesthesia has become a specialty we accept as a given, and we may not express our appreciation for the help we receive.

After the publication of the Flexner Report[1] of 1910, Dr. John W. Williams made this statement:
As far as I know there is only one medical school in the country which is properly equipped for teaching obstetrics and gynecology along the lines of a well conducted German woman's clinic. And I regret to say that it is not at Johns Hopkins Hospital, whose lying-in department is very inferior, and far below the standard maintained by the other departments of that institution. . . . After eighteen years of experience in teaching what is probably the best body of medical students ever collected in this country. . . . I would unhesitatingly state that my own students are unfit on graduation to practice obstetrics in its broad sense, and are scarcely prepared to handle normal cases.

His reason for making this statement was the lack of clinical experience students had with patients.

Please let me know if you would like to acquire the full-text article, complete with tables and bibliography. This is an edited version.




LIFE EXPECTANCY IN THE UNITED YEARS
IN THE LAST 100 YEARS
BY RACE, SEX, AND SELECTED YEARS

1900 1950 1996 Years 1900-96

White Males 46.6 66.5 73.9 + 27.3 Years
Black Males 32.5 58.9 66.1 + 33.6 Years

White Females48.7 72.2 79.9 + 31.2 Years
Black Females33.5 62.7 74.2 + 41.3 Years

All Males 46.3 65.6 73.1 + 26.8 Years
All Females 48.3 71.1 79.1 + 30.8 Years

Source: US Census Bureau, 1998, 2001.



LIFE EXPECTANCY FOR BOTH SEXES AT BIRTH
FOR SELECTED COUNTRIES
PROJECTED YEAR: 2000

WORLD 63.39
UNITED STATES 76.10

FIVE COUNTRIES WITH LONGEST LONGEVITY

1. CHINA/HONG KONG 82.84
2. JAPAN 80.00
3. AUSTRALIA 80.41
4. CANADA 80.01
5. FRANCE 79.19


FIVE COUNTRIES WITH SHORTEST LONGEVITY

1. NIGERIA 55.61
2. PAKISTAN 59.67
3. SOUTH AFRICA 57.17
4. INDIA 61.51
5. BRAZIL 60.87

Where does the US Rank?

17. IRELAND 76.24
18. UNITED STATES 76.10
19. CUBA 75.64
21. MEXICO 75.02

Source: United States Census Bureau, 1998.




LEADING CAUSES OF DEATH IN THE USA
BY SELECTED DISEASE IN 1900 AND 1998

1900: Cause of Death Numbers of Deaths

1. Pneumonia & Influenza 40,362

2. Tuberculosis 38,820

3. Diarrhea, Enteritis, Etc. 28,491

4. Heart Disease 27,427

5. Stroke 21,353

6. Nephritis 17,699

7. All Accidents 14,429

8. Cancer 12,769

9. Senility 10,015

10. Diphtheria 8,056
TOTAL 343,217


1998: Cause of Death Number of Deaths

1. Heart Disease 724,859

2. Cancer 541,532

3. Stroke 158,448

4. Chronic Obstructive
Pulmonary Disease COPD 112,584

5. Accidents 97,835

6. Pneumonia/Influenza 91,871

7. Diabetes 64,751

8. Suicide 30,575

9. Nephritis, Nephrotic Syndrome,
and Nephrosis 26,182

10. Chronic Liver Disease
And Cirrhosis 25, 192
TOTAL 1,873,829




CONTEMPORARY HEART DISEASE IN THE US
CARDIOVASCULAR DISEASE
CONTEMPORARY NATIONAL PROFILE:

Annual Deaths: 725,000

127 Deaths/100,000: Mortality Rate in US

21,000,000 cases of heart disease are reported annually.

58,000,000 Americans suffer from some heart disease.

50,000,000 Americans Suffer from Hypertension or High Blood Pressure.

12,000,000 Americans Suffer from Coronary Heart Disease.

6,200,000 Americans Suffer from Angina Pectoris.

7,000,000 Americans have suffered a Heart Attack.

4,400,000 Americans have had a Stroke.

1,800,000 Americans have Rheumatic Fever.

1,000,000 Americans have Congenital Cardiovascular Defects.

4,600,000 Americans have Congestive Heart Failure.

1 in 2.4 death in the US is from Cardiovascular Disease.

Since 1900, Cardiovascular Disease has been the leading cause of death, except for 1918, the year of the worldwide Influenza pandemic.

In the US, someone dies every minute of every day (1440/day) from Cardiovascular Disease.

Over 500,000 women die from heart disease each year.

Sudden Death: No Previous Symptoms:
Men.57% of those who die of heart disease.
Women 64% of those who die of heart disease.

1999 Total Cost to US for Heart Disease: $287,000,000,000.


STROKES:

1996160,000 Americans died of strokes.

On Average in the United States:

An American suffers a stroke every 53 seconds.

An American dies of a stroke every 3.3 minutes.

750,000 American suffer strokes every year.

Between 1988 and 1997, deaths from strokes declined by 13.4%, but Hospitalization rates increased in the same time period.

Leading Risk Factor for Stroke: Uncontrolled high blood pressure.

25%The Percentage of Americans with Hypertension or High Blood Pressure that have it under control.


Source: National Center for Health Statistics, American Heart Association, Centers for Disease Control and Prevention, 2001; American Heart Association.



LEADING CAUSES OF DEATH IN THE US BY AGE CATEGORY: 2000

AGE GROUP:

00-14 Years Old: 1. Accidents; 2. Cardiovascular Disease, 3. Cancer

15-24 Years Old: 1. Accidents; 2. Suicide; 3. Cancer

25-44 Years Old: 1. Accidents; 2. Cardiovascular Disease; 3. Cancer

45-64 Years Old: 1. Cancer; 2. Cardiovascular Disease; 3. Accidents

65-74 Years Old: 1. Cardiovascular Disease; 2. Cancer; 3. Chronic Obstructive Pulmonary Disease

75 and Over: 1. Cardiovascular Disease; 2. Cancer; 3. Chronic Obstructive Pulmonary Disease.



LEADING CANCER SITES BY GENDER AND DIAGNOSED CASES, 1998 ESTIMATES:

MALE FEMALE

1. Prostate: 184,500 Breast: 178,700

2. Lung: 91,400 Lung: 80,100

3. Colorectal: 64,600 Colorectal: 67,000

4. Urinary Cancer: 39,500 Endometrium: 36,100


LEADING CANCER DEATHS BY SITE AND GENDER: 1998 ESTIMATES:

MALE FEMALE

1. Lung: 93,100 Lung: 67,000

2. Prostate: 39,200 Breast: 43,500

3. Colorectal: 27,900 Colorectal: 28.600

4. Pancreas: 14,000 Pancreas: 14,900

Source: Centers for Disease Control; National Center for Health Statistics, 1998, 200, 2001.



DIABETES MELLITUS: 1998, 2000 Statistics

15.7 Million Americans are estimated to have diabetes in the US:
10.3 Million are diagnosed cases, and
05.4 Million are undiagnosed cases.

New Cases Diagnosed Per Year: 798,000.

In 1996, there were 193,140 deaths attributed to Diabetes or its complications.


1998 Death Rates:
White Males: 24.9/100,000 population or 13.8% of all Diabetes deaths.

Black Males: 46.6/100,000 population or 28.9% of all Diabetes deaths.

White Females: 19.6/100,000 population or 10.6% of all Diabetes deaths.

Black Females:: 49.0/100,000 population or 28.5% of all Diabetes deaths.


Two of three people with Diabetes who die will die of heart or blood vessel disease.

Heart Disease is the leading cause of Diabetes-related deaths in the US.

Type II Diabetes or Adult-Onset Diabetes accounts for 90%-95% of all cases of Diabetes.

High Risk for Diabetes Groups:
1. African Americans
2. Non-White Hispanics
3. Native Americans
4. Native Alaskans

For Adults 20-74, Diabetes is the leading cause of new cases of Blindness (Retinopathy).

Diabetic Retinopathy: 12,000-24,000 cases of Blindness each year.

Diabetes is the leading cause of End-Stage Renal Disease (Dialysis or Transplantation).

More than 50% of Lower Limb Amputations in the US are the result of untreated Diabetes.

60%-70% of all people with Diabetes experience Nerve System damage.


PREVALENCE OF DIABETES BY RACE/ETHNICITY IN PEOPLE 20 YEARS OR OLDER:

Non-Hispanic Whites: 11.3 Million or 7.8% of all non-Hispanic whites.
Non-Hispanic Blacks: 2.3 Million or 10.8% of all non-Hispanic blacks.
Mexican-Americans: 1.2 Million or 10.6% of all Mexican-Americans.
Other Hispanic/Latino Americans: Sufficient data not currently available to derive more specific data. Twice as likely to have diabetes as non-Hispanic males.
American Indians/Alaska Natives: 9% of all American Indians and Alaska Natives.
Asian Americans and Pacific Islanders: Prevalence data for diabetes insufficient and limited.


COMPLICATIONS OF DIABETES:

1. Heart Disease
2. Stroke
3. High Blood Pressure
4. Blindness
5. Kidney Disease
6. Nervous System disease
7. Amputations
8. Dental Disease
9. Complications of Pregnancy
10. Diabetes Ketoacidosis; Hyperosmolar Nonketotic Coma

Source: National Centers for Disease Control; National Center for Health; 1998, 2000; American Diabetes Association.



Source: National Centers for Disease Control; National Center for Health; 1998, 2000.



US TOBACCO USE BY VARIUS CATEGORIES OF AMERICANS: 1965, 1998, 1999, 2000,2001

Source: Centers for Disease Control Data and Statistics; National Center for Health Statistics.


1999 Percentage of US High School Student Population Who Smoke by Race, Gender, Ethnicity:

Cigarettes Smokeless Tobacco

White Males 38.2% 18.8%
White Females 39.1% 1.5%
Black Males 21.8% 2.5%
Black Females 17.7% 0.2%
Hispanic Males 34.0% 6.1%
Hispanic Females 31.5% 1.8%


High School Students Smoking in the US, 1991-1999:

1991: 27.5%
1993: 30.5%
1995: 34.8%
1997: 36.4%
1999: 34.8%



US Smokers 18 Years of Age and Older by Race and Gender, 1999:

Men Women

Whites 26.5% 23.6%
Blacks 29.0% 21.3%
Hispanics 24.7% 13.3%
Asian/Pacific
Islanders 17.9% 9.9%
Native Americans 41.7% 38.1%


CATEGORY 1965 1998 18 and Over, by Sex, Race.
All Persons 41.9% 24.0%
Male 51.2% 25.9%
Female 33.7% 22.1%
White Male 50.4% 26.0%
Black Male 58.8% 29.0%
White Female 34.0 22.6%
Black Female 31.8% 21.1%


1998: Largest Percentage of Smokers by Age Categories, Gender and Race:

18 and Over, Age Adjusted: Black Males, 29%
18 and Over, Crude: Black Male, 29%
All Males, 18-24, 31.3%
White Male, 18-24, 34.1%
Black Males, 46-64, 37.3%
All Females, 35-44, 26.4%
White Females, 18-24, 28%
Black Females, 35-44, 30.0%
Lowest of any Age and Racial Group: Black Female, 18-24, 8.3%


430,000 US Deaths Attributable Each Year to Cigarette Smoking, 1990-1994:
Average Annual Numbers of Deaths:

1. Lung Cancer: 123,000
2. Coronary Heart Disease: 98,000
3. Other Diagnoses: 81,000
4. Chronic Lung Disease: 72,000
5. Other Cancers: 32,000
6. Stroke: 24,000

Source: CDC, MMWR 1997: 46: 448-451.



Press Release, CDC, October 12, 2001, MMWR, Vol. 50, No. 40:

Recent decline in smoking may be due to the 49-cent price increase in cigarettes from December 1997 to December 1999.

In 1999, 47 million adults in the US were current smokers.

Smoking prevalence was highest among those aged 18-24 27.9%) and 25-44 (27.3%).

Smoking prevalence was highest among American Indians/Alaska Natives (40.8%), an lowest among Hispanics (181%) and Asian Americans(15.1%).

Among income groups, smoking was highest among adults living below poverty (33.1%).

In terms of educational attainment, adults with a GED had the highest smoking prevalence (44.4%), while those with masters, professional, or doctoral degrees had the lowest prevalence (8.5%).

An estimated 45.7 million US adults were former smokers in 1999, including 25.8 million men and 19.9 million women.

Daily smoking rates among female high school seniors have increased from 17.9% to 23.6% in 1997.

Between 1960 and 1990, the death rate from lung cancer among women increased by more than 400%.

In 1987, lung cancer surpassed breast cancer as the number one cause of cancer deaths among women. The American Cancer Society estimated that in 1998, lung cancer killed 68,000 women, and breast cancer killed 43,500 women. More than 152,000 women died from smoking-related disease in 1994.

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CANCER IN THE UNITED STATES...1950 TO 1994

Atlas of Cancer Mortality

Results -- National Mortality Rates

During the 25-year study period 1970-94, more than 9.5 million whites and 1.1 million blacks died from cancer (Table 1a). The national annual age-adjusted mortality rates per 100,000 person-years for all cancers combined ranged from 136 among white females to 294 among black males. Although counts and rates for more than 40 specific categories of cancer are presented, almost 60 percent of all cancer deaths among males were due to 4 primary sites of cancer: lung, prostate, colon, and pancreas. Among females, nearly 60 percent of all cancer deaths were due to cancers of the breast, lung, colon, ovary, and pancreas. During the 20-year study period 1950-69, more than 4.8 million whites died from cancer.

The 1970-94 national mortality rates for all cancers combined were 54 percent higher among white males than females and 84 percent higher among black males than females. Most forms of cancer were more common among males than females, except for cancers of the breast, gallbladder, and thyroid. Among whites, the male/female rate ratio was highest for lip cancer, surpassing 10-fold, while ratios were also notably high for cancers of the larynx, esophagus, and bladder, each exceeding three-fold. Among blacks, the male/female ratio was highest for cancer of the larynx (6.5), followed by cancers of the oral cavity and pharynx, and the esophagus, each ratio being four-fold or greater. The male/female ratio for lung cancer was nearly three-fold among whites and nearly four-fold among blacks. Due to the large numbers of deaths, all male/female rate ratios were significantly different from unity.

The U.S. rates for all cancers combined were 40 percent higher among black than white males and 17 percent higher among black than white females. For most specific forms of cancer, rates were higher among blacks than whites. The excess among blacks was most pronounced for esophageal cancer, with a black/white ratio exceeding three-fold in both males and females. Black/white ratios ranged between two- and three-fold for cancer of the cervix uteri among females; for cancers of the penis, prostate, oral cavity, and stomach among males; and for multiple myeloma in both sexes. On the other hand, rates for about one-third of all the cancers were higher among whites than blacks, most notably for cancers of the lip (males only), testis, eye, and brain, and for melanoma and non-Hodgkin's lymphoma. Most of the black/white rate ratios were significantly different from unity, except for rectal cancer among males, lung cancer among females, and nonmelanoma skin cancer in both sexes. The sex and race ratios varied somewhat with age. For all cancers combined, the higher rates among black than white males were limited to those aged 40 years and older, while the higher rates among males than females were primarily among those aged 60 and older.

Cancer mortality rates increased logarithmically with age, at least up to about age 40 for melanoma of the skin and cervical cancer, age 50 for breast cancer, and age 60 for many other sites. At older ages, the rates for certain cancers, such as cancers of the nasopharynx, oral cavity and pharynx, esophagus, larynx, lung, and brain, and Hodgkin's disease, did not continue to rise. Age-specific rates were bimodal for cancers of the bones and joints, testis, brain, and other endocrine glands, and for Hodgkin's disease and leukemia.


Devesa SS, Grauman DG, Blot WJ, Pennello G, Hoover RN, Fraumeni JF Jr. Atlas of cancer mortality in the United States, 1950-94. Washington, DC: US Govt Print Off; 1999 [NIH Publ No. (NIH) 99-4564].

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