proved economic conditions. Illustrative of the first factor is that in 1959 only 15 percent of ever-married women of childbearing age were childless. In 1950 the corresponding percentage was 23 and in 1940 the percentage was 27. Also an increasing proportion of couples are starting their families at an earlier age and more are having two to four children as compared with earlier years (fig. 3). The substantial increases in births during the past 20 years have significantly changed and will continue to change the age structure of the population. The major change is in the proportion of the population under 15 years which rose from 25 percent in 1940 to 31 in 1960. The proportion 65 years and over increased from 7 to 9 percent due to the relatively large numbers of births in the late 19th century, a high level of immigration, and declining mortality. In contrast, the proportion of persons aged 15 to 64 declined from 68 to 60 percent (fig. 4). The median age of the population rose from 29 years in 1940 to 30.2 in 1950 despite the increase in births, but declined to 29.5 years in 1960 because of the increase in the population at the younger ages. These population changes have had and will continue to have dramatic effects on the needs for various public services. The increase in persons under 20 years of age from 45 million in 1940 to 51 million in 1950 to 69 million in 1960-has required large-scale expansion of educational facilities and health and welfare services and has raised the requirements for housing, food, and a wide range of other products and services. There will be increased demand by 1970 and 1980 in the need for these facilities and services; such incurred demands will be almost completely independent of future birth rates. The rise in numbers of persons 65 years and over-from 9 million in 1940 to 12 million in 1950 and almost 17 million in 1960-has likewise increased needs for facilities and services of particular importance to the older ages (fig. 4). The more rapid reduction in mortality of women compared with that of men caused a continuation of the fall of the sex ratio in the population. In 1960 there were 97.8 males per 100 females in the entire population. At ages 25 to 44 the ratio was 96.9; 45 to 64, 95.8; and for persons 65 and over it dropped to 82.8. These figures take an added meaning when it is noted that in 1961, 39 percent of all women 55 years and older were widowed as compared wih 12 percent of the The number of widows at these ages was almost four times as large as the corresponding number of widowers. At ages 65 and over, 53 percent of all women are widows. men. The total age-adjusted death rate for females declined 65 percent from 1900 to 1960, while the rate for males fell only 49 percent (fig. 5). The death rates for females have decreased more rapidly than those for men at all ages, but the differences have been particularly notable after age 44. Between 1940 and 1960, the nonwhite population increased more rapidly than the white 52 percent compared with 34 percent. The proportion of nonwhites in the population rose from 10 to 11 percent from 1940 to 1960. This was due chiefly to the higher birth rates of the nonwhite population. For example, in 1960 the birth rate was about 32 per 1,000 population for nonwhites compared with about 23 for whites. At the same time the crude death rate for the nonwhite population decreased about 27 percent from 1940 to 1960 compared with 9 percent for whites. If age-adjusted rates are used, however, the difference is less marked since the rate of decrease in nonwhite mortality was 36 percent against 28 percent for whites during this period (fig. 5). The differences in the average expectation of life for the different race-sex groups can be measured by the mortality experiences of these groups. The average expectation of life has increased between 1939-41 and 1960 from 67.3 to 74.1 years at birth for white females, while for white males the increase was from 62.8 to 67.4 years. The largest increase occurred among nonwhite females, 55.5 to 66.3 years with life expectancy for nonwhite males rising from 52.3 to 61.1 years (table 2). Population growth has not of course been evenly distributed throughout the country. The largest increases occurred in the far western areas and in Florida and were due to higher rates of inmigration. The southern part of the country showed the largest rate of natural increase (births minus deaths), but this was partly offset by a net loss of population due to outmigration, particularly from rural areas. Between 1950 and 1960, the populations of the metropolitan areas grew more rapidly (26 percent) than did those of the remainder of the country (7 percent). The former increase was due to a net immigration of about 9 percent plus a natural increase of 15 percent. In contrast, the nonmetropolitan areas experienced a net loss of almost 9 percent from outmigration, which offsets more than one-half of the natural increase. Within the metropolitan areas, population growth was relatively much larger in the suburban areas (49 percent) than in the central cities of those areas which increased only 11 percent. In general, differences in net migration rates between different parts of the country are larger than differences in birth and death rates. In fact, fertility and mortality differences between geographic divisions of the country are becoming smaller. 2. Leading causes of death, 1920 and 1961 Progress in diagnostic knowledge limits the usefulness of studies in changes of causes of death over a long period of time. Better diagnostic facilities and improvements in cause-of-death reporting add an imponderable factor even to the comparison of deaths reported in 1920 and 1961. The leading causes as they were reported in 1960 and 1920 are shown in table 3. It may be recalled that in 1920 the pandemic of influenza had not completely receded. This disease and the accompanying pneumonia was the leading cause of death. Influenza and pneumonia are still among the leading causes, but the rate is now 30.2 per 100,000 population. Tuberculosis, the third leading cause in 1920, has been eliminated from the top group of health problems. On the other hand, the death rates for diseases of heart and malignant neoplasms (cancer) have increased substantially reflecting in part problems of an older population. 3. Indexes of morbidity and disability Restricted activity. For the year ending June 1960, there were 2,830,000 days of restricted activity due to illness of the civilian, noninstitutional population of the United States. Of these 1,055,000 or 37 percent were days of bed disability. On the average, each person had 16 days of restricted activity for the year ending June 1960 including 6 days of bed disability. This was approximately the same as that for the period July 1958-June 1959, but during July 1957-June 1958 when an Asian influenza epidemic occurred, each person had an average of 20 restricted-activity days and 8 bed-disability days. A day of restricted activity is defined as a day on which the person cut down on his usual activities for the whole of that day as a result of illness or injury. A day of bed disability, also considered as a restricted-activity day, is defined as a day on which the person spent all or most of the day in bed because of illness or injury. During July 1959-June 1960, more disability days were experienced by women than men and older persons reported more disability days than younger persons. People who live in the South had a higher rate of disability days than did persons living in other sections of the country; those in the North Central States had the lowest rate. Persons living in families whose income was under $2,000 a year experienced an estimated 28 days of restricted activity per capita a year, while household members with family incomes of $7,000 and over reported an average of 13 days a year. Persons with an annual family income under $2,000 had an average of 9.8 bed-days a year, or twice as many as the 4.8 days reported by persons with family incomes of $7,000 and over. Chronic limitation of activity.-Approximately 19 million persons or 11 percent of the population, exclusive of those in institutions, have some degree of activity limitation due to chronic illness or impairment. Of these 19 million, about 14.2 million have continuous limitation affecting their major activity, i.e., ability to work, keep house, or go to school. This estimate, based on data collected in household interviews during July 1959-June 1961, included about 6 million or 42 percent of the 14.2 million who had their present limitation for 5 years or more. The rate of continuous limitation of activity increases with age; about 1 in each 100 persons under 17 years of age was limited in major activity, and about 38 in every 100 persons aged 65 years and over were so limited. Of the 62 million persons who were classified as "usually working." about 6 percent or 4 million had some degree of activity limitation affecting their major activity. About 3.7 million of these people were limited in amount or kind of work this figure may be considered as a gross estimate of the number of workers in the United States who are handicapped in some degree by a chronic condition or impairment. Selected impairments.-An estimated annual average of 3.5 million persons in the civilian, noninstitutional population have visual impairments according to household interviews during the 24-month period July 1959-June 1961. Cataract, glaucoma, and other local diseases of the eye accounted for 50 percent of all cases of severe visual impairments. About 67 percent of all persons with severe visual impairments were 65 years or older. Data for the same period show an average of 6 million persons with hearing impairments, 1 million with speech defects, 946,000 with complete or partial paralysis, and 259,000 with absence of major extremities. Over 13 million individuals have orthopedic defects of the limbs, back, and trunk. Acute conditions.-During the 12-month period July 1960-June 1961, it is estímated that about 359 million acute illnesses or injuries (about 2 conditions per person per year) involving either activity restriction or medical attention were experienced by members of the civilian, noninstitutional population of the United States during the year. About half of all conditions were respiratory illnesses. The next largest groups, with very similar rates, were injuries and infective and parasitic diseases other than respiratory. For all persons in the population, acute conditions resulted in an average of 8.6 days of restricted activity and 3.3 days of bed disability per person per year. Rates were highest for children under 5 years of age, and in general declined during each succeeding age group. The rates of restricted activity and bed disability were, however, about the same for persons aged 65 years and over as they were for those in the youngest age group. Persons injured.-Data for the period July 1959-June 1961 show that on the average 45 million persons per year sustained injuries requiring medical attention or causing restriction of usual activities for a day or more. Among the total persons injured, 12 million or 27 percent were involved in accidents described as falls. About 4 million of the accidents resulting in injury were falls on stairs, steps, or from a height. Other types of injury that occurred frequently in the population are described as injury resulting from being struck by a moving object (other than vehicle) and from bumping into an object or person. The estimate includes about 3 million persons injured in moving motor vehicle accidents and 42 million persons injured in all other kinds of accidents. Approximately 23 percent of the 45 million persons injured had 1 or more days of bed disability associated with the injury. About 45 percent of all injuries occurred in the home or on home premises. Among females, 57 percent of the injuries were sustained in the home, while among males, only 36 percent occurred in the home. The rate of injury in the home was highest among children and among persons 65 years and older. Of the 45 million persons injured, 38 million or 84 percent had medical attention. 4. Indexes of use of health service Persons receiving care at home.-Approximately 1 million persons in the civilian, noninstitutional population required either constant care of part-time help in their home. About 60 percent of the total required constant care. For the survey period July 1958-June 1959, those persons who were reported as receiving personal care in the home required constant, or part-time help, or nursing care for such activities as dressing, eating, or toilet activities. Household members provided the bulk of personal care reported for either the constant or part-time care groups. However, nursing services, professional or practical, were utilized in a substantially greater proportion of cases by the constant care group-12 percent as compared with 4 percent for those requiring part-time care. The prevalence rate of persons receiving care at home rises consistently from about 2.3 per 1,000 population among persons under 15 years of age to 87.7 per 1,000 for persons 75 years and older. Of those receiving care at home, males constituted the majority of persons at the lower ages, while females represented the largest group at ages 45 and over. Paralysis, circulatory conditions, senility, and arthritis and rheumatism were the leading conditions involved and were responsible for over half of those receiving care. About 30 percent reported the interval under care as 5 years or longer, 38 percent between 1 and 4 years, and 27 percent as less than 1 year. Altogether more than 90 percent of the persons needing care had either major or partial limitation of activity. Persons receiving constant care constituted about three-fourths of all those who reported 90 or more bed-days. There were 23 physician visits per person for those receiving part-time or constant care at home as compared with an average of 5 for the U.S. population as a whole. About 80 percent of all persons receiving care were living with relatives. Physician visits.-During the 2-year period July 1957-June 1959, the number of physician visits made in the United States was 1,703,000. This amounts to an average annual number of 852 million visits per year or about 5 physician visits per person per year. A physician visit was defined in the survey as a consultation with a physician, either in person or by telephone, for examination, diagnosis, treatment, or advice, excluding inpatient hospital visits. Of the total number of physician visits made, approximately 66 percent took place in a physician's office, 10 percent at home, and 9 percent in an outpatient clinic of a hospital. About 10 percent of all visits were telephone consultations. Data collected during July 1957-June 1959 show that about 75 percent of the physician visits were for the diagnosis and/or treatment of an illness or injury. Visits for "general checkup" accounted for 8 percent and immunizations were involved in 7 percent of the visits. Beginning with the age group 15 to 24 years, women averaged a greater number of physician visits than did men. Part of the difference is accounted for by visits for the prenatal or postnatal care, but even excluding this type of visit, the rates for women were still higher than the rates for men. The rate of physician visits was higher among urban residents than among rural residents and higher for white persons than for nonwhite persons. The rate of physician visits varied directly with the amount of family income. Those in families having incomes under $2,000 had a rate of 4.6 physician visits per person per year as compared with 5.7 visits for persons in families earning $7,000 or more. Hospital discharges.-There was an average annual estimate of about 20 million patients discharged from short-stay hospitals according to data for the period July 1958-June 1960. The total hospital stay for these patients amounted to 167 million days. All data are based on estimates of the average annual number of hospital discharges and the number of hospital days for patients discharged from shortstay hospitals. Discharges and days for persons who died during the year prior to the interview are excluded. In the United States there are approximately 115 discharges from short-stay hospitals in a year among every 1,000 persons alive at the end of the year. These figures refer to the civilian, noninstitutional population. Excluding deliveries, the rate of hospitalization increases with age from 55 discharges per 1,000 children aged 5 to 14 to 154 discharges per 1,000 persons aged 75 years and over. Similarly, the average length of hospital stay increases with age, ranging from 4.7 days to 15.8 days per episode for the age groups mentioned. Although the rate of hospital discharges per 1,000 population is higher for females (99.4) than it is for males (87.5) even after deliveries have been excluded, the average length of stay for males is 2.1 days longer than the average length of stay for females. Of the total patients discharged from short-stay hospitals, 57.8 percent had a length of stay of less than 6 days and 88.4 percent stayed less than 15 days. The length of stay increased markedly with age. Dental care.-During the 2-year period July 1957-June 1959, people in the United States made approximately 517 million dental visits, representing an estimate of 258 million visits per year. This amounted to an average of 1.5 dental visits per person per year. The rates of dental visits varied greatly among the different subgroups of the population. Members of families having an annual income of less than $2,000 made an average of 0.7 dental visits per year as compared with a rate of 2.5 visits for those in families with an income of $7,000 or more. During the year July 1958-June 1959, information was collected on the number of dental visits a person had made during the 12-month period prior to the week of interview. About 60 percent of the population reported no visits during the year preceding the interview while 16 percent reported one dental visit. An additional 11 percent reported two visits, 4 percent reported three visits, and 9 percent reported that they had made four or more visits. 5. Some indications for the future The health and growth of the population depend upon many factors. The determinants are demographic, economic, and social and involve medical progress as well. A precise forecast of the future course of events in health and demography is not possible, but in the light of the past and present situation, it seems reasonable to expect certain developments in the future. Some of these are: ORGANIZATION OF PUBLIC HEALTH SERVICE TABLE 1.-Estimated population, 1900–1962 [In thousands. As of July 1, except where noted. Beginning 1940, includes Alaska and Hawaii. Estimate for 1900 to 1909 are sums of State estimates based on local data indicative of population change. Estimates for 1910 to 1962 are based on decennial censuses and statistics of births, deaths, immigration, emigration, and Armed Forces. See also Historical Statistics, Colonial Times to 1957, series A 1-31] Total population residing in United States 1 100, 549 104, 512 108, 541 110,055 111,950 114, 113 115, 832 117,399 119,038 120, 501 121, 770 Year including residing Armed in Civilian population Year including residing Civilian Armed in population Forces United Forces United abroad States 1 abroad States ! 145,746 148, 157 150,790 151, 599 153.892 156, 595 159,695 162, 967 166,055 1939. 131, 028 130,880 130,683 1957. 171,984 171, 187 169, 110 1940. 132, 594 132, 457 132, 129 1958. 174,882 174, 149 172, 226 1941. 133, 894 133, 669 132,060 1959_ 177,830 177, 135 175, 277 1942. 135, 361 134, 617 131, 444 1960 180, 676 179,983 178, 144 1943. 137,250 135, 107 128, 010 1961. 183, 742 183,043 181, 193 1944. 138,916 133,915 127, 227 1962: 3 1945 140, 468 133, 434 128, 112 Jan. 1... 1946. 141,936 140, 686 138, 932 Feb. 1... 185, 506 184, 772 182,439 182, 620 1947. 144,698 144, 083 143, 138 Mar. 1... 185,708 184,970 182,823 1 Excludes Armed Forces abroad. Total population including Armed Forces abroad (in thousands): 1917, 103,414; 1918, 104,550; 1919, 105,063. Civilian population (in thousands): 1917, 102,796; 1918, 101,488; 1919, 104,158. * Provisional. Source: Department of Commerce, Bureau of the Census, "Current Population Reports," series P-25, and reports and records. (a) It has been estimated that the population will grow from the enumerated population of 179 million in 1960 to 209 million or more in 1970. By 1980, the population may reach anywhere from 246 to 260 million, depending upon the assumptions of future fertility rates. The increase in population will obviously have an impact on many aspects of social and economic life, including the provision of health and medical services. (b) The babies born during World War II and the postwar years, a period of unprecedented rise in the birth rate, are beginning to reach their majority. It is expected that this will create another wave of marriages and of births. A strong buildup will probably start in the mid-1960's. This will produce a fast increasing load on the obstetrical and pediatric services. The 1970's and the 1980's will see these children become of school age with the attendant problems of providing educational facilities and teachers. (c) Because of the increasing difference in mortality between males and females, the already predominant female population will continue to increase faster than the male. |