THE VITAL STATISTICS SYSTEM

The administration of public health measures for the control of widespread diseases, such as heart disease, cancer, and stroke, is directed by local officials. In order to plan for applying control measures, detailed information is needed for each local jurisdiction about the specific groups exposed to the greatest risk or most susceptible to the disease to be controlled. Furthermore the information must be available year in and year out in order to measure the effectiveness of the programs.

The only comprehensive source for such statistical information is the data obtained from the registration of deaths. It covers the entire population: State by State, county by county, and city by city. All States and local areas have mortality data available to them but only a few are able to employ this resource effectively. The frequent failure to employ such data is, in part, attributable to lack of money and lack of competent personnel.

For the first half of this century, mortality studies were in the mainstream of research and health practice. Mortality statistics furnished an essential tool for epidemiological studies of our principal disease problems; such as, smallpox, tuberculosis, diphtheria, malaria, typhoid fever, scarlet fever, whooping cough, diarrhea and enteritis in children, and maternal complications due to childbirth.

The problems presented by the effective use of mortality data for heart disease, cancer, and stroke are much more subtle and difficult than those encountered in infectious diseases. As a result, higher skills in the use of statistics as well as greater resources are needed. Against these needs, we face the fact that the States and local areas have necessarily had to apply the resources for vital statistics largely to furnishing the public with legal records on demand. In consequence, State and local governments have tended to neglect the development and exploitation of statistics for the study and control of disease.

The States have sole authority for collecting records of births and deaths in the United States. The Federal Government develops national vital statistics from copies of the records supplied by the States. The only compensation to the States is for actual copying costs and this may not exceed 4 cents per record. Thus, the major share of the cost of the Federal-State system has been a State burden; yet, the major scientific applications of the system have been made by the Federal Government. The Federal Government is also almost entirely dependent upon the State efforts for maintaining the quality of information on the records. Aside from technical assistance provided to the States by the Federal Government, there is no present means by which the latter can give support adequate to the national requirements for data.

These facts point to the need for and propriety of Federal aid to the States in strengthening the system.

Financial aid to the States for vital and health statistics should be provided through a categorical grant program administered by the Public Health Service: the agency charged with the responsibility for collecting, analyzing, and publishing these national data. Such aid should finance the salary of competent statisticians and necessary supporting services. The aid should be dedicated to the following objectives:

Improving the quality and timeliness of data collected through death registration;

Carrying out regular epidemiological studies using the death record as a starting point; and

Intensive tabulation and analysis of the mortality data with special reference to describing the problems in detail and measuring progress and change.

The subcommittee recommends that a sum of $750,000 should be appropriated to the National Center for Health Statistics to initiate this grant program. This amount should be increased to $1,500,000 during the second year and increased gradually thereafter until it reaches $3,500,000 during the fifth year, representing roughly about 50 cents per vital record filed.

MULTIPLE-CAUSE CODING

The traditional practice in the compilation of official mortality statistics has been to attribute to each death a single disease entity as the underlying cause of death. This practice served the purposes of public health well, while infectious diseases constituted the major public health concern. With the decline in in

fectious disease mortality, and with the growing importance of the chronic diseases, official mortality statistics have become less satisfactory for the study of chronic conditions; such as, the cardiovascular diseases where more than one disease is usually present at the death. For example, a cardiac patient frequently dies of stroke but it is not possible to characterize this event suitably by the present method of compiling mortality statistics. The selection of a single disease for tabulation, in such events, inevitably results in the loss of information.

For the chronic diseases, the single or the underlying cause concept is outmoded. Cardiovascular disease often occurs not as a single process but as a disease complex. The underlying cause concept requires that the disease which started the sequency of events that led to death be identified. For the clinician, this task is frequently impossible. In the nature of events, mortality statistics on chronic disease give an incomplete and often inaccurate view.

It is recommended that data of this kind be prepared by coding all diagnoses reported on death certificates and tabulating statistics on disease complexes as well as the reported associations between various diseases. This procedure will require additional coding, punching, and tabulation after the development of coding principles and necessary guidelines. It is estimated this can be done by the National Center for Health Statistics for about $125,000 per annum.

Statistics of morbidity and disability.—Much progress has been made in measuring morbidity and disability as a result of the passage of the National Health Survey Act in 1956. The surveys authorized by this law are carried out by the National Center for Health Statistics with the help of the Bureau of the Census. Measures of disability and other types of impact on the family from recognized illness are available from the health interview survey. The survey has recently completed a study which included a carefully standardized cardiovascular examination of a representative sample of adults, aged 18 to 79 years. This study adds previously unavailable data on untreated morbidity.

Nevertheless, knowledge of the complete spectrum of morbidity remains far from incomplete. Most needed at the present time is detailed diagnostic information regarding treated cases of a kind that can be obtained from records of physicians, hospitals, and other medical and nursing institutions. The mechanisms, to be discussed below, for producing statistics on hospital, medical, and nursing care will also provide the diagnostic detail in statistics of morbidity.

A special word needs to be said about cancer statistics. The most comprehensive and useful surveys of cancer in the United States have been those made by the National Cancer Institute in 1937-39 and 1947-48. These surveys, covering 10 large cities in the country, were conducted by canvassing completely all potential sources of information about treated cancer in the cities surveyed. Nonresident cases were eliminated and census population statistics were used to provide the population-at-risk. Consideration should be given to repeating this survey on a wider scale at the time of the 1970 census.

Much has been said about the lag in time between the discovery of new medical scientific facts and the application of this knowledge. There is undoubtedly a considerable gap between, on the one hand, existing knowledge of the means of preventing or alleviating chronic diseases; i.e., the advanced methods of prevention, treatment, and rehabilitation and, on the other hand, the application of these methods in everyday medical care. We know good measure of the magnitude of this gap, however, because there is little or no systematic statistical information about methods of treatment in day-to-day use in the practice of medicine.

Evaluation of progress, or lack of progress, in closing the gap requires comprehensive statistics on patient care and treatment. Such statistics must be compiled from surveys of records at all levels of care, in the offices of physicians, in hospitals, and in long-term care institutions of all types.

Unlike other medically advanced nations of the world, the United States has never had detailed national statistics on hospital inpatients. However, a promising start has been made in the National Center for Health Statistics. Working with the American Hospital Association and the Blue Cross Association, the Center is developing a continuing sample survey of hospital discharge records which will not only produce an accurate cross section of the cases treated in short-term hospitals but will do so with a minimum of burden on the hospitals.

The initiation of this survey will be a contribution of great importance to our knowledge of methods of treatment, and, as has been pointed out earlier, such data will also help to fill in a missing piece in the coverage of the entire

spectrum of morbidity. The Public Health Service has requested $700,000 in additional funds for the first full year of operation of this survey. From the standpoint of the interests of the Commission, this request deserves full support. While this project represents an excellent start in collecting needed statistics on patient care and treatment, it does not, of course, cover the full range of care. Records of inpatient care in most hospitals are reasonably complete and uniform. Records of outpatient care in clinics and doctors' offices, and records of care in long-term institutions, such as nursing homes, are a different matter. Much methodological work needs to be done in order to make reliable studies of care in such places.

In resident-type institutions, for example, records must be designed that can be filled out in a uniform fashion by all such establishments. Many of the most seriously ill people are found in these reservoirs of chronic disease, but the problems in studying them are formidable. However, here, too, a start has been made in the National Center for Health Statistics, with a series of surveys of patients in places providing nursing and personal care. Such surveys should be contined and extended.

We still need to know a great deal more about the everyday care being given patients with heart disease, cancer, or stroke. What prescriptions are given? What regimens prescribed? What operations called for? When are specialists called upon? What rehabilitation efforts are made? The great majority of these decisions are made in the offices of the attending physicians. But as yet there have been few surveys in the United States to provide such descriptive information.

It is time to begin to interest the medical profession in participating in such studies. It is possible, by the use of sampling, to design studies in such a way that the burden on any one physician is minimal. The chief obstacle, perhaps is to overcome the natural reluctance of the physician to report intimate details of his practice. The organization carrying on the work must have a foolproof mechanism to insure confidentiality and a reputation for complete impartiality. The Commission strongly urges that the Public Health Service stimulate studies of general and specialty practices on a sampling basis to determine methods of treatment in everyday use.

Professional training and physician education.-There is an urgent need to improve the professional qualifications of statisticians and the statistical sophistication of physicians.

TRAINING IN HEALTH DEMOGRAPHY

As pointed out in the previous section, it is necessary to increase the resources available to vital statistics activities of the States in order to assure production of reliable and useful mortality statistics. The Commission's recommendation that a grant program be instituted for assistance to States in this area would provide minimum funds for payment of salaries, computer services, etc., but it would not solve the other problem that has been mentioned: the severe shortage of trained statisticians.

The changing character of public health practice coupled with the demographic, social, and economic changes in the United States has placed strong demands on health departments for skilled statistical services. Health departments are becoming involved in various kinds of research, most of which require a combination of high order statistical sophistication and a practical, operating statistical organization. There is need to develop practical skills for various levels of statistical work in data collection, data processing, data analysis, and data presentation. Among other things, this includes registration methods, coding practices, tabulating techniques, questionnaire construction, forms design, records management, computer programing, and statistical administration. To insure a satisfactory supply of trained personnel for these programs, the Subcommittee offers the following recommendation:

A grant program should be established to be administered by the National Center for Health Statistics for training in health demography. Such a program would provide both academic training at the graduate level at universities and applied training at the National Center for Health Statistics. It is anticipated that approximately 50 individuals would participate in the former type of training and about 20 in the latter each year. Annual cost is estimated at approximately $500,000.

MEDICAL CERTIFICATION

As has been implied, the death certificate has long been the chief source of information for guiding plans for the study and control of cardiovascular diseases

and cancer. Mortality statistics depend on the accuracy and completeness of thẻ medical certification entered on the death record.

A pilot study of the clinical evidence available in completing medical certifications demonstrated serious problems in reporting the conditions causing death. These problems reflect variations in understanding of the requirements for certification, in diagnostic information available regarding the decedent, and in State laws concerning the certification of deaths falling under the jurisdiction of the medicolegal system.

A program should be initiated to improve the quality and accuracy of cause-ofdeath statistics and to maintain a continuous measure of its quality. Its first goal should be to educate medical students, interns, and practicing physicians in a uniform understanding of what information should be reported on the death certificate. Second, a regular mechanism to measure the completeness and quality of the reported information, particularly for the cardiovascular diseases, should be established. Third, since a large number of sudden deaths from the cardiovascular diseases fall under the jurisdiction of coroners and medical examiners, efforts to improve the quality of reporting must extend to these officials, by strengthening and supporting the medicolegal responsibilities in each State.

COMMUNITY HEALTH PROGRAM

The Subcommittee attempted to obtain a national picture of the present status of community health programs concerned with heart disease, cancer, and stroke at a State and local level. Meaningful information and data describing services currently being provided at the State and local level to patients afflicted with these diseases was absent. The various programs within the Division of Chronic Diseases of the Public Health Service have also indicated that the absence of such data represents a serious deficiency in their program planning.

In order to carry out effective program planning, a national inventory of community health program activities is necessary. There is a need for benchmarks to describe the current level of program activity and from which progress in the future can be measured. To develop such a national inventory, the Subcommittee offers the following recommendation:

A Center of Program Statistics should be established in the Division of Chronic Diseases of the Public Health Service. This Center would coordinate the plans developed by each operating program to assemble pertinent program statistics to meet their needs. Each program should establish a statistical capability to formulate data collection methods and procedures, review the data assembled, analyze the information for completeness and accuracy, and identify program implications.

Periodic and recurring surveys should be initiated, using sampling methods wherever applicable, to provide data relative to each program. Whenever possible, data should be collected to permit a qualitative classification of each activity on the basis of its relative effectiveness in reducing morbidity, mortality, or disability.

It is estimated that during the initial year of the proposed program that an additional personnel ceiling of 32 persons will be required by the Division. An annual budget of $500,000 is recommended to cover salaries, administrative support, service contracts, and methodological research.

REPORT OF THE SUBCOMMITTEE ON RESEARCH

(Dr. Philip Handler,' Chairman, Dr. Frank Horsfall,' Mr. James Oates,' Gen. David Sarnoff,1 Dr. Edward Tatum, Dr. Efraim Racker.) Consultants to the Subcommittee on Research: Dr. Edward Dempsey,1 Dr. Renato Dulbecco, Dr. Philip P. Cohen, Dr. Irvine Page, Dr. Charles Dunlap, Dr. Harry Eagle, Dr. Irving London, Dr. J. F. A. McManus, Dr. Alexander Hollaender, Dr. Herman Rahn, Dr. Eugene Stead, Dr. Lewis Thomas, Dr. Maurice Visscher. Staff: Dr. John D. Turner

INTRODUCTION

Research related to heart disease, cancer, and stroke was, at all times, in the forefront of the minds of the members of this Commission. Each of the several Subcommittees of the Commission devoted much of its attention to current means for the acquisition of new knowledge concerning these disorders, their alleviation

1 Member of the Commission.

and prevention, and proposed plans for enhancing and extending the national effort in this regard. Nniquely among the Subcommittee of the Commission however, the Subcommittee on Research, which was composed of several members of the Commission augmented by Dr. Efraim Racker, of the Public Health Research Institute of the City of New York, and Dr. Edward L. Tatum, of the Rockefeller Institute, devoted itself to means of acquiring greater insight into fundamental aspects of the normal biology of man himself as well as those physiological phenomena which lead to the development of heart disease, cancer, and stroke. The Subcommittee engaged in two major activities:

1. The Subcommittee met with a group of invited consultants for several days in Washington to discuss specific means whereby our national capability for the conduct of biomedical research might be enhanced and extended.

The consultants present on that occasion were:

Dr. Philip P. Cohen, University of Wisconsin.

Dr. Renato Dulbecco, Salk Institute for Biological Studies.

Dr. Charles E. Dunlap, Tulane University.

Dr. Harry Eagle, Albert Einstein College of Medicine.

Dr. Alexander Hollaender, Oak Ridge National Laboratory.

Dr. Norvin Kiefer, Equitable Life Assurance Society.

Dr. Irvin London, Albert Einstein College of Medicine.

Dr. J. F. A. McManus, University of Indiana.

Dr. Irvine Page, Cleveland Clinic Foundation.

Dr. Herman Rahn, University of Buffalo.

Dr. Eugene Stead, Duke University.

The major recommendations and philosophy espoused in the report which follows reflect the discussions of this group. The Commission is much indebted

to these consultants for their imagination and wisdom.

2. The Subcommittee solicited, from the individual viewpoints of each of a series of knowledgeable experts, substantive summaries of the present state of diverse facets of the biological espects of heart disease, cancer, and stroke. Most generously, our respondents contributed summaries which were invaluable to the Subcommittee. Unfortunately, considerations of space alone preclude publication of these summaries in their entirety. Accordingly, it appeared desirable to present with the report of the Subcommittee a single capsular summary of current knowledge and research into the biology of heart disease, cancer, and stroke, as gleaned from the essays so generously contributed. For the effort involved in preparation of these summaries, the Subcommittee is particularly indebted to Mrs. Norma Golumbic, of the National Cancer Institute, and Dr. John D. Turner, of the National Heart Institute, and of the staff of this Commission. Although the Subcommittee is pleased indeed to present these summaries, for which it must acccept responsibility jointly with the immediate authors thereof, it is pleased also to acknowledge its indebtedness and express its gratitude to the scientists who so carefully presented thoughtful essays which reflect both their knowledge and their scientific philosophy while expressing its deepest regrets that this volume cannot include these essays in their entirety. Here, we can only list these worthy contributors to this common effort.

Dr. Edward H. Ahrens, the Rockefeller Institute, "Hardening of the Arteries: Can It Be Prevented by Appropriate Choice of Diet?"

Dr. Albert J. Dalton, National Cancer Institute, "The Role of Electron Microscopy in Cancer Research."

Dr. Harry Eagle, Albert Einstein College of Medicine, "Significant Features of the Growth of Mammalian Cells in Tissue Culture."

Dr. W. U. Gardner, Yale University, "Endocrine Factors in the Etiology and Pathogenesis of Cancer."

Dr. Alfred Gelhorn, Columbia University, "Endocrine Factors and Neoplastic Growth."

Dr. Leonard D. Hamilton, Sloan-Kettering Institute for Cancer Research, "Ionizing Radiation in the Genesis of Cancerous Change in Cells."

Dr. W. Stanley Hartroft, University of Toronto, "Etiology and Pathogenesis or Arteriosclerosis."

Dr. Charles Heidelberger, University of Wisconsin, "Chemical Inhibition of the Growth of Normal and Malignant Cells."

Dr. Sibley W. Hoobler, University of Michigan, "Hypertension."

Dr. Kurt J. Isselbacher, Harvard University, "Lipoproteins of Serum and Tissues."