International Health Statistics: What the

Numbers Mean for the United States

September 1994

OTA-BP-H-116

NTIS order #PB94-127008

GPO stock #052-003-01354-1
Recommended Citation:

U.S. Congress, Office of Technology Assessment, International Health

Statistics: What the Numbers Mean for the United States--Background Paper,

OTA-BP-H-1 16 (Washington, DC: U.S. Government Printing Office,

November 1993).

For sale by the U.S. Government Printing Office

Suintendent of Documents, Mail Stop: SSOP, Washington, DC 20402-9328

ISBN 0-16 -042972-2
Foreword

T

he United States spends more per capita on health care than any other

developed country and yet ranks poorly in some key indicators of

health. Policymakers have hoped that by looking to countries with better

health status measures and lower spending, they might find solutions to

some U.S. health and health care problems.

This Background Paper reviews how the United States compares with

other developed countries on available health status measures, evaluates the

validity of the data used to make such comparisons, and describes how international comparisons might be interpreted in the context of health care reform.

Among the key findings of the Background Paper are that the United States generally fairs poorly relative to other developed countries on available health indicators, with higher death rates among infants, children, and young to middleaged adults. The large differences, however, reflect much more than just differences in health care systems. Some of the most important determinants of a

nation’s health status fall outside the usual bounds of the health care systemincluding personal habits (e.g., smoking, exercise) and other factors related to

socioeconomic status.

The Background Paper is part of a larger project, International

Differences in Health Care Technology and Costs. The main report, to be published in 1994, looks at variations in expenditures and resources used in some

specific areas of health care among developed countries. The House Committee

on Ways and Means, Chairman Dan Rostenkowski, asked OTA to undertake this

assessment.

The development of this Background Paper was greatly assisted by an

advisory panel, chaired by Rosemary Stevens of the University of Pennsylvania.

In addition, many other individuals provided information and reviewed drafts of

the paper. OTA gratefully acknowledges the contribution of each of these individuals. As with all OTA documents, the final responsibility for the content of

the assessment rests with OTA.

d+- -

Roger C. Herdman, Director

iii
Rosemary Stevens, Ph. D., Chair

University of Pennsylvania

Philadelphia, PA

Stuart Altman, Ph.D.

Brandeis University

Waltham, MA

Jan E. Blanpain, M.D.

Leuven University, Belgium

Leuven, Belgium

Harry P. Cain II, Ph.D.

Blue Cross and Blue Shield

Association

Washington, DC

Thomas W. Chapman, M. P. H.,

FACHE

The Greater Southeast Healthcare

System

Washington, DC

Louis P. Garrison, Jr., Ph.D.

Syntex Development Research

Palo Alto, CA

Annetine Gelijns, Ph.D.

Columbia University

New York, NY

William Glaser, Ph.D.

New School for Social Research

New York, NY

John Iglehart

Health Affairs

Bethesda, MD

Ellen M. Immergut, Ph.D.

Massachusetts Institute of

Technology

Boston, MA

Lynn E. Jensen, Ph.D.

American Medical Association

Chicago, IL

Stanley B. Jones

Consultant

Shepherdstown, WV

Bengt Jonsson, Ph.D.

Stockholm School of Economics

Stockholm, Sweden

Kenneth G. Manton, Ph.D.

Duke University

Durham, NC

Edward Neuschler, M.P.P.

Health Insurance Association of

America

Washington, DC

Jean-Pierre Poullier, Ph.D.

Organisation for Economic

Co-operation and Development

Paris, France

Mark Schlesinger, Ph.D.

Yale University

New Haven, CT

NOTE: OTA appreciates and is grateful for the valuable assistance and thoughtful critiques provided by the advisory panel members. The

panel does not, however, necessarily approve, disapprove, or endorse this background paper, OTA assumes full responsibility for the background paper and the accuracy of its contents.

iv
Clyde J. Behney

Assistant Director, OTA

Health, Life Sciences, and the

Environment

Hellen Gelband

Project Director for International

Differences in Health Care

Technology and Costs

ADMINISTRATIVE STAFF

Beckie Erickson

Office Administrator

Dan B. Carson

PC Specialist

Carolyn Martin

Word Processing Specialist

Project Staff

PRINCIPAL STAFF

MARlA HEWlTT

Study Director

David Kaufman

Research Assistant

OTHER CONTRIBUTING STAFF

Arna M. Lane

Research Analyst

Eric L. Gille

Secretary
Abbreviations

ADA

AIDS

BMI

BSE

CDC

FIMR

HIV

ICE

ICD

ICIDH

IMR

IOM

IWG

Americans With Disabilities Act

acquired immunodeficiency syndrome

body mass index

breast self-examination

Centers for Disease Control and

Prevention (U.S. Department of Health

and Human Services)

fete-infant mortality rate

human immunodeficiency virus

International Collaborative Effort (NCHS)

International Classification of Diseases

(WHO)

International Classification of

Impairments, Disabilities and

Handicaps (WHO)

infant mortality rate

Institute of Medicine

The Inter-Country Working Group on

Comparative Health Statistics (NCHS)

LSOA Longitudinal Study of Aging (United

States)

MONICA Monitoring of Trends and

NCHS

OTA

REVES

SIDS

SIPP

WHO

WONCA

YPLL

Determinants in Cardiovascular Diseases

project (WHO)

National Center for Health Statistics

(CDC)

Office of Technology Assessment

(U.S. Congress)

Réseau Espérance de Vie en Santé

sudden infant death syndrome

Survey of Income and Program

Participation (U.S. Department of

Commerce)

World Health Organization

World Organization of National Colleges,

Academies, and Academic Associations

of General Practitioners/Family Physicians

years of potential life lost

vi
contents

1

2

3

Summary and Findings 1

Introduction 1

Key Findings 2

Detailed Findings 3

Purposes and Limitations of International

Comparisons of Health 3

Sociodemographic Characteristics of

Comparison Countries 3

Infant Mortality 4

Mortality Comparisons 5

Morbidity, Disability, and Quality-of-Life

Indicators 5

Health-Related Behaviors 6

Conclusions 6

Purposes and Limitations of

International Health Comparisons 9

Problems in Making International Health

Comparisons 10

How Should International Health Status

Comparisons Be Made? 11

summary 12

Sociodemographic Characteristics of

Comparison Countries 15

Population Size, Geographic Distribution, and

Age Composition 15

Living Arrangements and Household

Composition 17

Ethnic and Racial Composition 19

School Attendance 19

Labor Force Participation 21

Income and Poverty 24

Health Insurance Coverage 25

Summary 27

4

5

6

Infant Mortality 29

International Comparisons of Infant Mortality

Rates and Trends 29

■ Infant Mortality Rates 29

H Infant Mortality Trends 33

Technical Difficulties in Making International

Comparisons of Infant Mortality 34

International Differences in Risk Factors

Associated With Infant Mortality 37

Low Birthweight 37

Multiple Births 40

Teenage Pregnancy 40

Use of Prenatal Care 42

Elective Abortion 42

Sociodemographic Differences 42

Summary 45

Mortality Comparisons 47

Life Expectancy 47

Survival to Adulthood 48

Years of Potential Life Lost 48

Age-Specific Mortality 48

Cause-Specific Mortality Comparisons 50

■ Accidents, Homicide, and Other Violence 51

■ Cancer 54

■ Circulatory System Disease 55

H Infectious and Parasitic Diseases 56

E United States and Canada Mortality

Comparisons 56

Summary 57

Morbidity, Disability, and Quality-of-Life

Indicators 59

Morbidity, Disability, and Quality-of-Life

Indicators 59

■ Morbidity Indicators 60

vii
■ Disability Indicators 61

■ Quality-of-Life Indicators 64

Summary 67

7 Health-Related Behaviors 69

Smoking and Alcohol Consumption 69

H Smoking 70

■ Alcohol Consumption 72

Preventive Health Practices 76

■ Comparisons of the United States and

Canada 76

■ Comparisons Between Europe and the

United States 80

summary 83

APPENDIXES

A Acknowledgments 87

B International Comparability of Cause-of-Death

Data 90

C International Mortality Comparisons by Age:

Tables and Figures 95

REFERENCES 147

Boxes

4-A

6-A

6-B

6-C

Socioeconomic Differences in Pregnancy

Outcomes in Selected Countries 45

WHO International Classification of

Impairments, Disabilities, and Handicaps 60

Examples of Differences in Disability-Related

Questions Included in Population-Based

Surveys 63

Selected Health Status and Quality-of-Life

Measures 65

Figures

3-1 Percentage of Elderly Population (Age 65 and

Older, Living Alone in Private

(Noninstitutional) Households: United States

and Selected Countries, Selected Data from

the 1980s 17

3-2 Percentage of Elderly Population (Age 65 and

Older) Living in Institutions (Medical and

Nonmedical): United States and Selected

Countries, Early to Mid-1980s 19

3-3

3-4

4-1

4-2

4-3

4-4

4-5

5-1

5-2

5-3

6-1

7-1

c-1

c-2

c-3

c-4

c-5

C-6

c-7

Unemployment Rates, United States and

Selected Countries, 1990 24

Income Distribution: United States and Selected

Countries, Selected Years 25

Infant Mortality, Distribution of Time of Death,

United States and Selected Countries, 1990 34

Infant Mortality, Distribution of Cause of Death,

United States and Selected Countries, 1988 35

Infant Mortality Trends, United States and

Selected Countries, 1950 to 1990 36

Birthweight Distribution, Singleton Total Births

for U.S. Whites 38

Birthweight Distribution, Singleton Total Births

for ICE Countries 38

Trends in Life Expectancy at Birth, United

States and Selected Countries, 1955-84 50

Probability of Survival to Age 65 for Those

Surviving to Age 25, United States and Selected

Countries, 1990 53

Years of Potential Life Lost Before Age 65,

United States and Selected Countries,

1984-87 54

Survival Curves for Australian Males and

Females, 1988 66

Trends in Overweight Proportion of Adult

Population (Age 18 and Older), Canada and

United States, 1985 and 1990 80

Age-Specific Death Rates (per 100,000), Males,

United States and Selected Countries,

1987-88 127

Age-Specific Death Rates (per 100,000),

Females, United States and Selected Countries,

1987-88 129

Age-Specific Death Rates (per 100,000) for

Accidents, Males, United States and Selected

Countries, 1987-88 131

Age-Specific Death Rates (per 100,000) for

Accidents, Females, United States and Selected

Countries, 1987-88 133

Age-Specific Death Rates (per 100,000) for

Homicide and Other Violence, Males, United

States and Selected Countries, 1987-88 135

Age-Specific Death Rates (per 100,000) for

Homicide and Other Violence, Females, United

States and Selected Countries, 1987-88 137

Trends in Age-Standardized Death Rates (per

100,000) for Injury and Violence, Males, United

States and Selected Countries, 1955-84 139
C-8

c-9

c-lo

c-1 1

C-12

Age-Specific Death Rates (per 100,000) for

Cancer, Males Age 45 and Older, United States

and Selected Countries, 1987-88 141

Age-Specific Death Rates (per 100,000) for

Cancer, Females Age 45 and Older, United

States and Selected Countries, 1987-88 142

Trends in Age-Standardized Death Rates (per

100,000) for Circulatory System Disease,

United States and Selected Countries, 1955-84

143

Age-Specific Death Rates (per 100,000) for

Circulatory System Disease, Males Age 45 and

Older, United States and Selected Countries,

1987-88 145

Age-Specific Death Rates (per 100,000) for

Circulatory System Disease, Females Age 45

and Older, United States and Selected

Countries, 1987-88 146

Tables

3-1

3-2

3-3

3-4

3-5

3-6

3-7

3-8

4-1

4-2

4-3

Selected Demographic Characteristics, United

States and Selected Countries, 1990 16

Elderly Percent of Population by Age, United

States and Selected Countries, Selected

Years 18

Percent of Households With Children by Marital

Status of Parent, United States and Selected

Countries, Selected Years 20

Foreign or Foreign-born Population, United

States and Selected Countries, 1990 21

Level of Education Completed by Age and Sex,

United States and Selected Countries, Circa

1980 22

Labor Force Participation Rates, by Sex and

Age, United States and Selected Countries,

Selected Years 23

Poverty Indicators, United States and Selected

Countries, Mid-1980s 26

Child Poverty, United States and Selected

Countries, Circa 1980 26

Infant Mortality Rates and Ranks, United States

and Selected Countries, 1990 30

Rates and Ranks of Infant, Neonatal,

Postneonatal, and Fete-Infant Mortality in the

United States and Selected Countries, 1990 31

Infant Mortality Rates, by Race, Geographic

Division, and State: United States, Average

Annual 1987-89 32

4-4

4-5

4-6

5-1

5-2

5-3

5-4

6-1

6-2

7-1

7-2

7-3

7-4

7-5

7-6

7-7

7-8

Characteristics of Birthweight Distributions and

Mortality Rates, United States and Selected

Populations, 1983-86 39

Live Birth Rates by Maternal Age, United States

and Selected Countries, Circa 1990 41

Births to Unmarried Women, Selected

Countries, Selected Years 43

Life Expectancy at Birth and at Ages 15,45,65,

80, United States and Selected Countries,

1990 49

Percent of Population Surviving to the Age of 1,

25,45, and 65, United States and Selected

Countries, 1990 52

Rates of Motor-Vehicle-Related Deaths,

Selected Countries, Circa 1990 55

Expected U.S. Deaths If United States Had

Canadian Age-Specific Mortality Rates,

1989 57

Cumulative AIDS Incidence Through Mid1993, United States and Selected Countries 61

Self-Perceived Health, United States and

Selected European Countries, 1987 68

Smoking prevalence by Age, Selected European

Countries (1987-88) and the United States

(1988) 71

Cigarette Smoking by Adults (Age 18 and

Older), by Age, Sex, and Education, United

States and Canada, 1985 and 1990 72

Smoking Prevalence, United States and Selected

European Countries, Mid-1960s and Late

1980s 73

Alcohol Consumption, Selected European

Countries and the United States, 1988 74

Current Alcohol Consumption by Adults (Age

18 and Older), by Age, Sex, and Education,

United States and Canada, 1985 and 1990 75

Trends in Adults Having Recent Blood-pressure

Checks, by Age, Sex, and Education, United

States and Canada, 1985 and 1990 77

Trends in Women Having Had Pap Tests Within

3 Years of the Survey and Monthly Breast SelfExamination, by Age and Education, United

States and Canada, 1985 and 1990 78

Trends in Adults’ Regular Use of Seatbelts and

Ownership of Smoke Detectors, by Age, Sex,

and Education, United States and Canada, 1985

and 1990 79

ix
7-9 Trends in Adult Participation irregular

Physical Activity, by Age, Sex, and Education,

United States and Canada, 1985 and 1990 81

7-10 Awareness, Use, and Frequency of Women’s

Cervical Smear Test in Selected European

Countries, 1988 82

7-11 Mammography Use by Women Aged 50 and

Older in Selected European Countries,

1988 83

7-12 Completed Immunization Rates for Preschool

Children, the United States and Selected

European Countries, Most Recent Available

Year 84

7-13 Reported Pertussis and Measles Morbidity,

United States and Selected European Countries,

1980-86 85

B-1 Background Information on Mortality Statistics,

Circa 1989 92

C-1 Trends in Age-Specific Death Rates (per

100,000), Males, United States and Selected

Countries, 1955-59 to 1980-84 96

C-2 Trends in Age-Specific Death Rates (per

100,000), Females, United States and Selected

Countries, 1955-59 to 1980-84 99

C-3a Age and Cause-Specific Death Rates (per

100,000), United States, 1988 101

C-3b Age and Cause-Specific Mortality Rates of

Selected Countries Compared with U.S.

Rates, 1988 102

C-4 Trends in Age-Specific Death Rates (per

100,000) for Cancer, by Sex, Age 45 to 74,

United States and Selected Countries, 1950-54

to 1980-84 114

c-5

C-6

C-7

C-8

c-9

Trends in Age-Standardized Death Rates (per

100,000) for Selected Cancer Sites, United

States and Selected Countries, 1950-54 to 1980-

84 116

Trends in Age-Standardized Death Rates (per

100,000) for Cerebrovascular and Ischemic

Heart Disease, United States and Selected

Countries, 1950-54 to 1980-84 118

Comparison of U.S. and Canadian Death Rates

(per 100,000) for the Five Leading U.S. Causes

of Death, Males, Age 15 to 24, 1989 119

Comparison of U.S. and Canadian Death Rates

(per 100,000) for the Five Leading U.S. Causes

of Death, Females, Age 15 to 24, 1987 120

Comparison of U.S. and Canadian Death Rates

(per 100,000) for the 10 Leading U.S. Causes of

Death, Males, Age 25 to 44,1989 121

C-10 Comparison of U.S. and Canadian Death Rates

(per 100,000) for the 10 Leading U.S. Causes of

Death, Females, Age 25 to 44, 1989 122

C-n Comparison of U.S. and Canadian Death Rates

(per 100,000) for the 10 Leading U.S. Causes of

Death, Males, Age 45 to 64, 1989 123

C-12 Comparison of U.S. and Canadian Death Rates

(per 100,000) for the 10 Leading U.S. Causes of

Death, Females, Age 45 to 64, 1989 124

C-13 Comparison of U.S. and Canadian Death Rates

(per 100,000) for the 10 Leading U.S. Causes of

Death, Males, Age 65 and Over, 1989 125

C-14 Comparison of U.S. and Canadian Death Rates

(per 100,000) for the 10 Leading U.S. Causes of

Death, Females, Age 65 and Over, 1989 126
Summary

and

Findings 1

T

he United States spends a higher proportion of national

income on health care than any of its peers in the

international community and yet continually ranks

poorly in some key indicators of health. Death rates for

infants, children, and young and middle-aged adults, for example, are substantially higher than in other industrialized countries. Policymakers have hoped that by looking to countries with

better health status measures and lower spending, they might find

solutions to U.S. health care problems. However, the determinants of a nation’s health status are myriad, many falling outside

the usual bounds of the health care system. This Office of

Technology Assessment (OTA) analysis of international health

statistics concludes that while comparisons are extremely useful

for identifying health differences and beginning to elucidate the

reasons for them, they are not particularly useful in formulating

prescriptions for the U.S. health care system.

INTRODUCTION

The health of a nation’s people can be gauged, however

imperfectly, through aggregate statistics on factors such as

births, deaths, personal behavior, and the use of health care.

Seeing how countries stack up and how big the differences are

among them is a first step in identifying the factors that enhance

or detract from health. The range of values for these ‘‘health

indicators” among countries provides clues about the practical

limits of what can be achieved. Eventually, some of the

knowledge gained may be put into practice through health

policy; however, the link between health indicators and the

health care system is not necessarily direct. Because many

factors outside the health care system itself-ranging from
2 I International Health Statistics: What the Numbers Mean for the United States

unhealthy behavior on the part of individuals to

the availability of guns to the wide ranging effects

of unequal income distribution-affect the level

of health of a population, changes in the health

care system alone will not necessarily improve

health indicators.

This background paper describes:

how the health of U.S. residents compares with

people in 12 other developed nations,

why international comparisons are hard to

interpret, and

what new measurements and analytic approaches

might improve international comparisons of

health.

The comparison countries are Australia, Canada,

France, Germany,l Italy, Japan, the Netherlands,

New Zealand, Norway, Spain, Sweden, and the

United Kingdom. Other countries are compared

sometimes, as well, and separate comparisons

between the United States and Canada have been

made in several areas.

This paper is part of a larger project, International Differences in Health Care Technology

and Costs. The main report, to be published in

1994, looks at variations in expenditures and

resources used in some specific areas of health

care among developed countries. The House

Committee on Ways and Means, Chairman Dan

Rostenkowski, asked OTA to do this assessment.

KEY FINDINGS

Do available international statistics allow us to

determine whether real differences in health

status exist?

■ Despite some measurement problems, international statistics show real differences in health

status between the United States and other

developed countries. Measures that can be used

with some confidence include age-specific

mortality, life expectancy, and broadly defined

cause-specific mortality. International comparisons of infant mortality can be made when

vital registration reporting differences are taken

into consideration. In contrast, comparisons

based on detailed cause of death (e.g., deaths

from tuberculosis, specific types of heart disease, and suicide) are not amenable to making

international comparisons. There are virtually

no population-based data available with which

to make meaningful international comparisons

on the prevalence of disease and disability.

How does the United States compare with

other developed countries?

■

■

■

Compared with 12 other developed countries,

the United States generally has higher death

rates among infants, children, and young to

middle-aged adults. Many of these mortality

differences are quite large. If, for example, the

United States had Canada’s more favorable

age-specific mortality rates, it would have 9

percent fewer deaths (i.e., 192,200 U.S. deaths

would have been avoided in 1989). Most of the

‘‘excess’ U.S. deaths relative to Canada are in

the 45 to 64 age group.

The gap between the U.S. and other countries’

infant mortality rates may not be as wide as

indicated by reported statistics. Some of the gap

is explained by differences in how doctors

record fetal and infant deaths in different

countries. Nevertheless, while there is ample

evidence that the U.S. international rank of 24

of 39 countries is overly pessimistic, the true

rank of the United States is probably no better

than 20, a rank that has deteriorated considerably over time.

The United States compares quite favorably to

other developed countries on some important

health risk factors. For example, fewer U.S.

than Canadian or European residents smoke,

and more U.S. than Canadian or European

residents undergo some tests for cancer.

1 All data throughout this paper are from the former Federal Republic of Germany.
Within the United States, infant mortality rates

correlate inversely with socioeconomic status.

Differentials related to socioeconomic status as

large as those found in the United States exist

in several other developed countries, even

where there is universal access to high-quality

medical care.

How should international health status differentials be interpreted?

One cannot determine the exact reasons for

international differences in health status with

available international statistics. Among the

factors that might contribute to differences are:

socioeconomic, environmental, and cultural

factors; personal risk behaviors; and access to

health care.

Because health status is the result of complex

interactions between many social, biological,

and health care factors, health status indicators

may be considered as useful social indicators.

They are not by themselves useful measures of

the success or failure of a country’s health care

system.

DETAILED FINDINGS

Purposes and Limitations of International

Comparisons of Health

The reasons for comparing the health status of

different countries include exploring the causal

mechanisms of disease, identifying important

public-health problems, and investigating how

health care policies affect health. Differences in

national systems for reporting data hamper some

international comparisons. Although deaths are

uniformly reported in developed countries, consensus is lacking about which nonfatal health

outcomes are important and about how to measure them and collect the data. The World Health

Organization (WHO), the U.S. National Center

for Health Statistics (NCHS),2 and others have

Chapter l-Summary and Findings I 3

recently launched efforts to improve and standardize public-health surveillance, in part to help

monitor progress toward achieving national goals

for health by the year 2000.

A model for international comparisons of

health is the NCHS International Collaborative

Effort (ICE) on Perinatal and Infant Mortality.

Great disparities between the fetal- and infantmortality rates of the United States and those of

other developed countries prompted NCHS to

organize a consortium of international experts on

perinatology, epidemiology, and statistics. Recognizing that available sets of national data were

not comparable, the group has assembled an

international database, which allows detailed

comparisons of fetal and infant mortality. Using

a similar model, a second ICE is currently

addressing issues related to aging, and a third ICE

will address issues related to injury.

Sociodemographic Characteristics of

Comparison Countries

The chief sociodemographic difference between the United States and the comparison

countries lies in the sizes of their populations. The

United States has nearly 250 million residents,

twice as many as Japan, nearly 10 times as many

as Canada, and 75 times as many as New Zealand.

Another difference lies in what proportions of

the residents fall into the various age groups

within each country. The United States has a

relatively young population and will remain

younger than Western Europe and Japan through

the year 2025, even though our baby boom cohort

will have reached the age of 65 by then.

The United States is racially and ethnically

diverse, with about one-fifth of its residents

belonging to minority groups. Although comparable data on the ethnic and racial compositions of

other countries are limited, available information

suggests that foreign migration to Western Eu2 The National Center for Health Statistics is an agency of the Centers for Dtie Control and Prevention within the U.S. Dep artment of

Health and Human Services’ Public Health Service.
4 I International Health Statistics: What the Numbers Mean for the United States

rope has increased in recent years, contributing to

the presence of sizable, disadvantaged, minority

populations.

High proportions of residents participate in the

labor forces of all the comparison countries, and

the principal differences lie in the extent to which

women and the elderly are economically active.

Women’s participation in the labor force is

highest in Sweden, lowest in Australia, and

intermediate in the United States. The United

States, Norway, and Japan have relatively more

elderly in the labor force than do the other

countries.

Poor health is associated with poverty and with

large disparities in income levels, both of which

apply to the United States. Poverty rates are

higher in the United States than in most comparison countries, and the distribution of income is

relatively unequal in the United States, compared

with other countries such as Sweden, Norway,

and Japan.

Health insurance coverage improves health,

and most residents of all 12 comparison countries

are covered. By contrast, a large segment of the

U.S. population has no health insurance.

Infant Mortality

Of 39 developed countries, the United States

ranked 24th in infant mortality in 1990. The U.S.

infant-mortality rate (9.2 per 1,000 live births)

was 35 percent higher than Canada’s rate (6.8 per

1,000 live births) and twice as high as Japan’s rate

(4.6 per 1,000 live births). The U.S. international

standing was much better in 1950 and 1960, but

infant mortality has declined much more rapidly

in the other counties than in the United States.

Interpreting international differences in infantmortality rates is difficult, because counties vary

in how they report vital events. Available evidence suggests that infant-mortality rates are

inflated in the United States, because many events

that would be considered fetal deaths in other

countries are counted as live births in the United

States. U.S. rates would be comparable to those of

Japan if infant deaths were combined with fetal

deaths that occurred after at least 20 weeks of

gestation. Such a comparison might be invalid,

however, because evidence suggests that the

United States undercounts early fetal deaths.

Moreover, despite the fact that the current international rank of the United States is overly pessimistic, its true rank is probably no better than

20th.

Among the factors associated with whether an

infant will live or die in its first year are the

infant’s race, sex, birth order, place of residence,

birthweight, gestational age, and whether it is

born alone or as part of a set of twins, triplets or

other multiples; additional factors include the

mother’s age, prior experience with pregnancy,

state of health, personal habits (e.g., smoking,

. . drinking alcohol, obtaining prenatal care), and

socioeconomic status. How these biological and

social factors interact to influence infant mortality

is unclear, but available data should aid in the

assessment of how the factors vary in relation to

infant-mortality rates in the United States and

abroad.

By applying new analytic methods to an

international perinatal- and infant-mortality database, researchers have assessed how infant mortality in the United States has been affected by the

prevalence of low birthweights and by the proportion of deaths that occur at specific birthweights.

The ICE research suggests that when definitions

of low birthweight take population-specific birthweight distributions into account (rather than use

an arbitrarily defined value for all populations),

the relatively high infant-mortality rate in the

United States may reflect birthweight-specific

mortality more than birthweight distribution. This

implies that efforts to decrease the U.S. infantmortality rate must target interventions both to

lower the prevalence of infants born in the

high-risk, low-birthweight end of the distribution

curve and to lessen the chances of deaths for

infants of all birthweights.

The fetuses and infants of women who become

pregnant while under the age of 20 or over the age
Chapter l-Summary and Findings I 5

of 39 are more likely to die or have health

problems. There are more births by women of

these age groups in the United States than in the

other developed countries. This fact may explain

up to 25 percent of the difference between the

infant-mortality rate of the United States and the

more favorable rates of countries like Canada and

Japan. Nonetheless, the socioeconomic status,

lifestyles, and health of women at the extremes of

maternal age, rather than age itself, probably

account for the differences.

Patterns of use of prenatal care in the United

States differ from those in some Western European countries. Pregnant women in the United

States tend to seek care later but to average a

greater number of prenatal-care visits than do

women in France, Denmark, and Belgium.

Significant socioeconomic differentials in infant mortality exist in the United States as well as

several other developed countries, even where

access to high-quality medical care is universal.

Improving access to maternal- and child-health

services in the United States would likely decrease the overall infant-mortality rate, but variation among the Nation’s subpopulations might

well persist.

Mortality Comparisons

In comparisons of death rates, the United States

ranks relatively poorly among industrialized countries. Age at death is reliably reported in developed countries, and the age-specific death rate is

a useful measurement for international comparisons. Compared with the age-specific death rates

of other developed countries, U.S. rates are

among the highest through the age of 64 and

somewhat lower after the age of 65. These trends

generally remain the same when the other countries’ death rates are compared with the death

rates of only the white residents of the United

States. The high rates of death for young age

groups mean that U.S. residents are born with

relatively lower life expectancies and that many

years of potential life are lost. An analysis of

age-specific death rates since 1955 shows that

they have been persistently high in the United

States and that reductions in mortality have

generally not been as great in the United States as

in comparison countries. An important exception

to this trend is that mortality rates have declined

significantly for U.S. men aged 45 to 54. The

United States has made the least progress, however, in reducing mortality rates for men aged 25

to 34.

For people below the age of 35, injuries are

major causes of death, and the U.S. rates of death

from injuries are among the highest for developed

countries. The rate of death from homicide and

other violence is at least twice as high for the

under-35 age group in the United States as in any

of the comparison countries. After the age of 35,

cancer and heart disease are the major causes of

death in all the developed countries. U.S. rates of

death from heart disease for both men and women

aged 35 to 65 are among the highest, but U.S.

rates of death from cancer are not exceptionally

high compared with those of other developed

countries.

If U.S. age-specific death rates were the same

as the Canadian rates, the United States would

have 9 percent fewer deaths. In 1989, for example, 192,200 fewer people would have died. The

excess death is primarily concentrated in the

45-to-64 group. Higher rates of heart disease in

the United States than in Canada account for most

of the disparity in the death rates for this age

range.

Morbidity, Disability, and

Quality-of-Life Indicators

There is no general consensus regarding disability measurements, but they are important for

determining g whether gains in life expectancy

have come at the expense of quality of life. The

WHO International Classification of Impairments,

Disabilities and Handicaps (ICIDH) has been

accepted by many nations and is used for clinical

and health services research, health services
6 I International Health Statistics: What the Numbers Mean for the United States

planning, and population health monitoring. The

ICIDH framework has been criticized, but many

of the problems are likely to be resolved in the

planned revision of the classification scheme. In

view of differences in how health services are

delivered, internationally comparable data on

disability will probably come from populationbased surveys rather than administrative records.

Achieving consensus on a disability classification

would be a first step toward the comparability of

information about disability on such surveys. At

present, both the content and methods of surveys

differ so greatly that disability comparisons

cannot be made.

Despite international disagreement over what

disability means, there is general agreement that

public-health efforts should focus on extending

the years of life without disability. An indicator

that shows great promise in monitoring health is

a measurement of healthy-life expectancy, which

is the number of years someone at a particular age

can, on average, expect to live without experiencing any of various impairments, disabilities, or

handicaps. Although the different countries have

not yet agreed on how to measure healthy-life

expectancy, many of them have included it as an

indicator in their health goals, and efforts are

underway to measure and monitor it. An international group of researchers (REVES) is working

toward standardizing this measurement.

Health-Related Behaviors

Smoking cigarettes and drinking heavily are

known to have both immediate and long-term

health effects. As many as 20 percent of the deaths

in developed countries can be attributed to

smoking alone. Available evidence suggests that

relatively fewer people smoke in the United

States than in Canada and selected Western

European countries. In the mid-to late-1980s, for

example, the proportion of men smoking was 30

percent in the United States, 36 percent in

Canada, and ranged from 40 to 62 percent in

Europe. Current smoking-related deaths can be

traced to smoking patterns that existed a decade

or more ago. In the mid-1960s, males were less

likely and females were more likely to smoke in

the United States than in Western Europe.

Relatively more Canadian than U.S. residents

drink alcohol, but the prevalence of heavy drinking is similar in Canada and the United States.

People appear to abstain from alcohol or to drink

infrequently at about the same rates in the United

States and Europe.

Certain preventive health services (i.e., mammography, Pap tests) tend to be used more in the

United States than in Europe, and U.S. women are

more likely than Canadian women to participate

in cervical-cancer screening and to examine their

breasts for lumps every month. U.S. residents are

less likely than Canadians, however, to have their

blood pressures checked, use seatbelts regularly,

and have smoke detectors in their homes. U.S.

residents are more likely than Canadians to be

overweight and less likely, especially if they are

elderly, to engage in regular exercise.

CONCLUSIONS

No simple statistic or set of statistics can fully

describe the success of a nation’s health care

system. A rough picture can be drawn, however,

from the state of the population’s health, the

availability of health services, access to state-of-theart medical technology, and public satisfaction

with the health care system. The United States

excels in providing high-technology care but

appears to lag behind most other developed

countries in the remaining indicators of a good

health care system.

This background paper takes a broad look at

some health outcomes, as depicted by nationally

available public health data, most of which are

death statistics. The United States ranks poorly in

most categories. U.S. death rates from infancy

through the age of 64, for example, are generally

higher than those of the 12 other comparison

countries.
Chapter l-Summary and Findings I 7

Determining how much of each disparity is real

and how much is artifactual is often difficult,

because each country has a unique system for

monitoring public health. The gap between infant

mortality rates, for instance, may not be as wide

as the reported statistics indicate. Some of the

differences between U.S. rates and those of other

countries can be explained by international variations in how doctors record the deaths of infants

and fetuses. Nonetheless, other statistics, which

show conclusively that premature deaths are more

prevalent in the United States than elsewhere in

the developed world, are extremely reliable.

A complex of factors affects health status, and

how these relate to the poor relative position of

the United States is uncertain. One major difference between the United States and the other

developed countries is the extent to which residents are covered by health insurance, which

affects the accessibility of services, the types and

quality of care, the intensity of that care, and

patient health. The broader coverage in the other

countries may contribute to the fact that, for

example, childhood immunization and other facets of well-child care are more widespread in

Europe than in the United States. Whether this

plays a significant role in shaping the health of a

nation’s people cannot be determined at this time.

A number of U.S. and international agencies,

however, are developing methods that will allow

more exact comparisons in the future.
Purposes and

Limitations of

International

Health

Comparisons 2

T

he health of U.S. residents is compared with that of

residents of other developed countries to answer both

medical and health policy questions (128). Identifying

international differences in health status can be the first

step in uncovering the causal mechanism of disease. The

observation of large differences in U.S. and Japanese rates of

cardiovascular disease led to comparisons of dietary behaviors

later identified as important heart disease risk factors.1 International comparisons can also be used to corroborate a trend

observed within one country. For example, the decline in

cardiovascular disease noted in the United States has also been

observed in several other developed countries (183).

International differences in health status can also indicate

major public health problems. The observation that infant

mortality rates are higher in the United States than in many other

developed countries has alarmed policymakers and prompted

studies of international differences in maternal and child health

care delivery, perinatal risk factors, and vital statistics reporting

(217,220,232).

In an effort to gauge how changes in U.S. health policies or

practices might affect the health of the population, comparisons

are sometimes made between the United States and countries

whose sociodemographic characteristics are similar to those of

the United States but whose health care financing or delivery

mechanisms differ. Such predictions, however, are difficult to

base on international comparisons because so many other

1 A comparison of coronary heart disease, stroke, and suspected risk factors among

Japanese and Japanese-Americans in Hawaii and the U.S. mainland led to the

identification of dietary habits (fat consumption) as causal factors in the development of

cardiovascular disease (12).
10 I International Health Statistics: What the Numbers Mean for the United States

factors-including population, social, and environmental characteristic--influence health status.

Interpreting international differences in health

status is further complicated by evidence that

some differences in health indicators reflect

disparities in how countries define and measure

health outcomes. Nonetheless, although difficult

to interpret, measurements of health status are

important social indicators, and great differences

in the health status of the residents of two or more

countries can stimulate further research into the

underlying complex of contributing factors.

PROBLEMS IN MAKING INTERNATIONAL

HEALTH COMPARISONS

The ability to make international comparisons

rests on the availability of accurate national

health statistics. The usual sources for data on the

health status of the population include (256):

vital statistics (e.g., certificates of births and

deaths);

population and housing censuses;

routine health service records (e.g., hospital

discharge data);

epidemiologic surveillance data (e.g., reporting

of infectious disease and other health occurrences);

sample surveys (e.g., household surveys of

health characteristics, knowledge, and practices);

disease registers (e.g., cancer registers); and

nonhealth sector sources (e.g., employment

records of workplace injuries).

The most comparable health status data come

from vital statistics systems, such as for births and

deaths, because developed countries register virtually all events and generally adhere to certain

international standards for recording the events.

But despite the degree of uniformity, differences

in data collection can undermine international

comparisons. Countries appear to differ, for

example, in distinguishing between infant and

fetal deaths and recording causes of death (see

chapters 3 and 4).

Most residents of developed countries live to at

least the age of 70, and death rates at younger ages

are relatively low. Measures that assess the

consequences of living with chronic illnesses or

disability are therefore also important. One country may have a lower death rate than another, but

devote inadequate resources to maintaining a

good quality of life for people who are chronically

ill or disabled. Mortality data are uniformly

available for developed countries, but virtually no

morbidity or disability data are currently available for making international comparisons although some interesting measurements have been

conceptualized (see chapter 5).

International comparisons of morbidity and

disability are extremely difficult to make, in part

because a consensus regarding measurements of

outcomes is lacking, and also because countries

have very different systems for monitoring morbidity and disability. The burden of disease and

injury can be measured in several ways, each of

which poses unique difficulties in an international

context, The prevalence of chronic disease can be

measured through medical examination surveys,

through self-reports on interview, from hospital

discharge information, or from disease registers

or surveillance systems.

Each of these informational sources may be

used to assess health status within countries. In

the United States, for example, information on the

prevalence and consequences of disease and

injury comes from the National Health and

Nutrition Examination Survey, in which a sample

of U.S. residents is interviewed, examined by a

clinician, and provided laboratory tests (229).2

2 Few other developed countrica have an ongoing periodic hesdth exminati on SUIVey d.m.ilar to the U.S. National Health and Nutrition

Examination Survey. Canada conducted examination aurveys in 1978-79 (provincial swveys have subacquently been conducted), Finland

conducted a survey in 1977-80, and the former (3erman Democratic Republic conducted annual examina tiona of ita working population

(175,272),
Chapter 2–Purposes and Limitations of International Health Comparisons! 11

Self-reported health status, disability, utilization

of health care, and risk factors for disease are

determined through the National Health Interview Survey. Hospital records are examined in

the National Hospital Discharge Survey to identify why hospitalizations occur and which surgical and diagnostic procedures are used. The extent

to which a condition prompts visits for ambulatory care is evaluated through ambulatory care

surveys.

3

Most health-related information (other than

mortality data) used in international comparisons

comes from population-based surveys. Most countries include information on chronic illness,

disability, and self-perceived health on these

surveys, but the questions asked in the surveys

differ to such an extent that comparisons of

responses cannot easily be made (44,272). International efforts are underway to standardize

morbidity and disability concepts and survey

questions (see chapter 5).

Using hospital discharge data for international

comparisons has the potential advantage of examining health outcomes closely linked to specific

clinical interventions (e.g., hospital surgical outcomes) (154). Such comparisons, however, are

not always feasible because some countries don’t

record surgical procedures as part of their hospital

statistics (e.g., France, Italy, Japan, and Spain).

Furthermore, hospital-based data may not be

comparable because of differences in how data

are collected4 and how hospitals are defined.5

Added difficulties arise because in some countries, including the United States, surgical procedures once performed in hospitals are increasingly being conducted on an outpatient basis and

are thus not fully reflected in hospital statistics.

International hospital-based comparisons are also

di.i%cult to make because of the lack of uniform

information with which to adjust outcomes for

differences in the health status of hospitalized

patients. Such adjustments are important because

of apparent differences in the rates at which

procedures are used, which could mean that

countries use different criteria in selecting patients for some procedures.6

HOW SHOULD INTERNATIONAL HEALTH

STATUS COMPARISONS BE MADE?

The availability of computerized international

health databases has facilitated international comparisons of health status, but such comparisons

are limited because of differences in how the

individual countries define and collect data that

are reported to these databases (1 32,265). Several

efforts are underway to thoroughly analyze the

comparability of data sources that serve as the

basis of international health comparisons.

The Inter-Country Working Group on Comparative Health Statistics (IWG) was established in

1991 through the U.S. National Center for Health

Statistics (NCHS) to promote international comparability of health data. The group, which

includes representatives from Canada, England

and Wales, France, the Netherlands, and the

United States, has developed a checklist to

provide a standard format for evaluating the

characteristics and comparability of health statistics among countries (41). After using the checklist to assess the comparability of national data on

mortality and hospitalization associated with

3 In the United States, ambulatory care data are available through the National Ambulatory Medical Care Survey, and the National Hospital

Ambulatory Care Survey which cover visits to physicians offkxs, hospital outpatient clinics, and other ambulatory care providers (233),

‘$ U.S. hospital discharge data, for example, are obtained from a sample survey, whereas French discharge data are based on a complete count

of discharges from public hospitals, only half of which respond in a given year (199).

5 Discharges from long-term care facilities are included in some countries’ hospital discharge surveys (e.g., Canada, England and Wales,

France, Sweden) but are excluded in the U.S. National Center for Health Statistics (NCHS) hospital discharge survey (199), Information on

nursing home stays in the United States is available through the National Nursing Home Survey (40)

6 International comparisons of some of the characteristics of hospitalized patients and the conditions that lead to hospitalization can be made

using selected countries’ hospital discharge data (103).
12 I International Health Statistics: What the Numbers Mean for the United States

diabetes, the IWG concluded that trends in

different countries would be difficult to compare

because of probable differences in data collection,

coding, and clinical practices (41).

A model for conducting international comparisons of health status is NCHS’s International

Collaborative Effort (ICE) on Perinatal and Infant

Mortality. Since 1984, representatives of the

United States and 10 other industrialized countries have conducted comparative analyses using

a database maintained by ICE members (128).

ICE has been instrumental in identifying some

sources of international differences in infant and

fetal mortality (see chapter 3). A second ICE, the

International Collaborative Effort on Aging was

established in 1988. Existing data will be used to

research the following prioritized areas (225,239):

■

■

■

9

9

A

health promotion and disease prevention;

measurement of vitality in older persons;

comparative analysis of hip fracture;

functional disabilities; and

measurements of outcomes of nursing home

care.

third ICE is planned to address injury.

The U.S. NCHS also publishes an International Health Data Reference Guide, which

provides information from 34 nations on the

availability of selected national vital, hospital,

health personnel resources, and population-based

health survey statistics (222).

The World Health Organization (WHO),7 the

health unit of the United Nations, assumes an

important role in standardizing, collecting, and

disseminating statistical information about

health. For example, WHO publishes and revises

the International Classification of Diseases, Injuries, and Causes of Death, a classification system

used throughout the world to ensure the uniformity of mortality statistics.8 WHO has also published the International Classification of Impairments, Disabilities, and Handicaps, which has

facilitated the collection of disability statistics

(see chapter 5). The WHO Regional Office for

Europe surveyed the statistical agencies of selected countries and detailed the difficulties of

making international morbidity and disability

comparisons because of differences in how health

indicator data are collected in population-based

surveys (see chapter 5) (44).

SUMMARY

The purposes of international comparisons of

health status include exploring causal mechanisms of disease, identifying possible important

public-health problems, and investigating the

health consequences of health care policies.

Differences in national systems for reporting

health data make some international comparisons

difficult. Although deaths are uniformly reported

in developed countries, consensus is lacking as to

which nonfatal health outcomes are important,

and as to how these outcomes should be measured

and collected. WHO, the U.S. NCHS, and others

have recently launched efforts to improve and

standardize public health surveillance, in part to

help monitor progress toward achievement of

national “year 2000” health goals (212,266,272).

A model for making international comparisons

of health is the U.S. NCHS International Collaborative Effort on Perinatal and Infant Mortality.

Large apparent differences between the United

States and other developed countries with regard

to birth outcomes prompted NCHS to organize a

consortium of international experts on perinatology, epidemiology, and statistics. Recognizing

that available sets of national data were not

comparable, the group has assembled an intema7 As of 1990, WHO had 166 member states in six regions: Afric% the Americas, Eastern Mediterran~ Europe, Southeast Asiq and the

Western PacKlc (262). Developed countries include Australia CanadtL Europe, hwae~ Japaq New Zealand, the former Union of Soviet Socialist

Republics, and the United States (260).

8 WHO also publishes the World Heuhh Stutiszz”cs Annual, which summarizes, for individual countries, demographic, and vital statistics

and selected health system characteristics (e.g., health personnel data) (260).
Chapter 2–Purposes and Limitations of International Health Comparisons I 13

tional database so that detailed comparisons of NCHS to address issues related to aging, and a

fetal and infant mortality can be made. Using a third ICE on injury is planned.

similar model, a second ICE is underway at
Sociodemographic

Characteristics of

Comparison

Countries 3

I

nternational comparisons of health status are generally

based on aggregated information that does not allow

analysts to control for socioeconomic variables that could

affect health status. This chapter describes how countries

compare in selected demographic and socioeconomic characteristics.1

POPULATION SIZE, GEOGRAPHIC DISTRIBUTION,

AND AGE COMPOSITION

The size, geographic distribution, and age composition of a

nation’s population play major roles in determining the allocation and use of health care resources. Urban and rural distribution

can affect physical access to services and the availability of

specialized tertiary care. The aging of developed countries’

populations affects health status measures and increases demands on social and health services.

The population of the United States is much larger than that of

any of the comparison countries and some of the larger States are

more populous than some of the comparison countries. California, for example, has more residents than Canada does. The

population of the United States is 75 times greater than that of the

least populous country, New Zealand. Even Japan, whose

population is the second largest of the comparison countries, has

less than half as many residents as the United States does (table

3-1).

At least three-quarters of residents in almost all comparison

countries are urban dwellers (table 3-l). The most urbanized

1 Much of the information in this chapter comes from the U.S. C- Bureau’s Center

for International Research The Center maintains an international cbtabasc containing

demographic and socioeconomic information (%). 15
93

Table 3-l-Selected Demographic Characteristics, United States and Selected Countries, 1990

Population Population crude Population urban

Population under age 25 aged 65 and over birth rate natural increase

Country

population

(thousands) (percent) (percent) (per 1,000)a

(per 1,000)b(percent)c

United States 249,415 36.5% 12.5% 15.1 6.3 75%

Australia 17,071 38.3 11.2 15.0 7.5 86

Canada 26,620 35.4 11.5 14.1 6.6 77

France 56,720 34.2 14.6 13.8 3.5 74

Germany d

79,357 29.7 15.0 11.2 -1.1 NA

Italy 57,661 32.4 14.6 9.9 -0.3 69

Japan 123,611 33.4 12.0 11.3 4.3 77

Netherlands 14,849 34.4 127 12.7 4.0 89

New Zealand 3,362 39.9 11.1 16.7 8.6 85

Norway 4,253 34.2 16.4 12.4 1.9 75

Spain 38,959 36.6 13.4 12.1 3.0 79

Sweden 8,529 31.2 18.0 12.9 0.8 84

United Kingdom 57,418 33.8 15.7 13.6 1.8 89

KEY: NA = not available.

aThe crude birth rate is the number of live births per 1,000 population and is shown for the period 1985-1990.

bThe rate of natural population growth is the difference between the crude birth and death rates and is shown for the period 1985-90.

cThere is no uniform definition of urban populations. Countries have different definitions, sometimes based on such factors as population density and economic characteristics.

Urbanization data are for 1991.

dBased on data from the former Federal Republic of Germany.

SOURCES: Y. Kanegae, Chief, lntenational Statistical Affairs Section, Ministry of Health and Welfare, Tokyo, Japan, personal communication, July 1993; M.A Khawaja Chief

Demographer, Population and Demography Division, Department of Statistics, Christ Church, New Zealand, personal communication, August 1993; K. Kinsella Chief,

Aging Studies Branch, census Bureau, U.S. Department of Commerce, Suitland, MD, personal communication, June 1993; U.S. Department of Commerce, Bureau of the

census, An Aging World II, International Population Report (P25, 92-3) (Washington DC: U.S. Government Printing Office, 1992); World Health organization, World

Health Statistics Annual, 1991 (Geneva, Switzerland: World Health Organization, 1992); World Bank Worldf Development Report 1993 (New York NY: Oxford

University Press, 1993).

-.

0

s
Chapter 3-Sociodemographic

countries are the United Kingdom and the Netherlands, with nearly 90 percent of their populations

residing in urban areas. Somewhat less urbanized

are Italy, France, Norway, and the United States,

with roughly 70 to 75 percent of their populations

residing in urban areas.

The population of the United States is younger

than most comparison countries, in that a larger

share of its population is under the age of 25 and

a smaller share of its population is aged 65 and

over (table 3-l). Birth rates higher than those in

Europe contribute to a greater expansion of

population in the United States. By contrast,

Germany and Italy, where the number of deaths

exceeds the number of births, are experiencing

natural declines in population.2

The proportion of the population aged 65 and

over in the United States will not increase

significantly until after 2010, when the large birth

cohorts of the baby boom (from 1946 to 1964)

begin turning 65. By the year 2025, nearly one in

five (19 percent) U.S. residents could be aged 65

and over (table 3-2). Even so, the United States as

a whole will likely remain younger than Japan and

most countries of Western Europe (196). Among

the world regions, Europe has the highest proportion of residents aged 65 and over (14 percent in

1990), and by the year 2025, more than 1 in 10

Europeans are likely to be at least 75 years old

(196). By the year 2025, an estimated 1 in 13 U.S.

residents are projected to be at least 75 years old.

LIVING ARRANGEMENTS AND

HOUSEHOLD COMPOSITION

Living arrangements and household composition may influence health status, especially for the

elderly and children. International differences in

the extent to which a country’s elderly live alone

or in institutions may indicate cultural preferences, the availability of families and informal

networks to provide support, access to home or

institutional care, or differences in the elderly’s

Characteristics of Comparison Countries I 17

Figure 3-l—Percentage of Elderly Population

(Age 65 and Older) Living Alone in Private

(Noninstitutional) Households: United States

and Selected Countries, Selected Data

from the 1980s

Country

Japan

Italy

Australia

New Zealand I

Canada I

I

28

1

Swedenc 40

0 10 20 30 40

Percent

a Refers to men aged 65 and over, women aged 60 and over.

b Based on data from the former Federal Republic of Germany.

c Refers to pensioners, with usual pension age being 65 years.

SOURCE: U.S. Department of Commerce, Bureau of the Census,

WorldAging II, International Population Reports (P25, 92-3) (Washington, DC: U.S. Government Printing Office, 1992).

physical ability to live independently. According

to data from the 1980s, the proportion of the

elderly (age 65 and older) population living alone

in private (non-institutional) households ranges

from a low of 10 percent in Japan to a high of 40

percent in Sweden. Nearly one-third (31 percent)

of the elderly in the United States live alone, a

proportion comparable to those of France (33

percent) and the United Kingdom (30 percent)

(figure 3-l).

About 6 percent of the elderly in Australia,

France, and the United States compared with 11

percent in the Netherlands live in institutions

(either medical or non medical) (figure 3-2).

Residents of Japan are much more likely than

residents of Germany to live with children (the

percentage of households including children being

42 and 25, respectively) (table 3-3). More than

z Estimates of natural cbanges in population take into account numbers of births and deaths, but ignore migration.
18 I International Health Statistics: What the Numbers Mean fort he United States
Chapter 3--Sociodemographic Characteristics of Comparison Countries I 19

Figure 3-2—Percentage of Elderly Population

(Age 65 and Older) Living In Institutions

(Medical and Nonmedical): United States and

Selected Countries, Early to Mid-1980s

Country

Japan

United States

France

Australia

Canada

Switzerland

Sweden

Netherlands

SOURCE: U.S.

9

1 1 1 10

11 1 1 I 1

0 2 4 6 8 10 12

Percent

Department of Commerce, Bureau of the Census,

World Aging II, International Population Reports (P25, 92-3) (Washington, DC: U.S. Government Printing Office, 1992).

one-third (35 percent) of U.S. households include

children. Households composed of single parents

and their children constitute a high proportion (8

percent) of households in the United States,

although the rate is not much higher than those of

some other countries (6 percent, for example, of

Canadian households fall into this category).3

ETHNIC AND RACIAL COMPOSITION

Health status disparities between racial and

ethnic groups occur in the United States (48).

Some of these differences reflect social factors,

such as income and education (2,64,91,92,153).

The population of the United States is characterized by racial and ethnic diversity. In 1990, for

example, Asians, Blacks, Hispanics, and Pacific

Islanders constituted as many as one in five U.S.

residents (197). Data on racial and ethnic composition are not always collected by comparison

countries, but available data suggest that increased migration from less developed countries

to Western Europe and other developed regions

has increased population diversity there (131).

For example, about 6 percent of the residents of

France and 5 percent of the residents of the

Netherlands were foreign, often from less developed countries (e.g., Algeria, Morocco, and

Turkey), and from relatively disadvantaged

groups (table 3-4) (241). An estimated 8 percent

of U.S. residents, 15 percent of Canadian residents, and 23 percent of Australian residents are

foreign-born (table 3-4) (105,131 ).4

SCHOOL ATTENDANCE

Educational attainment (as measured by school

attendance) is generally positively related to

health status (133a,171). In the United States, for

example, 1986 death rates among those who had

not graduated from high school were two to three

times higher (depending on race and sex) than

those of college graduates (133a).

Available data on school attendance suggest

that U.S. residents are well educated compared

with residents of selected comparison countries.5

Around 1980, for example, the proportion of

young adults (age 25 to 44) who had completed

post-secondary education was twice as great in

s The proportion of households with children that arc headed by a single parent is 23 percent in the United States and 15 percent in Canada

(table 3-3).

4 European countries use nationality to define the ‘‘foreign’ population and non-European countries generally use place of birth to define

the “foreign-born” population (131).

s Data on school attendance are not widely available, and statistics may vary by country for several reasons, including differences in

educational systems, differences in categories used to describe educational level, varying dwntions of particular educational levels, different

concepts of attendance, and differences in reporting attendance to international organizations< These factors hamper international comparisons,

and available data must be interpreted with caution (196).
Households Percent of

with children Percent of all households with

(thousands) o households children

Married SingleTotal Households parents parent

households Single- With with with Married SingleCountry Year (thousands) Total parents parent children children children parents parent

United States

Australia

Canada

France

Germanyb

Japan

Sweden

United Kingdom

1988

1982

1986

1988

1988

1985

1985

1987

91,066

5,214

8,992

20,853

27,403

37,980

3,670

NA

31,920

1,770

3,406

7,070

6,918

15,836

1,051

NA

24,601

1,569

2,903

6,301

5,984

14,896

873

NA

7,319

201

769

178

NA

35.1%

33.9

37.9

33.9

25.2

41.7

28.6

32.0

27.0%

30.1

32.3

30.2

21.8

39.2

23.8

28.0

8.0%

3.9

5.6

3.7

3.4

2.5

4.9

4.0

77.1%

88.6

85.2

89.1

86.5

94.1

83.1

87.3

22.9%

11.4

14.8

10.9

13.5

5.9

16.9

12.7

KEY: NA= not avalable.

aThe definitions of households, children and the treatment of unmarried cohabiting couples may differ across countries so comparisons should be made with caution. Households may

include related or unrelated individual A small proportion of other household type may contain children. Households of unmarried cohabiting couples may be classified as singleparent households, married couple households, or ‘other' households, depending on responses to surveys, in all countries except Canada, France, and Sweden where they are explicitly

included under married couples. Singleparent subfamilies living in larger households are excluded from the data on single-parent households. Children are defined as under 18 years

old with the following exceptions: Australia includes all children under 15 and full-time students aged 15 to 20 years. The United Kingdom includes alI children under 16 and full-time

students aged 16 and 17; data refer only to Great Britain (excludes Northern Ireland), and are based on a household survey that has not been inflated to national levels. Numbers in

thousands. Figures may not add to totals due to rounding.

bBased on data from the former Federal Republic of Germany.

Table 3-3-Percent of Households with Children by Marital Status of Parent,

United States and Selected Countries, Selected Yearsa

SOURCE: U.S. Department of Commerce, Bureau of the Census, Children’s We//-Being, International Population Reports (P-95, No. 80) (Washington, DC: U.S. Government printing

office, 1990).
Chapter 3-Sociodemographic Characteristics of Comparison Countries I 21

Table 3-4-Foreign or Foreign-borna Population, United States and Selected Countries, 1990

Foreign or foreign-borna

population Significant cultural or

Country (percent) language minority groups

United States

Australia

Canadab

Denmark

France

Germanyc

Italy

Netherlands

Norway

Sweden

United Kingdom

7.9%

22.6

14.7

3.1

6.4

8.2

1.4

4.6

3.4

5.6

3.3

Cuban, Mexican

Yugoslav

Carribean, Vietnamese, Yugoslav

NA

Algerian, Moroccan, Portuguese

Turk, Yugoslav

NA

Moroccan, Turk

Pakistani, Vietnamese

Iranian, Turk

Caribbean, Guyanan, Indian

KEY: NA = not available.

aEuropean countries use nationality to define the “foreign” population. Non-European countries use place of birth to define the foreign-born

population.

bData for Canada are for 1986

cBased on data from the former Federal Republic of Germany.

SOURCES: S.J. Lapham, The Foreign Born Population in the United States: 1990,” special tabulations of the Ethnic and Hispanic Branch,

Population Division, Bureau of the Census, U.S. Department of Commerce, Washington, DC, Dec. 18, 1992; Organisation for

Economic Co-operation and Development, SOPEM; Trends in International Migration (Park, France: Organisation for Economic

Co-operation and Development, 1992).

the United States as in Canada (table 3-5).6 Of the

six countries where data are available, however,

school attendance was highest in New Zealand

where more than 90 percent of young adults (age

25 to 44) completed secondary schooling, and

more than 30 percent completed some postsecondary education as of 1981 (table 3-5).

LABOR FORCE PARTICIPATION

The extent to which a nation’s population

participates in the labor force is a well-recognized

economic indicator and can affect or reflect health

status to varying degrees. In the United States, for

example, an individual’s employment can affect

his or her access to health insurance, and absence

from work or inability to work is a morbidity

measure commonly used to reflect health status in

health surveys (see chapter 6). Participation in the

labor force may have indirect effects on health

status, as well. Since 1970, for example, young

women participation in the workforce has

increased from nearly 50 to 75 percent in the

United States, and some observers have speculated that this movement from the home to the

workforce has affected the health of mothers and

their young children.

More than 90 percent of the men aged 25 to 44

in all comparison countries participate in the

labor force,7 but participation by men over the age

of 44 declines at different rates in different

countries (table 3-6) (196). More than half of the

women aged 25 to 44 participate in the labor

A ~~= of IWO school atten~m in the United States and Canada show that U.S. residents were more likely to have COmpkted

secondary education. Among young adults (age 25 to 44), 87 percent of men and 87 percent of women in the United States, as eomparcd to

77 percent of men and 79 percent of women in Cam@ had completed high school (162),

7 A country’s labor force or economically active population is usually defined as all persons who are working, actively seeking work or

temporarily out of work because of illness, layoff, vacatioq or strike. Because qorting of labor force participation varies as a result of, for

example, the inclusion or exclusion of certain categories of workers, international comparisons need to be made cautiously (l%).
22 I International Health Statistics: What the Numbers Mean fort he United States

8

q

CD

N

o
Chapter 3-Sociodemographic Characteristics of Comparison Countries I 23

m

.5-c

E

C/j

3

m2

.

j

Z

l%!
24 I International Health Statistics: What the Numbers Mean for the United States

Figure 3-3-Unemployment Rates, United States

and Selected Countries, 1990

(percentage of labor force)

Country

Sweden

Japan

Norway

United Kingdom

United States

Germany

Australia

Canada

New Zealand

France

Netherlands

Italy

Spain

E:, - I ‘-- [

I

I

I

3

024 6 8 10 12 14 16

Percent

SOURCE: Organisation for Economic Co-operation and Development,

OECD Health Systems: The Socio-Economk Environment Statistical

References, Volume II (Paris, France: Organisation for Economic

Co-operation and Development, 1993).

forces of all comparison countries, but participation ranges from a low of 59 percent in Australia

to a high of 86 percent in Sweden. Three-quarters

of young women are economically active in the

United States. Labor force participation by men

and women aged 65 and older is relatively high in

the United States (16 and 9 percent, respectively)

and is exceeded only in Norway (24 and 12

percent) and Japan (36 and 16 percent) (table 3-6).

Unemployment rates in 1990 were low in the

United States (5.6 percent) relative to Spain (15.8

percent) and Italy (10.5 percent), but are somewhat higher than the very low rates of Sweden

(1.5 percent) and Japan (2.0 percent) (figure 3.3)

(133).

INCOME AND POVERTY

Significant disparities exist between the health

status of poor people and that of people with

higher incomes in the United States and other

developed countries (46,133a,153,246). In the

United States, for example, 1986 death rates

among people with a yearly income of less than

$9,000 were three to seven times higher (depending on race and sex) than people with a yearly

income of $25,000 or more (2,133a).

Comparisons among industrialized countries

have generally found little relationship at the

aggregate level between mortality and per-capita

personal income or other measures of the average

standard of living (46,246). But some research

suggests that a country’s poverty rates and

income distribution are associated with the health

status of the population (83,244). A study of

European countries, for example, found that

improvements in life expectancy over a decade

(generally from 1975 to 1985) were strongly

related to reductions in poverty (245). According

to the Luxemburg Income Study, which evaluated

comparable income data from nine countries,8 the

nations with the most equality in distribution of

income are Germany, Norway, and Sweden, and

those with the greatest inequality are Switzerland

and the United States. Australia, Canada, and the

United Kingdom occupy the middle of the

ranking (10). Household income distribution data

from the early to late 1980s show that the poorest

fifth of households in the United States held a

smaller share of income, and the wealthiest fifth

of households held a larger share of income

relative to most other comparison countries (figure 3-4) (25 1). In the mid 1980s the United States

had the highest poverty rates and the lowest

6 The Luxemburg Income Study provides comparable data on income distribution in AustraliiL Canada, the Netherlands, Norway, Swede%

Switzerland, Wex Gumany (the former Federal Republic of GermanY), the u~t~ Kingdom and the United States. The study defined family

net cash income as gross original income plus public and private transfers minus direct (income and payroll) taxes. Income distribution is

described in terms of the share of total income going to successive tenths of the population (245).
Chapter 3-Sociodemographic Characteristics of Comparison Countries I 25

Figure 3-4-income Distribution: United States and Selected Countries, Selected Yearsa

50

\

‘,

L

\/ Highest 20 percent

40 \

\ NJ,

.

c

c

a)

~

g 30-

?

Fourth qulntlle /

o .

u

4 )

c

-

2 0 Third qumtlle

% 4

g

(u ~ Second qumtlle

r 1 11 I

u)’

-~+–-

t~~+

10 ! {

~“~—+-’~-

Lowest 20 percent 1I

1

I

01 1 1 1 1 I 4

New Australla united France Canada Italy United Spain Germany Nether- Norway Sweden Japan

Zealand States Kingdom lands

a Data for France, Japan, Norway, and the United Kingdom are for 1979. Data for Spain are for 1980-81. Data for the Netherlands are for 1983. Data

for Germany (the former Federal Republic of Germany) are for 1984. Data for Australia and the United States are for 1985. Data for Italy are for

1988. Data for Canada are for 1987.

NOTE: This figure shows the distribution of household Income accruing to percentile groups of households ranked by total household Income.

Households in each country were ranked according to total household Income. Each country’s listing of ranked households was then divided into

5 equal “quintiles.” This figure shows each household quintile’s share of total national household income for each country. The poorest households

in the United States (i.e., the 20 percent of households with the lowest household incomes) hold a relatively small share of income (4.7 percent). Of

the comparison countries, only Australia’s poorest households hold a smaller share (4.4 percent) than do those In the United States. Japan and

Sweden’s poorest households appear to be better off Insofar as they hold a larger share of income (8.7and 8.0 percent, respectively) than the poorest

households in any of the other comparison countries. The wealthiest households in New Zealand and the United States (i.e., the 20 percent of

households with the highest household incomes) hold larger shares of income (44.7 and 41.9 percent, respectively) than comparable households

in any of the comparison countries. These data support the contention that the United States has relatively unequal Income distribution.

SOURCE: World Bank, World Development Report 1993: Investing in Health (New York, NY: Oxford University Press, 1993).

poverty escape rates than some other developed HEALTH INSURANCE COVERAGE

countries (table 3-7) (39). Whether people are covered by health insurPoverty rates for children are generally higher ance affects their access to health services; the

in the United States than in selected comparison types, quality, and intensity of care delivered; and

countries. In the mid-1980s, as many as 17 patient health (193). The proportion of the popupercent of children in the United States lived in lation with health insurance is smaller in the

poverty, compared with 5 percent in Sweden and United States than in any of the comparison

8 percent in the former Federal Republic of countries. In 1991, an estimated 13 percent of the

Germany (table 3-8). U.S. population lacked health insurance coverage
26 I International Health Statistics: What the Numbers Mean for the United States

Table 3-7--Poverty Indicatorsj United States and Selected Countries, Mid-1980s

Single-year Persistent Poverty

Country poverty ratea poverty rateb

escape ratec

United States

Black

White

Canada

France (Lorraine)

Germanyd

Ireland

Luxemburg

Netherlands

Sweden

20%

49

15

17

4

8

11

4

3

3

14%0

42

10

12

2

2

NA

<1

<1

NA

22%

15

25

23

32

24

22

29

23

45

KEY: NA= not applicable.

aPercent of families with income less than 50 percent of the median.

bPercent with leSS than 50 percent of median income for 3 years in a row.

cPercent of families with income 40 to 50 percent of the median whose income jumped to greater than 60 percent of the median 1 year later.

dBased on data from the former Federal Republic of Germany.

SOURCE: Adapted from G. J. Duncan, B. Gustafsson, R. Hauser, et al., ‘Poverty Dynamics in Eight Countries," Journal of Population

Economics 6(3):215-234, August 1993.

Table 3-8--Child Poverty,a United States and Selected Countries, Circa 1980

Poverty rate

Poverty rate for families

for children — with ch dren il

All Single All Single

Country Year families parent families parent

United States 1979 17.1% 51.% 13.8% 42.9%

Australia 1981 16.9 65.0 15.0 61.4

Canada 1981 9.6 38.7 8.6 35.3

Germanyb1981 8.2 35.1 6.9 31.9

Sweden 1981 5.1 8.6 4.4 7.5

United Kingdom 1979 10.7 38.6 8.5 36.8

aPoverty is defined as the percentage of peopole who have adjusted disposable income below the U.S. poverty line ($5,763 for a family of three in

1979) converted Into national currencies using the purchasing power parities developed by the Organisation for Economic Co-operation and

Development. The definition of adjusted disposable income includes all forms of cash income (earnings, property income, and all cash

transfers inducting the value of food stamps in the United States and housing allowances In Sweden and the United Kingdom) and it subtracts

income and payroll taxes. This definition differs slightly from the definition of Income used in the official United States calculation of poverty

rates. The source of the estimates of earnings, government transfers, and poverty rates Is the Luxemburg Income Study.

bBased on data from the former Federal Republic of Germany.

SOURCE: U.S. Department of Commerce, Bureau of the Census, Children’s Well-Being, International Population Reports (P-95, No. 80)

(Washington, DC: U.S. Government Printing Office, 1990).
Chapter 3-Sociodemographic Characteristics of Comparison Countries I 27

(144). All but one of the 12 comparison countries

have public health insurance programs that cover

at least 90 percent of their respective populations

(133).9

SUMMARY

The most outstanding sociodemographic difference between the United States and the 12

comparison countries is population size. The

United States has nearly 250 million residents,

twice as many as Japan, nearly 10 times as many

as Canada, and 75 times as many as New Zealand.

Another difference is age distribution. The

United States has a relatively young population

age distribution and will remain younger than

Japan and Western European countries through

2025, even though the U.S. baby boom cohort

will have reached age 65 by then.

The U.S. population is racially and ethnically

diverse, with as many as one in five residents

belonging to minority groups. Although comparable data on ethnic and racial composition from

other countries are limited, available data suggest

that foreign migration to Western Europe has

increased in recent years, contributing to the

presence of sizable, disadvantaged minority populations.

Labor force participation is relatively high in

all comparison countries and varies chiefly in the

extent to which women and the elderly are

economically active. Women’s participation in

the labor force is highest in Sweden, lowest in

Australia, and intermediate in the United States.

The United States, along with Norway and Japan,

have relatively more elderly in the labor force

than do other comparison countries.

Poverty is associated with poor health, as are

large disparities in the distribution of income

throughout a nation. Income distributions are

relatively unequal in the United States and more

equal in Japan, Norway, and Sweden. Poverty

rates are higher in the United States than in most

comparison countries.

Health insurance coverage improves health

(193). Among the comparison countries, only the

United States has a large segment of population

without any health care insurance.
Mortality 4

I

nfant mortality is sometimes used as a yardstick for

comparing the outcomes of health systems in countries at

similar levels of socioeconomic development although it

does not represent the overall health status of a nation

(226,256). In comparisons of developed and developing countries, infant mortality may be a social or economic indicator, but

in developed countries infant mortality is not highly correlated

with established socioeconomic measures (e.g., per-capita gross

domestic product and the percentage spent on health) (45).

Infant mortality rates are useful for identifying problems with

the health status of infants and mothers and the delivery of health

care and related services to these groups (226). Thus, learning

why infant mortality rates are up to twice as high in the United

States as in other developed countries could lead to improvements in U.S. health programs for mothers and infants. The

reasons for international differences in infant mortality are

complicated, however, and to understand these differences

requires consideration of differences in population characteristics, individual risk behaviors, and features of vital statistics

systems. Ongoing examinations of the range of individual and

societal factors that influence infant mortality has already

provided valuable insight into why U.S. infant mortality is

relatively high.

INTERNATIONAL COMPARISONS OF INFANT

MORTALITY RATES AND TRENDS

Infant Mortality Rates

Infant mortality is measured as the annual number of deaths of

infants below age 1 per annual number of live births and is

expressed as deaths per 1,000 live births per year. Among 39 29
30 I International Health Statistics: What the Numbers Mean for the United States

Table 4-1-infant Mortality Rates and Ranks, United States and Selected Countries, 1990

~

Country Ratea Rank Country Ratea Rank

Japan

Sweden

Finlandb

Hong Kong

Singapore

Canada

Switzerland

Germany, Federal Republic of

Norway

Netherlands

France

German Democratic Republic

Denmark

Northern Ireland

Scotland

Austria

England and Wales

Belgium

Spainc

Australia

4.60

5.96

6.03

6.14

6.67

6.82

6.83

6.98

7.02

7.06

7.33

7.33

7.39

7.49

7,73

7.84

7.88

7.94

8.07

8.17

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Ireland 8.20

New Zealand 8.31

Italy 8.53

United States 9.22

Greece 9.66

Israel 9.84

Cuba 10.74

Portugal 10.99

Czechoslovakia 11.25

Puerto Rico 14.77

Bulgaria 14.77

Hungary 14.82

Costa Rica 15.26

Poland 16.00

Chile 16.82

Kuwaitd

17.33

Yugoslavia 20.20

Union of Soviet Socalist Republics 21.96

Romania 30.09

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

aNumber of deaths of infants under 1 year per 1,000 live

bData are for 1989.

cData are for 1988.

‘Data are for 1987.

births.

NOTES: Rankings are from lowest to highest infant mortality rates based on the latest data available for counties or geographic areas with at Ieast 1

million population and with “complete” counts of live birth and Infant deaths as Indicated In the United Nations 1990 Demographic

Yearbook.

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for

Health Statistics, International infant Mortality Data Set, Hyattaville, MD, 1993.

selected developed countries in the world, 1990

infant mortality rates range from a low of 4.6 in

Japan to 30.1 in Romania (table 4-l). With a rate

of 9.2, the United States ranks 24th, which puts it

in the bottom half.

When comparisons of infant mortality are

restricted to the United States and 12 other

selected developed countries, the difference between the lowest and highest rates is two-fold

(from 4.6 in Japan to 9.2 in the United States)

(table 4-2).1 In 1990, the United States ranked last

in overall infant mortality, 1lth of 13 in neonatal

deaths (those occurring during the first 27 days of

life)2 and 10th of 13 in postneonatal deaths (those

occurring between 28 days and 1 year of age)3

(table 4-2). The United States continues to rank

poorly (8th of 13) when the infant mortality rate

of only the country’s white population is compared with the infant mortality rates of other

nations. International variation in infant mortality

1 All subsequent comparisons with the United States are based on the following 12 countries: Australia, Canada, France, Germany (the

former Federal Republic of Germany), Italy, Japan, the Netherlands, New Zealand, Norway, Spain, Sweden, and the United Kingdom.

2 Mortality within the first 27 days of life (neonatal death) is described by the nconatalmortality rate, which is the annual mtrnkof neonatal

deaths per annual number of live births, and is expressed per 1,000 live births per year,

q Mortality between 28 days and 1 yew of age Qostnconatal death) is descxibcd by the postnconatal mortality rate, which is the annual

number of postnccrnatal deaths per annual number of live births, and is cxprmcd per 1,000 live births per year.
Table 4-2-Rates and Ranks of Infant, Neonatal, Postneonatal, and Feto-infant Mortality

in the United States and Selected Countries, 1990

Infant Neonatal Postneonatal Fete-infant

mortality ity

country Ratea

Rank Rateb Rank Ratec Rank Rated

Rank

United States

Australia

Canada

England and Wales

France e Germanyf

Italyg

Japan

Netherlands

New Zealand

Norway

Spainh

9.22

8.17

6.82

7.88

7.33

6.98

8.53

4.60

7.06

8.31

7.02

8.07

5.96

13

10

3

8

7

4

12

1

6

11

5

9

2

5.85

4.85

4.61

4.58

3.55

3.54

7.25

2.60

4.81

4.07

3.92

6.05

3.50

11

10

8

7

4

3

13

1

9

6

5

12

2

3.38

3.31

2.21

3.32

3.79

3.44

2.08

1.99

2.24

4.24

3.10

2.95

2.46

10

8

3

9

12

11

2

1

4

13

7

6

5

13.21

12.06

10.72

12.44

13.66

10.37

13.96

8.38

12.74

12.37

11.55

14.69

9.50

NOTES: Rankings are from lowest to highest infant mortality rates based on the latest data available for countries or geographic areas with at least 1 million population and with ‘complete”

counts of live births and infant deaths as indicated in the United Nations 7988 Demographic Yeabook Some of the international variation in infant mortality rates is due to

variation among counties in distinctions between fetal and infant deaths, The fete-infant mortality rate attempts to reduce internationaJ variation due to clinical distinctions

between fetal and infant deaths.

SOURCE: U.S. Department of Health and Human Services, Public Health Service, C-enters for Disease Control and Prevention, National Center for Health statistics, International Infant

Mortality Data Set, Hyattsville, MD, 1993.

10

6

4

8

11

3

12

1

9

7

5

13

2
32 I International Health Statistics: What the Numbers Mean for the United States

Table 4-3--infant Mortality Rates, by Race, Geographic Division, and State:

United States, Average Annual 1987-89

All Whltea Blacka

Geographic division and State 1987-89 1987-89 1987-89

United States

New England

Connecticut

Maine

Massachusetts

New Hampshire

Rhode Island

Vermont

Middle Atlantic

New Jersey

New York

Pennsylvania

East North Central

Illinois

Indiana

Michigan

Ohio

Wisconsin

West North Central

Iowa

Kansas

Minnesota

Missouri

North Dakota

Nebraska

South Dakota

South Atlantic

Delaware

District of Columbia

Florida

Georgia

Maryland

North Carolina

South Carolina

Virginia

West Virginia

East South Central

Alabama

Kentucky

Mississippi

Tennessee

West South Central

Arkansas

Louisiana

Oklahoma

Texas

9.9

8.1

8.8

7.8

7.6

8.0

8.9

7.4

10.3

9.5

10.7

10.1

10.5

11.6

10.4

11.0

9.6

8.7

8.9

8.7

8.7

7.8

10.1

9.1

8.5

9.9

11.3

11.8

21.9

10.3

12.5

11.0

11.9

12.6

10.2

9.4

11.3

12.1

9.9

12.5

11.1

9.6

10.4

11.4

9.1

9.1

8.3

7.3

7.4

7.8

6.8

8.0

8.4

7.4

8.2

7.3

8.7

8.0

8.5

8.9

9.3

8.3

8.3

7.8

8.0

8.2

7.8

7.1

8.7

8.4

7.7

8.1

8.6

9.2

14.4

8.1

9.4

8.3

9.1

9.4

7.8

9.1

8.9

9.1

9.2

9.0

8.5

8.2

8.6

8.4

8.5

8.1

18.6

17.7

19.5

-b16.7

-b15.9C

-b19.7

19.2

18.7

22.8

20.4

21.5

20.5

22.4

17.3

17.0

18.6

22.6 C

18.9

22.8

17.5

-b20.6C

-b18.5

20.5

25.3

17.8

18.5

17.7

18.8

17.9

18.2

18.7c

17.7

17.9

16.7

16,4

19.2

15.9

16.6

16.1

14.1

15.8
Chapter & Infant Mortality I 33

Table 4-3--infant Mortality Rates, by Race, Geographic Division, and State:

United States, Average Annual 1987-89 (Continued)

All Whitea Blacka

Geographic division and State 1987-89 1987-89 1987-89

Mountain

Arizona

Colorado

Idaho

Montana

Nevada

New Mexico

Utah

Wyoming

Pacific

Alaska

California

Hawaii

Oregon

Washington

9.2

9.5

9.4

9.6

10.0

8.7

8.9

8.3

9.2

8.8

10,4

8.7

8.1

9.3

9.3

8.7

8.9

9.1

9.3

9.1

7.7

8.3

8.0

9.1

8.1

8.0

8.0

5.5

9.1

8.7

19.3

21.4

16.5

-b-

-b20.0

22.6C

-b-

-b18.9

15.7C

18,8

14.4C

21.4C

20.6

aDeaths are tabulated by race of decedent; live births are tabulated by race of ‘other”

bData for States with fewer then 1,000 live births for the 3-year period are considered highly unreliable and are not shown.

cData for States with fewer than 5,000 live births for the 3-year period are considered unreliable.

SOURCE: US. Department of Health and Human Servicea, Public Health Service, Centers for Disease ControI and Prevention, National Center for Health

Statistics, Health United States and prevention Profile: 1991, DHHS Pub. No. (PHS)92-1232 (Hyattsville, MD: U.S. Department of Heath and

Human services, May 1992).

rates exceeds the rather large variation observed

among U.S. regions and States (tables 4-2 and

4-3)0

TIME OF DEATH

The timing of infant deaths varies greatly

among the 13 comparison countries. The United

States, which recorded the highest infant mortality rate in 1990, had the greatest proportion of its

infant deaths (38 percent) during the first day of

life (figure 4-l). In New Zealand, which had the

second highest infant mortality rate, most deaths

(51 percent) occurred in the postneonatal period

(from 28 to 1 year of age).

CAUSE OF DEATH

Perinatal conditions (e.g., birth trauma, respiratory distress syndrome), congenital anomalies,

and sudden infant death syndrome (SIDS) are the

leading causes of infants’ deaths, and account for

60 to 85 percent of all deaths in each of the 13

comparison countries (figure 4-2). In 1988, a

relatively high proportion of deaths in the United

States were attributable to perinatal causes (46

percent), which is consistent with the large

proportion of deaths occurring here during the

first day of life. Japan, with the lowest recorded

infant mortality rate, has the highest proportion of

deaths attributable to congenital anomalies (35

percent). There appear to be differences in how

countries diagnose and report deaths from SIDS.

As many as 33 percent of infants’ deaths in New

Zealand are attributed to SIDS, whereas only 4

percent of such deaths in Japan are attributed to

SIDS.

Infant Mortality Trends

The United States has not always ranked poorly

in infant mortality when compared with other

developed countries. In 1950, the infant mortality

rates of Spain, Italy, Japan, Germany, France,

Canada, and the United Kingdom were higher

than the U.S. rate (figure 4-3). By 1970, however,
34 I International Health Statistics: What the Numbers Mean fort he United States

Figure 4-1-infant Mortality, Distribution of Time of Death, United States and Selected Countries, 1990°

II

Canada United

States

Italy Australia Spain Norway Nether- United Japan Germany Sweden New France

lands Kingdom Zealand

- d day ~ 1-6 days D 7-27 days D 28-364 days I

a Data for Italy are for 1988 and data for Spain are for 1987.

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for

Health Statistics, International Infant Mortality Data Set, Hyattsville, MD, 1993.

most other countries4 had experienced sharper

declines in infant mortality than the United States.

Rates of decline since 1950 were greatest for

Japan and Spain. Since 1970, rates in Italy, Spain,

and Germany have dropped the most.

TECHNICAL DIFFICULTIES IN MAKING

INTERNATIONAL COMPARISONS OF

INFANT MORTALITY

Recent evidence suggests that international

differences in resuscitation practices and the

classification of infant deaths may elevate the

U.S. infant mortality rate somewhat (190). Physicians in the United States appear to be more likely

to resuscitate extremely premature and low birthweight infants who later die.5 These births are

classified as live births and are included in the

U.S. infant mortality statistics. Other countries

appear to be more likely to class@ such births as

fetal deaths. Because most countries do not

require registration of fetal deaths of fewer than

28 weeks of gestation, these extremely premature

infants are not counted within the registration

system.6 That the United States also has a much

higher proportion of deaths occurring within 24

hours of birth and with extremely low birthweights (under 500 grams) suggests that different

x Ofthccountries withhighcrinfant mortality rates thsnthe United States in 1950, the rates in Germany, Spa@ and Italy continued to exceed

the U.S. rate in 1970 (figure 4-3).

S Extremely premature infants are those born at less than 28 weeks of gestation. Extremely low birthweight infants arc those born weighing

less than 500 grams (70).

s Distinguishing a live birth fkom a stillbirth can be dif6cult, The World Health Orgsniza tion recommends that a birth be considered live

if the newborn shows any sign of life, such as hcmtbca~ breathing, umbilical cord puhatio~ or voluntary muscle movement (253).
Chapter 4-infant Mortality I 35

Figure 4-2-infant Mortality, Distribution of Cause of Death, United States and Selected Countries,

——

l-”-i .

1988”

Italv, United Nether- SDaln Norway Australia Canada Sweden United German Japan New France

States lands ‘ Kingdom Zealand

T

1

~ mPerlnatal~ Congenital anomalies ~ Sudden Infant Death Syndrome n Other

a Data for Canada, Spain, and New Zealand are for 1987.

SOURCE: World Health Organization, World Health Statistics Annual (Geneva, Switzerland: World Health Organization, 1989, 1991, 1992).

resuscitation (and possibly reporting) practices

affect the reported statistics (71).

Some countries have birth registration practices that might contribute to reporting differences. In France, for example, infants may be

classified as stillbirths if they die before their

births are registered, which may be as much as 2

days after birth (73,108). In some countries, a

particular outcome might be preferred for cultural

or other reasons, which may cause health care

providers’ or parents’ reports of outcomes to be

unreliable (68, 121). For example, some observers

speculate that Japan’s low infant mortality rate

and very high fetal mortality rate may be explained in part by social and cultural customs that

favor the recording of infant deaths as stillbirths

because the latter are not recorded in Koseki, the

Japanese family registration system (73).7

The fete-infant mortality rate (FIMR), a measure combining late fetal and infant deaths,8

overcomes some of the problems in comparing

countries with different ways of classifying live

births and fetal deaths. Using the FIMR instead of

the infant mortality rate (IMR) for international

ranking of the 13 comparison countries, the

United States moves from 13th to 10th, not a

marked improvement (table 4-2).

The FIMR avoids some problems that arise

because of international differences in clinical

practice and classification, but the FIMR includes

7 Some speculate that the preference for registering stillbirths stems from the fact that an infant death is considered a significant health

problem in a family medical histo~, whereas a stillbirth is not. Such family histories have historically been reviewed while arranging maniages

(70).

8 The fete-infant mortality rate is the number of late fetal deaths (after at least 28 weeks of gestation) plus the number of infant deaths within

the first year of life per 1,000 live births plus late fetal deaths (231).
36 I International Health Statistics: What the Numbers Mean for the United States

Figure 4-3-infant Mortality Trends, United States and Selected Countries, 1950 to 1990a

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

1950

Spain

Italy

Japan “France” United Kingdom ‘Norway” Netherlands “Sweden”

Germany Canada United States New Zealand Australia

a The latest data for Spain are for 1988.

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for

Health Statistics, International Infant Mortality Data Set, Hyattsville, MD, 1993.

only late fetal deaths, although some evidence

suggests that the U.S. infant mortality rate includes births that other countries would likely

categorize as early fetal deaths (those occurring at

20 to 27 weeks of gestation). Only a few

countries, including Norway, Japan, and the

United States, compile statistics on early fetal

deaths. When early and late fetal deaths are

combined with infant deaths, the United States

FIMR is lower than that of Norway and only 16

percent higher than that of Japan (17.35 versus

14.90) (70). This comparison may be unreliable,

however, because reporting early fetal death is

more complete in areas that require reporting at

earlier gestational ages.9 Fetal death registration

begins at 12 weeks of gestation in Japan, at 16

9 Within the United States, for example, States tbat require reporting fetal death fYom conception report higher fetal mortality rates than

States that require reporting fetal deaths starting at 20 weeks of gestation (226). When the U.S. FIMR calculation (including fetal deaths from

20 weeks of gestation) is limited to the eight States that report fetal deaths from coneeptiou the rate is about one-third higher than the Japanese

rate (19.9 versus 14.9). In this comparison however, U.S. reporting (stardngfiom conception) might be more complete thsn Jspanese reporting,

which starts at 12 weeks of gestation.
Chapter 4-infant Mortality I 37

weeks in Norway (l), and at 20 weeks in most of

the United States.10 Perhaps, therefore, Norway

and Japan have more complete reporting of fetal

deaths than does the United States.

The gap between the 1990 U.S. and Japanese

infant mortality rates closes somewhat when

infants of 20 to 27 weeks of gestation are

excluded from the calculation. Under that condition, the U.S. infant mortality rate declines

relative to the Japanese rate, but the U.S. rate

remains approximately 25 to 30 percent higher

than the Japanese rate (70). Alternatively, one can

compare the rates of infant mortality occurring at

least 24 hours after birth or at least 7 days after

birth. Both measures avoid most of the problems

that arise from disparities in how live births and

fetal deaths are classified. Even these measures

for ranking, however, leave the United States in

the bottom half, at 20th, of the 39 countries shown

in table 4-1 (70).

INTERNATIONAL DIFFERENCES

IN RISK FACTORS ASSOCIATED WITH

INFANT MORTALITY

Although reporting differences make international comparisons of infant mortality difficult,

an attempt has been made to assemble perinatal

and infant mortality data from developed countries into a standardized database to further

international comparisons. The International Collaborative Effort (ICE) on Perinata1 and Infant

Mortality, established in 1984 by the U.S. National Center for Health Statistics (NCHS), is a

collaboration of researchers from the public and

private sectors of the United States and 10 other

industrialized nations: Denmark, England and

Wales, Germany, Hungary, Israel, Japan, Norway, Scotland, and Sweden. A major accomplishment is the ICE database of standardized information from each country,ll which can be analyzed

to aid our understanding of how and why countries differ in particular outcomes of pregnancy.

Factors associated with whether an infant will

live or die in its first year include its race, sex,

birth order, place of residence, birthweight, gestational age, and whether it is born alone or as part

of a set of twins, triplets, or other multiple.

Additional factors include the mother’s age, prior

pregnancy outcomes, health status, personal habits (e.g., prenatal care, smoking, alcohol consumption), and socioeconomic status (101). How

these biologic and social factors interact to

influence infant mortality is unclear, but the

12 and improved availability of richer data sets

research tools should help unravel the causal

mechanisms. Internationally comparable data are

available for some, but not all, of these correlates

of infant mortality.

Low Birthweight

Low birthweight results from prematurity, poor

growth, or a combination of the two, and is

associated with a high risk of death. Using the

ICE database, analysts have explored the contributions of the birthweight distribution-that is,

the frequency with which various birthweights

occur in a particular population-and birthweightspecific mortality rates to overall infant mortality

(100). Analyses have shown that birthweight

distributions always follow a bell-shaped curve

with a residual group of high-risk, low birthweight infants at the left tail, but that different

10 Statm vw in ~efi fet~ deati registration requirements. Most States require reporting fetal deaths occurring at gestations of 20 weeks

or more, and some States (e.g., Massachusetts) also require the registration of the deaths of fetuses weighing 350, 400, or 500 grams or more

at birth. Other States (e.g., New York) require the registration of atl pregnancy outcomes (226).

I I ne most rant data set includes information on infant and fetal death by plurality, birthweight lengti of gestitioni ad cause of d~~

(71). The database includes information from linked files on births and infants’ deaths.

12 me s~dwd U.S. b~ ~fificate, for ex~ple,was modfl~fi 1989 to ~clude ~OmatiOn on matermd medical~d hfC!Style risk faCtO~

(e.g., weight gain+ educational attainrnent, smoking status) and health care (210). Data sets are created to include infant death certificates

matched or linked to birth certificates enabling researchers to assess the relative contributions of risk factors to infant mortality.
38 I International Health Statistics: What the Numbers Mean for the United States

Figure 4-4-Birthweight Distribution, Singleton

20

15

i 10

&’

5

Total Births for U.S. Whites

o~

1 1 I I I I

o I,ooo 2,000 3,000 4,000

Birthweight (garns)

SOURCE: U.S. Department of Health and Human services, Public

Health Service, Centers for Disease Control and Prevention, National

Center for Health Statistics, Proceedings of the International Collaborative Effort on Perinatal Infant Mortality, Volume III, DHHS Pub. No.

(PHS) 92-1252 (Hyattsville, MD: U.S. Department of Health and Human

Services, October 1992).

countries vary greatly in the distribution of

birthweights that occur (figure 4-4).13

Comparisons of population-specific birthweight

distributions show that, on average, babies born in

Norway, for example, are heavier than Black

babies born in the United States or babies born in

Osaka, Japan (i.e., the birthweights of Norwegian

babies are to the right of those of Japanese and

U.S. Black babies on the distribution curve)

(figure 4-5).14 Japanese and U.S. Black babies

have on average similar birthweights but the

distributions of births differ. The birthweights of

Figure 4-5 Birthweight Distributions, Singleton

30

20

fj

If!

10

0

Total Births for ICE Countries

/\ Osaka, Japan

/ \

II

/’ /

o I,ooo 2,000 3,000 4,000

Birthweight (garns)

KEY: ICE = International Collaborative Effort

SOURCE: U.S. Department of Health and Human services, Public

Health Service, Centers for Disease Control and Prevention, National

Center for Health Statistics, Proceedings of the International Collaborative Effort on Perinatal and Infant Mortality, Volume III, DHHS Pub. No.

(PHS) 92-1252 (Hyattsville, MD: U.S. Department of Health and Human

Services, October 1992).

most Japanese babies are near the median birthweight whereas a disproportionate number of

U.S. Black babies have low birthweights, which

occupy the left tail of the distribution curve.

A population’s average birthweight is not a

good predictor of overall infant mortality. Sweden and Japan, which have the lowest infant

mortality rates, have the highest and lowest

average birthweights, respectively (table 4-4).

And Japan and U.S. Blacks, which have the
Table 4-4-Characteristics of Birthweight Distributions and Mortality Rates, United States and Selected Populations 1983-86

Predominant Percent in Mortality 1.00 0

distribution Standard residual Percent Percent Post- FetoPopulation mean deviation distribution <1,500 gm <2,500 gm Neonatal neonatal Infant Fetal infant

United States

Whltesa

Blacksa

Denmark

England and Wales

Israel

Jews

Non-Jews

Japan (Osaka)

Sweden

3,469

3,217

3,478

3,354

3,294

3,301

3,192

3,537

504

508

509

491

472

486

410

508

2.0

4.3

2.2

2.2

2.7

2.3

1.3

1.8

0.86

2.56

0.81

0.89

1.13

1.02

0.59

0.65

4.7

11.6

4.9

6.1

7.0

6.8

5.3

3.8

4.4

8.0

3.6

4.9

6.6

10.7

3.3

3.8

2.9

5.9

2.5

3.9

2.9

8.6

2.0

2.4

7.3

13.8

6.1

8.8

9.6

19.2

5.3

6.2

4.3

6.5

4.4

5.3

4.4

10.3

5.5

3.7

11.5

20.3

10.4

14.1

13.9

29.3

10.8

9.9

*U.S. data are for nine selected States: California, Georgia, Michigan, Minnesota, Missouri, North Carolina, upstate New York Utah, end Wisconsin.

SOURCE: J.C. Kleinman, “Implications of Differences in Birthweight Distribution for Comparisons of Birthweight-Specific Mortality,” Proceedings of the International Collaborative Effort

on Perinatal and Infant Mortality, Volume III, U.S. Department of Health and Human Servicesr Public Health Service, Centers for Disease Control and Prevention, National

Center for Health Statistics, DHHS Pub. No. (PHS) 92-1252 (Hyattsviller MD: U.S. Department of Health and Human Services, October 1992).

—
40 I International Health Statistics: What the Numbers Mean fort he United States

lowest average birthweights, have the lowest and

highest infant mortality rates in the ICE countries.

Because birthweight distributions are unique

across populations, some observers have suggested that mortality risks be evaluated in terms

of percentiles of the birthweight distribution.

Instead of defining low birthweight by means of

a uniform, arbitrary birthweight cutoff point

(usually less than 2,500 grams), low birthweight

could be defined for each country as a percent of

the birthweight distribution (129). If, for example,

the birthweight representing the 10th percentile

were used to define low birthweight, 2,788 grams

would be considered low for U.S. Whites, as

would 2,440 grams for U.S. Blacks, and 2,677

grams for infants born in England and Wales

(129). If each population’s birthweight distribution were considered unique and normal for that

population, differences in birthweight-specific

mortality rates would become more important

factors in determining infant mortality (231).15

Among the ICE populations studied, two

subpopulations with exceptionally high mortality

rates stand out: non-Jewish residents of Israel and

Blacks in the United States (table 4-4). Both of

these subpopulations have infant and fete-infant

mortality rates twice as high as those of the

respective majority populations. The explanations for the subpopulations’ exceptionally high

infant mortality rates differ. Non-Jewish residents

of Israel have the highest reported IMR and FIMR

of all comparison countries, and yet the mean

birthweight is higher, and the proportion of low

birthweight infants (defined here as those weighing less than 2,500 grams) is lower than that in the

majority Jewish population. This subpopulation’s

excess infant mortality rate appears to reflect high

mortality rates at every birthweight. The high

infant mortality rate of U.S. Blacks reflects both

a relatively large proportion of low birthweight

infants and high mortality rates at higher birthweights.

Rates of infant and fete-infant mortality are

higher for U.S. Whites than for residents of

Sweden and Denmark, but lower than for those of

England and Wales. Both birthweight distribution

and birthweight-specific rates contribute to these

differences, but their relative importance is uncertain (100). If the prevalence of low birthweights

were the major contributor to infant mortality,

targeted interventions designed to increase birthweight could lead to decreases in infant mortality.

If, however, mortality rates were high at all

birthweights (as is the case for Israel’s nonJewish population), a broader set of interventions

would be needed.

Multiple Births

The risk of death is greater for infants born as

twins, triplets, or other multiples than for infants

born alone, chiefly because infants of multiple

births weigh much less than those born singly.

The occurrence of multiple births varies by

country and population group, although most of

them report rates of about 20 multiple births per

1,000 births and stillbirths. Multiple births occur

most often among U.S. Blacks and least often

among the Japanese, whose rates are 25 and 13,

respectively (76). In view of the disparity between

these extremes, international comparisons of

infant mortality should be made separately for

single and multiple births.

Teenage Pregnancy

Babies born to teenage mothers are more likely

to die than are babies born to older mothers,

probably because of differences in the mother’s

social and environmental characteristics. Mothers

giving birth in their teens, for example, are more

likely to have low incomes, poor educations, and

inadequate prenatal care. Although birth rates for

teenagers are much higher in the United States

than in comparison countries (table 4-5), and

there is a correlation between a country’s infant

15 B~e@ttis&ibutiomwithin countries tend to be stable over IiIYIe (43).
Table 4-5-Live Birth Rates by Maternal Age, United States and Selected Countries, Circa 1990

Country Year All ages <20a

20-24 25-29 30-34 35-39 40-44 45+b

United States

Australia

Canada

France

Germany c

Italy

Japan

Netherlands

New Zealand

Norway

Spain

Sweden

United Kingdom

1989

1990

1989

1990

1988

1988

1990

1990

1990

1990

1986

1989

1990

61.8

58.3

54.5

54.5

43.7

39.4

38.9

49.9

67.2

58.0

47.1

57.1

56.5

59.4

22.0

24.8

9.1

10.3

9.6

3.6

8.3

34.4

16.9

16.7

12.7

33.0

115.4

79.6

82.5

75.8

56.2

58.6

44.3

48.2

101.2

93.3

65.8

92.8

91.1

116.6

139.0

126.1

140.0

111.4

97.2

138.0

126.4

147.5

145.0

112.0

149.0

122.7

76.2

101.6

81.9

92.3

78.1

68.6

92.2

106.5

105.7

95.2

73.5

103.4

87.0

29.7

34.6

26.4

35.8

26.0

26.5

20.6

31.0

36.8

32.4

31.2

38.7

31.0

5.2

5.5

3.8

7.7

4.5

5.4

2.4

3.7

5.4

4.7

8.9

6.4

5.0

aRates computed on female population ages 15 to 19.

bRates computed on female population ages 45 to 49.

cBased on data from the former Federal Republic of Germany.

SOURCE: United Nations, 1991 Demographic Yearbook table 11 (New York, NY: United Nations, 1992).

0.2

0.2

0.1

0.5

0.2

0.3

0.0

0.5

0.3

0.3

0.8

0.3

0.3

u

—

*
42 I International Health Statistics: What the Numbers Mean for the United States

mortality rate and the prevalence of teenagers

giving birth, the elimination of such births from

the computation would have little effect on infant

mortality rates. Disregarding births to teenagers

in the United States, for example, would lower the

infant mortality rate by only 4 percent for Whites

and 7 percent for Blacks, and would have

essentially no effect on our international infant

mortality ranking (102).

Relatively low use of contraceptives among

sexually active teenagers in the United States, in

part, explains higher teenage pregnancy rates in

the United States than in Europe (185). Pregnant

U.S. teenagers are, however, more likely to use

elective abortion than their European counterparts (185).

The high proportion of births by women under

the age of 20 or over 39 correlates with the high

rate of infant mortality in the United States. If

women in the United States gave birth at the same

ages as women in Japan, where there are relatively few births to very young and older women

(table 4-5), the U.S. infant mortality rate would be

about 10 percent lower than it is (108). However,

the socioeconomic, lifestyle, and health status

characteristics of U.S. mothers at the extremes of

the maternal age distribution, rather than age

itself, probably account for the differences (70).

Births to unmarried women increased markedly between 1%0 and 1989 in the United States

and many other developed countries, reflecting

the rise in births to teens and older well-educated

women

l6 (table 4-6). An exception is Japan,

where the proportion of births to unmarried

women has remained constant at 1 percent. In the

United States, the proportion of all births to

unmarried women increased from 5 percent in

1960 to 27 percent in 1989. The proportions are

even greater in other countries. In 1989, roughly

one-half of the births in Denmark and Sweden

were to unmarried women.

Use of Prenatal Care

Early, comprehensive, prenatal care improves

birth outcomes (191a). The proportion of pregnant women lacking prenatal care or seeking

prenatal care late (after 15 weeks of pregnancy) is

greater in the United States than in selected

Western European countries (21 percent in the

United States compared with 4 percent in France,

8 percent in Denmark, and 14 percent in Belgium). These differences in prenatal care persist

even when comparisons are restricted to collegeeducated women. Despite the fact that U.S.

women seek care later than European women, the

median number of prenatal care visits is higher in

the United States (11 visits) than in Denmark (10

visits) or in France (7 visits) (22).17 Differences in

the number of prenatal visits might reflect differences in the recommendations of local professionals. In the United States, for example, the

American College of Obstetricians and Gynecologists and the American Academy of Pediatrics

recommend from 13 to 15 prenatal care visits. By

contrast, the Royal College of Obstetricians and

Gynecologists in Great Britain recommends only

7 to 9 visits (191a).

Elective Abortion

High rates of elective abortion seem to be

correlated with low infant mortality rates in some

countries (e.g., Japan, Sweden) (45). Infant mortality might be reduced if high-risk pregnancies

were selectively terminated (30). This relationship does not exist in the United States, where the

infant mortality rate is relatively high despite a

very high elective abortion rate (45).

Sociodemographic Differences

Significant racial, ethnic, and socioeconomic

differentials in infant mortality and other health

outcomes exist not only in the United States, but

16 ~ & Unitd States, for mple, the proportion of all mothers that were Mver-ti ed women 18 w 44 years old with 1 or more years

of college doubled from 1982 to 1992 from 5.5 to 11.3 percent (5).

17 The number of prenatal care visits is unavailable for Belgium from this source.
Table 4-6-Births to Unmarried Women, Selected Countries, Selected Yearsa

Total Percent Total Percent Total Percent Total Percent

live born to live born to live born to live born to

births unmarried births unmarried births unmarried births unmarried

Country (1,000) women (1 ,000) women (1,000) women (1 ,000) women

United States

Canada

Denmark

France

Germany b

Italy

Japan

Netherlands

Sweden

United Kingdom

4,258

479

76

820

969

910

1,624

239

102

918

5

4

8

6

6

2

1

1

11

5

3,731

372

71

850

811

902

1,932

239

110

904

11

10

11

7

6

2

1

2

18

8

3,612

360

57

800

621

640

1,616

181

97

754

18

13

33

11

8

4

1

4

40

12

4,041

62

766

662

567

1,269

189

116

27

23

46

28

11

6

1

11

52

27

aFor U.S. figures, beginning 1980, marital status is inferred from a comparison of the childs’ and parents' surnames on the birth certificate for those States that do not report on marital

status. No estimates are included for misstatements on birth records or failures to register births.

bBased on data from the former Federal Republic of Germany.

SOURCE: U.S. Department of Commerce, Bureau of the Census, Statistics Ah&mtoftie Unitid States, 7992 (1) 12th Ed.) (Washington, DC: U.S. Government Printing Office, 1992).
44 I International Health Statistics: What the Numbers Mean fort he United States

also in several other developed countries where

access to high quality medical care is universal. In

the former Federal Republic of Germany, for

example, 1988 infant mortality rates were 25

percent higher for births by migrant workers than

for those by nonmigrants.18 In Sweden, neonatal

mortality rates were 50 percent higher and late

fetal mortality rates were 80 percent higher for

manual workers than for nonmanual workers (box

4-A).

EFFECTS OF RACE IN THE UNITED STATES

Black infants are twice as likely as White

infants to die (234).19 Blacks have higher rates of

low birthweight, the leading risk factor for infant

mortality, and mortality rates are higher among

Blacks than Whites for infants with normal

birthweights. The racial disparity in reproductive

outcomes in the United States cannot be explained fully by known sociodemographic differences. Even in low-risk populations, Black infants have higher death rates than White infants

(102). For example, mortality rates for infants

born to college-educated parents are nearly twice

as high for Blacks as for Whites.20 A higher

incidence of low birthweight explains the higher

infant mortality rates for this selected population

(163).21

About 40 percent of the racial disparity in

postneonatal mortality in the United States can be

attributed to differences in how maternal risk

characteristics (i.e., marital status, age, parity,

educational attaimment, prenatal care) are distributed. The remaining 60 percent possibly derives

from income and behavioral factors (101).

The medical risk factors of mothers may

account for some of the racial differences in infant

mortality rates. According to studies of U.S. birth

certificate data, anemia was reported more than

twice as often in Black mothers as in White

mothers (34.7 per 1,000 compared with 14.6 per

1,000), and the rate of chronic hypertension was

nearly twice as high in Black mothers as in White

mothers (10.8 compared with 5.7) in 1990.22

Differences in how much weight mothers gain

may also account for infant mortality disparities.

According to available guidelines, gaining at least

22, but not more than 35 pounds, is optimal. Black

women are more likely than white women to gain

fewer than 21 pounds during pregnancy (234).23

Some studies suggest that maternal smoking is

responsible for approximately 20 to 40 percent of

all instances in which infants have low birthweights. Higher rates of low birthweight among

Blacks, however, cannot be explained by smoking practices: Black mothers are less likely to

smoke during pregnancy than White mothers; and

among those who do smoke during pregnancy,

Black mothers smoke less than White mothers

(234). Alcohol use can cause fetal alcohol syndrome

24 and affect birthweight (234). 25 T h e

proportions of women reporting alcohol consumption during pregnancy are similar for Blacks

and Whites, but a greater proportion of Black than
Chapter 4-infant Mortality I 45

White women who drink report high alcohol Interpreting international differences in infant

consumption .26

SUMMARY

Of 39 developed countries, the United States

ranked 24th in infant mortality in 1990. The U.S.

infant mortality rate (9.2) was 35 percent higher

than Canada’s rate (6.8) and twice as high as

Japan’s rate (4.6). The U.S. international standing

was much better in 1950 and 1960, but other

countries have since experienced more rapid

declines in infant mortality.

mortality rates is difficult, because countries vary

in how they report vital events. Available evidence suggests that infant mortality rates are

inflated in the United States because many events

that would be considered fetal deaths in other

countries are counted as live births in the United

States. Although U.S. rates would be comparable

to those of Japan if infant deaths were combined

with fetal deaths that occurred after at least 20

weeks of gestation, such a comparison might be

invalid because of evidence suggesting that the

United States undercounts early fetal deaths.

Zb Among the mothers who CO nsumed alcohol during pregnancy, Black mothers were twice as likely as the White mothers to hsve consumed

three or more drinks per week (37 percent compsred with 18 percent) (234).
46 I International Health Statistics: What the Numbers Mean for the United States

Moreover, despite the fact that the current international rank of the United States is overly pessimistic, its true rank is probably no better than 20th

of 39, a rank that has deteriorated considerably

over time.

Among the factors that influence whether an

infant will live or die in its frost year are the

infant’s race, sex, birth order, place of residence,

birthweight, gestational age, and whether it is

born alone or a part of a set of twins, triplets, or

other multiples; additional factors include the

mother’s age, prior pregnancy outcomes, health

status, personal habits (e.g., prenatal care, smoking, alcohol consumption), and socioeconomic

status. How these biologic and social factors

interact to influence infant mortality is unclear,

but available international data should aid in the

assessment of how these factors vary in relation

to infant mortality rates in the United States and

abroad.

By applying new analytic methods to an

international perinatal and infant mortality database, researchers have assessed the relative roles

of birthweight distribution and birthweightspecific mortality on infant mortality in the

United States. The ICE research suggests that

when definitions of low birthwe ight take populationspecific birthweight distributions into account

(rather than use an arbitrarily defined value for all

populations), the relatively high infant mortality

rate in the United States may reflect birthweightspecific mortality more than birthweight distribution. This implies that efforts to improve the U.S.

infant mortality rate must target interventions

both to lower the prevalence o f infants born in the

high-risk, low birthweight end of the distribution

curve and to lessen the chances of death for

infants of all birthweights.

The age of the mother, her use of prenatal care,

her race and ethnicity, and her socioeconomic

status are all factors associated with infant

mortality. There are relatively more births in the

United States by women under the age of 20 or

over the age of 39, groups who tend to be at

greater risk of poor pregnancy outcomes. The

difference in age distribution may explain up to

25 percent of the difference between the infant

mortality rate of the United States and countries

with more favorable rates, such as Canada and

Japan. Nonetheless, the socioeconomic, lifestyle,

and health status characteristics of U.S. mothers

at the extremes of the maternal age distribution,

rather than age itself, probably account for the

differences.

Patterns of use of prenatal care in the United

States differ from those in some Western European countries. Pregnant women in the United

States tend to seek care later, but average a greater

number of prenatal care visits than do women in

Denmark and France.

Significant socioeconomic differentials in infant mortality exist in the United States as well as

in several other developed countries, even where

access to high quality medical care is universal.

Improving access to maternal and child health

services in the United States would likely decrease the U.S. infant mortality rate, but variation

among the Nation’s subpopulations might well

persist.
Mortality m

Comparisons 5

M

ost residents of developed countries can expect to

live beyond the age of 70, and deaths at younger ages

have become relatively infrequent. Consequently,

measures of premature deaths occurring during early

adulthood are increasingly being used to gauge the health status

of populations. This chapter describes some commonly used

mortality measures and provides data showing trends and the

1987-881 status of the United States and selected comparison

countries. 2

Mortality data are generally considered the most reliable

sources of health indicators, because deaths in developed

countries are generally reported in accordance with international

reporting standards (67). The countries differ, however, in their

use of diagnostic technology, their use of autopsy to confirm

cause of death, and their training of medical personnel, which

contributes to differences in how their physicians certify causes

of death. Consequently, international comparisons of causes of

death must be made cautiously (see appendix B) (67,160).

LIFE EXPECTANCY

Of all the comparison countries, residents of Japan have the

highest life expectancy at birth (76.2 years for males and 82.1

years for females in 1990) and can expect to live 3 to 4 years

longer than U.S. residents, whose life expectancy at birth (71.8

1 ‘he most recent year for which mortality data regarding Spain and New Zealand are

published in the WorkiHeaffh SkuisticsAmud is 1987 (260,261,263,264). Data for 1988

are presented for the other countries.

2 Comparison countries include Australiq Cana@ France, Germany, Italy, Japm the

Netherlands, New Zealand, Norway, Spaiq Sweden+ and the United Kingdom. Data for

Germany are from the former Federal Republic of Ge rrnany and refer to West Germany. 47
48 I International Health Statistics: What the Numbers Mean for the United States

years for males and 78.8 years for females in

1990) is among the lowest (table 5-1).3 Since

1955-59, Japan has experienced a greater improvement in life expectancy at birth than any

other developed country.4 The United States, by

contrast, has maintained its historically lower life

expectancy (figure 5-l). Expected years of remaining life can be measured at various ages and

is lower in the United States than in most other

countries up to the age of 80, at which point the

U.S. position improves somewhat compared with

other countries (table 5-l).

SURVIVAL TO ADULTHOOD

U.S. residents are less likely than residents of

the other countries to survive to the age of 45 or

65 (e.g., the proportion of males who reach 65 is

74 percent in the United States and 83 percent in

Japan) (table 5-2). Even though infant and child

mortality are higher in the United States than in

most of the comparison countries, such deaths are

relatively few and differences in adult mortality

account for most of the disparities in the survival

rates (table 5-2). In fact, individuals who survive

childhood and reach the age of 25 are less likely

to reach 65 in the United States than in any of the

comparison countries (e.g., the proportion of

25-year-old males who survive to age 65 is 76

percent in the United States and 84 percent in

Japan) (figure 5-2).5

YEARS OF POTENTIAL LIFE LOST

An indicator of premature or untimely death is

“years of potential life lost” (YPLL) (107). If

deaths prior to the age of 65 were considered

premature, an individual dying at the age of 20

would have lost 45 years of potential life.6 Not all

premature deaths are avoidable, and YPLL is

really a measure of mortality prior to the attainment of old age. A country’s YPLL increases

when conditions that affect children and youth

(e.g., birth defects, injuries, AIDS) result in death,

but chronic diseases that cause death at older ages

have little effect on YPLL. Of the comparison

countries, Japan and Sweden have the lowest

YPLL and the United States has the highest

YPLL, reflecting the relatively high U.S. infant

and child mortality rates (figure 5-3) (209).

AGE-SPECIFIC MORTALITY

Compared with the rates of the other countries,

U.S. age-specific death rates7 are among the

highest up to the age of 65, and then are relatively

lower (figures C-1 and C-2).8 U.S. rates are

especially high during adolescence and early

adulthood (i.e., the ages of 15 to 24 and 25 to 34).

For males in these age groups, for example, the

U.S. death rates are more than twice those of

Japan and the Netherlands.

U.S. death rates for ages up to 65 have been

consistently high from the 1950s to the 1980s

(tables C-1 and C-2). Of the 13 comparison

3 Life expectancy is the average number of years an individual is expected to live and can be measured from birth or subsequent ages Life

expectancy is calculated from life tables, which are constructed using current age-specific death rates, as if these rates would remain unchanged

throughout the lifetime of the cohort. Life expectancy for infants born in the 1980s, for example, is calculated from 1980 age-specific death

rates even though the 1980 birth cohort will, as it ages, be subjected to the age-specific rates prevailing in 1990, 2000, and subsequent years.

A Declining death rates among those aged 55 and older have contributed largely to increases in Japan’s life expectancy (277).

5 The probability that a person tiving to a certain age (e.g., 25) will survive to another age (e.g., 65 years) is called temporary life

expectancy (3). ‘his measure is useful whensummarizing the mortality experience for difYenmt broad age groups (99).

b No agreement has been reached regarding the age or age limits considered for the determina tion of YPLL. Some calculate it for the age

group 1 to 64, whereas others calculate it ~ither from birth or through the age of 69 (57). The Centers for Disease Control and Prevention (CDC)

used the ages 1 through 65 in its calculation of YPLL until 1986, when it began including mortality during the fwst year of life (206). More

recently, CDC has estimated YPLL befcre the age of 85 (205).

T The age-spec~lc death rate is the unnual number of deaths among persons of a given age group divided by the estimated mid-year

population of that age group (114).

g Figures and tables designated by a C are in appendix C.
Table 5-l-Life Expectancy at Birth and at Ages 15, 45,65 and 80, United States and Selected Countries, 1990

At birth Age 15 Age 45 ~ ~

country Male Female Male Female Male Female Male Female Male Female

United States

Australia

Canada

France

Germany a

Italy

Japan

Netherlands

New Zealand

Norway

Spain

Sweden

United Kingdom

71.80

73.61

73.81

73.37

72.63

73.58

76.17

74.17

71.57

73.29

73.58

74.70

73.03

78.80

80.05

81.11

81.76

79.16

80.31

82.05

81.08

79.27

80.77

80.54

80.73

78.68

57.90

59.57

59.75

59.25

58.47

59.51

61.79

60.07

57.73

59.22

59.54

60.39

58.95

64.70

65.81

66.86

67.50

64.86

66.11

67.57

66.84

65.28

66.50

66.32

66.34

64.44

30.70

31.35

31.70

31.56

30.16

31.07

33.10

31.33

29.99

30.84

31.42

31.97

30.35

35.90

36.67

37.83

38.53

35.79

36.88

38.29

37.66

36.37

37.26

37.14

37.21

35.26

15.10

15.05

15.80

15.98

14.24

14.96

16.35

14.94

14.09

14.85

15.35

15.51

14.12

18.90

19.05

20.69

20.69

18.18

19.03

20.11

20.02

19.26

19.51

19.10

19.54

18.00

7.10

6.92

8.20

7.40

6.27

6.94

7.07

7.07

6.60

7.02

7.00

7.21

6.62

9.00

8.80

10.99

9.52

7.98

8.65

8.91

9.81

9.70

9.29

8.42

9.28

8.46

aBased on data from the former Federal Republic Of Germany.

SOURCES: M. MacDorman, National Center for Health Statistics, Centers for Disease Control and Prevention, Public Health Service, U.S. Department of Health and Human Services,

Hyattsville, MD, personal communication, Sept. 1993; U.S. Department of Commerce, Bureau of the Census, Center for International Research, unpublished tabulations,

Suitland, MD, 1992.
50 I International Health Statistics: What the Numbers Mean for the United States

Figure 5-l—Trends in Life Expectancy at Birth, United States and Selected Countries, Males, 1955-84

1980

.79

“ Japan ‘ N’etherlards - Snain r ‘Austral(a’ Un;ted Kingdom N&w Zeala;d ‘Germany’

Sweden Norway Canada Italy France United States

countries, Japan showed the most pronounced

decline in rates for every sex and age group during

that period. In general, agc-specific mortality

declines within the United States did not keep

pace with those of the comparison countries, and

the United States showed relatively poor improvement for some age groups. The United

States, for example, showed the lowest decline in

mortality among men aged 25 to 34. Nonetheless,

the U.S. decline in mortality among men aged 45

to 54 was second only to the Japanese decline.

But, even this improvement was insufficient to

boost the relative international standing of the

United States. By the late 1980s, the U.S. death

rate for men aged 45 to 54 was the second highest

of the 13 comparison countries (only France’s

rate was higher) (figure C-l).

CAUSE-SPECIFIC MORTALITY

COMPARISONS

This section presents cause-specific death rates

and trends for five categories that account for

most deaths in developed countries: accidents;

homicide and other violence; cancer; circulatory

system disease; and infectious and parasitic

diseases. Examining such broad categories of

disease minimizes the effects of international

cause-of-death reporting differences (see appendix B).

-84
Chapter 5-Mortality Comparisons I 51

Figure 5-l—Trends in Life Expectancy at Birth, United States and Selected Countries, Females, 1955-84

-~/ 1965-6 9

1980

79

.84

6@ ;

I I I I 1 I 1 I I I 1 f

Japan I Norway Canada Austral)a United States

Netherlands

United Kingdom New Zealand

Sweden France Spain Italy Germany

SOURCE: World Health Organization, World Health StatisticsAnnual: 1986 (Geneva, Switzerland: World Health Organization, 1986).

Accidents, Homicide, and Other Violence for more than one-half of U.S. deaths (table C-3).

Adolescent and young adult mortality is espe- The U.S. rates of accident-related death for

cially high in the United States, compared with persons aged 15 to 44 are exceeded only by those

other developed countries. Leading causes of of New Zealand.l0 The rates of accident-related

death among U.S. residents aged 15 to 44 include deaths in many of the other comparison countries

accidents (e.g., motor vehicle accidents, falls, are half that of the United States for this age group

poisonings),9 homicide, and other violence. For (e.g., the Netherlands, United Kingdom, Japan)

individuals aged 15 to 24, these causes account (figures C-3 and C-4).11

9 Accidents and adverse effects include International Classification of Diseases (XD-9) codes E800 through E949 (254).

10 ~ ~e u~t~ Sbtes, motor vetic]e ac~iden~ account for between one-half and ti+tuWC~ of accident-related dmti ~OW ~o*@

15 to 44. Rates of death by motor vehicle accidents in the United States are exceeded only in New Zealand.

11 hidenM death rates for the elderly (65 and older) are highest in France, among the lowest in the Utitd Kingdm and ~taate

in the United States.
—

Table 5-2-Percent of Population Surviving to the Age of 1, 25,45, and 65, United States and Selected Countries, 1990

Male Female

Survival to age... 1 25 45 65 1 25 45 65

Country

United States

Australia

Canada

France

Germanya

Italy

Japan

Netherlands

New Zealand

Norway

Spain

Sweden

United Kingdom

99.0%

99.1

99.2

99.2

99.2

99.1

99.5

99.2

98.9

99.2

99.2

99.3

99.1

97.1%

97.5

97.6

97.7

98.0

97.8

98.5

98.1

96.6

97.7

97.7

98.3

97.9

92.1

94.7

94.4

93.5

94.8

95.2

96.3

95.9

93.3

95.0

94.4

95.5

95.5

74.1%

79.0

77.6

76.1

77.0

78.4

83.1

80.2

75.5

77.9

78.2

80.7

78.4

99.2%

99.3

99.4

99.4

99.4

99.3

99.6

99.4

99.1

99.4

99.3

99.5

99.3

98.4%

98.6

98.7

98.7

98.8

98.7

99.1

98.8

98.2

98.8

98.7

99.0

98.7

96.3%

97.3

97.1

97.0

97.1

97.4

97.9

97.4

96.5

97.5

97.3

97.4

97.2

85.1%

88.5

87.2

89.7

88.1

89.4

91.5

89.0

86.1

89.4

90.1

89.0

86.6

aBased on data from the former Federal Republic of Germany.

SOURCES: M. MacDorman, National Center for Health Statistics, Centers for Disease Control and Prevention, Public Health servicer U.S. Department of Health and Human Services,

Hyattsville, MD, personal communication, Sept. 1993; U.S. Department of Commerce, Bureau of the Census, Center for International Research, unpublished tabulations,

Suitland, MD, 1992.
Chapter 5-- Mortality Comparisons I 53

Figure 5-2—Probability of Survival to Age 65 for Those Surviving to Age 25, United States and

/

/

/

/

/

E

Selected Countries,n 1990

9; 3

. .

91 3

Females

‘ Japa n Franc e Norway Sweden Germany United Kingdom United States

Spain Italy Netherlands Australia Canada New Zealand

a Data for Germany from the former Federal Republic of Germany.

SOURCE: U.S. Department of Commerce, Bureau of the Census, Center for International Research, unpublished tabulations, Suitland, MD, 1992.

The U.S. rates of age-specific homicide and U.S. rates of fatalities from motor vehicle

other violence12 for residents aged 15 to 34 are at accidents are among the highest when measured

least twice as high as the rates of any of the in terms of total population, but are relatively low

comparison countries (figures C-5 and C-6). The when measured in terms of vehicle miles traveled

Swedish homicide rate surpasses the U.S. rate at (table 5-3).

the age of 35 for women and 45 for men. In most Cancer and circulatory system disease overtake

countries, including the United States, mortality accidents as the leading causes of deaths for U.S.

from accidents, homicide, and other violence residents aged 45 and above (table C-3).

have declined since the 1950s (figure C-7).13

12 HOmi~l&, ~jw PWO=IY ~ict~ ~ other pCTSOnS, and other violence include ICD-9 ~d= E960 through E999 (254).

13 ~~end ~~ wewon age-5~&Hd~th ~tes ~uro~n S~&@ ~d&lU&motor vehicle accidents, poisoning, suicide,

homicide, and other violence (ICD-9 codes E800E999). In the United States, homicide rates have increased somewhat while accident-related

death rates have declined.
54 I International Health Statistics: What the Numbers Mean for the United States

Figure 5-&Years of Potential Life Lost Before Age 65, United States and Selected Countries, 1964-67°

6000

5500

~ 5000

g

g

.-

: 4500

5

a)

>4000

3500

3000 ILii

United New France Australia Spain Canada Germany Italy United Norway Nether- Sweden Japan

States Zealand Kingdom lands

a Year of data for Spain iS 1984; for Italy, 1985; for Australia, Canada, France, Netherlands, New Zealand, Norway, Sweden, and United States, 1986;

for Germany, Japan, and United Kingdom, 1967. Data for Germany from the former Federal Republic of Germany.

SOURCE: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, “Mortality in

Developed Countries,” Morbidity and Moprtality Weekly Report 39(13) 205-209, April 6, 1990.

Cancer

For persons aged 45 to 64, death rates from

cancer

14 were intermediate in the United States

compared with those of other industrialized

countries in 1988 (figures C-8 and C-9). Comparison countries show different trends in agespecific rates of death from cancer between

1955-59 and 1980-84 (table C-4). For example,

the rates of death from cancer for men 45 to 54

years old increased during this period in all

countries but the United Kingdom, Netherlands,

and Japan, whereas the corresponding rates for

women declined in all but the United Kingdom,

New Zealand, and Australia,

Combining mortality data for all cancers masks

trends that diverge by cancer site. Data on

age-standardized death rate15 trends show that

cancers of the trachea, bronchus, and lung have

increased greatly while stomach cancer has declined between 1955-59 and 1980-84 for both

men and women in all comparison countries.

During this period, death from breast cancer

mortality has increased for women in all countries

but Sweden (table C-5).

Among the factors that might lead to international differences in cancer death rates are disparities in genetic predisposition to cancer, the

prevalence of risky behaviors (such as smoking),

environmental conditions, survival of cancer

patients, the extent to which physicians diagnose

cancer and report it on death certificates, and how

death certificates are coded. Sorting out the

relative role each of these factors plays in causing

international differences in cancer mortality lev14 km (i.e., malignant neoplasms) includes ICD-9 codes 140 tiu@ 2M (M4).

1s Age-adjusted death rates are calculated by applying comparison countries’ sgespecflc death rates to an arbitmrily chosen standard

population with aknmvn age diatributio:~ Comparisons are made with the number of expected deaths observed in the standard population (1 14).
Chapter 5-Mortality Comparisons I 55

Table 5-3--Rates of Motor-Vehicle-Related Deaths, Selected Countries, Circa 1990

Death rate (per 100

Death rate (per million vehicle

Country Year 100,000 population) miles traveled)a

United States

France

Germanyb

Japan

Netherlands

Norway

Spain

Sweden

United Kingdom

1988

1989

1989

1990

1989

1989

1987

1988

1990

19.54

18.15

12.26

11.73

9.44

9.13

17.27

9.59

9.80

2.1

3.9

2.8

3.1

2.3

2.0

10.9

1.9

2.1

aDeath rates per 100 million vehicle miles traveled are for 1990 for all countries.

bBased on data from the former Federal Republic of Germany.

SOURCES: L. Hall, National Highway Traffic Safety Administration, U.S. Department of Transportation, Washington, DC, personal

communication, March 1993; World Health Organization, World Health Statistics Annual (Geneva, Switzerland, World Health

Organization, 1991 and 1992).

els and trends is the subject of study and debate

(34,37,66,79,87,275). 16 Recent studies suggest

that some of the increase in reported cancer deaths

might be secondary to increased use of diagnostic

tests, especially among the elderly (47,78,109,

117,118).

Circulatory System Disease

U.S. rates of death from circulatory system

disease 17 were at their highest between 1955 and

1959,18 have declined precipitously since then

(figure C-10), but remain among the highest

relative to comparison countries (figures C-11

and C-12).19 For men and women 45 to 64 years

old, 1987-88 rates of death from circulatory

system diseases were highest in the United States,

New Zealand, and the United Kingdom and

lowest in Japan and France.

Circulatory system disease includes disorders

with different underlying causes. Atherosclerosis,

for example, is a major risk factor for ischemic

heart disease and hypertension is a major underlying risk factor for cerebrovascular disease. Some

suggest that vital statistics cannot be used to

accurately determine secular trends in types of

heart disease (174), in part because physicians in

some countries tend to use certain diagnostic

categories, such as ischemic heart disease, more

often than do their counterparts in other countries

(179,184). 20

Trend data, though imperfect, indicate that

cerebrovascular disease21 rates have declined in

all countries (table C-6). For men, ischemic heart

lb mco~ssio~ &mSI ACCOUnt@ Wlce will publish a comparison of sumival from cancers of the lung, colon+ and breast and

Hodgkin’s lymphoma in the United States and Canada (139).

17 cfi~ato~ ~s~m diseases include ICD-9 codes 390 through 459 (254).

18 Age-s~&~ @Wop=n s-d) mtes were higher in the United States than in any Of the 12 COmpfiOn counties (261).

19 For us, ~m ~g~ 35 t. 64, dea~ ~t= from ha ~~e &opp~ by more tinone-third betwea 1955-59 and 1980-84. By COntZtW,

heart disease rates in Ge rmany and Sweden have historically been low and have remained relatively stable during this period (260)

20 ~ way ~dims we rep~ ~ ~.so fi~t~ by c~ges iII & 1~ over time (ep~y the c-e fivm 1@’7 to 1~-8). When

circulatory system diseases are analyzed as a group, the effects of these ICI) changes are minimbd (184).

z] cerebmv~~~ disease includes ICD-9 coda 430-438 (254).
56 I International Health Statistics: What the Numbers Mean for the United States

disease22 mortality rates vary: They have declined

markedly in the United States, Italy, and Canada;

have remained relatively stable in Germany and

Spain; and have increased in Sweden, France, and

Norway (table C-6). For women, rates of death

from ischemic heart disease mortality have declined in all countries but France.23

Factors that may have contributed to the

decline in heart disease in the United States and

elsewhere include reductions in coronary risk

factors such as cigarette smoking, hypertension,

and high-fat diets, and improvements in medical

therapy for patients with heart disease (59).24 The

World Health organization’s MONICA project,25

an international study of risk factors for cardiovascular diseases, is assessing the extent to which

trends in coronary heart disease and cerebrovascular disease are related to such factors as

smoking, blood pressure, cholesterol, and bodymass index (249).26

Infectious and Parasitic Diseases

Deaths from infectious and parasitic diseases27

are most common among the elderly, but increasingly, deaths related to human immunodeficiency

virus (HIV) infection are important causes of

death among young people.28 The United States

had the highest infectious disease-related 1987-

88 death rates among men and women aged 24 to

64. Among elderly men and women (age 65 and

older), infectious and parasitic disease death rates

(primarily septicemia) are highest in Japan and

the United States (table C-3).

United States and Canada

Mortality Comparisons

Mortality rates are lower for Canadian residents than for U.S. residents at almost every age.

If the United States had had the same age-specific

death rates as Canada in 1989, about 200,000

fewer U.S. residents would have died-a difference of 9 percent (table 54).29,30 The deaths of

more than one-quarter of the children (under the

age of 15) and more than one-third of the men

aged 25 to 44 who died in the United States that

year could be viewed as “excess” deaths relative

to Canada’s mortality experience. An examination of the leading causes of death by age in the

United States shows that higher U.S. rates of

homicide and HIV and acquired immunodeficiency syndrome (AIDS) account for much of the

differential among young people (ages 15 to 24),

but that higher U.S. rates of death from heart

disease account for most of the excess deaths,

which are concentrated in the over-44 age group.

31

22 Ischemic heart dis~se includes IfD-9 codes 410-414 (254).

23 ~ most cou~es, ischemic hem jiseme is a more common cause of death than cerebrovascuhr (_&Xe. Thc reverse tlppC@’s to k hUe

in Japaq where cerebrovascular diseast is the predominant cause of circulatory disease death. Some evidence suggests that this trend might

result from reporting, because Japanese physicians appear to overdiagnose cerebral stroke (72).

M ~provemmts iII hospi~me (e. ij., the use of coronary care units) for patients SUffel@ aCUte myOCdid inf~tion ~ not fo~ to

contribute to declines in U.S. rates of d?ath from acute myocardial infarction between 1973-74 and 1978-79 (60).

n~~aonw MONICA s~ds for MON]toring of&ends and det erminants in Cardiovascular diseases (248).

26 Da~onfi5k factom ~ebe~ ga~er~ ~ou@Wpu~tion-~ed s~eys of ~em s~~ by COWbOm~ (XXlkm iu27 COUrltI’ies. StiO~

California is the only U.S. center represented in WHO’s MONICA project (248).

27 ~Wtious ~d Pmitic dis=m include ICD.9 codes ~1-139, but exclude codes 480-4$6 (pneumonia),

28 Damon tie incidence of AIDS is provided in chpter 6.

29 ~ tie Ufitd Stites ~d tie Sme ~lge-s~fic d~~ rates ~ Ca~@ an es~t~ 96,234 fewer m&x ~d 95,979 fewcx females wotid

have died.

30 H tie comp~on were co~m~ 10 tie U,S. w~te popu~tioq &em wodd hve been 5 percent fewer d~ti k the Utdtd StdCS.

31 Even ~Ou@ the Pmwfionof u-s. d~ths ~mid~ed excess is h@~t for youg~ age groups, most cxxss U.S. d@hs are co~ntrated

among men aged 25 to 64 and women iigd 65 and older, because that is when most deaths occur (table C-5).
Chapter 5-- Mortality Comparisons I 57

Table 5-4-Expected U.S. Deaths If United States Had Canadian Age-Specific Mortality Rates, 1989

Percentage of U.S.

U.S. deaths Expected U.S. deaths Excess U.S. deaths deaths that are

number if Canadian rates Number Percent excess deaths

Male

Under 15

15 to 24

25 to 44

45 to 64

65 and older

All ages

Female

Under 15

15 to 24

25 to 44

45 to 64

65 and older

All ages

31,895

27,165

99,482

234,432

720,811

1,113,785

23,966

9,323

41,961

143,892

816,977

1,036,119

23,375

22,406

63,825

193,840

714,105

1,017,551

17,404

7,529

31,109

115,086

769,012

940,140

8,520

4,759

35,657

40,592

6,706

96,234

6,562

1,794

10,852

28,806

47,965

95,979

8.9%

4.9

37.1

42.2

7.0

100,0

6.8%

1.9

11.3

30.0

50.0

100.0

26.7%

17.5

35.8

17.3

0.9

8.6

27.4 %

19.2

25.9

20.0

5.9

9.3

SOURCES: Statistics Canada, The Leading Causes of Death at Different Ages, (Ottawa, Ontario: Statistics Canada, 1989); U.S. Department

of Commerce, Bureau of the Census, U.S. Population Estimates, by Age, Sex, Race, and Hispanic Origin: 1980-1991 (P25-1095)

(Washington, DC: U.S. Department of Commerce, February 1993); U.S. Department of Health and Human Services, Public

Health Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Advance Report of Final

Mortality Statistics, 1989, Monthly Vital Statistics Report 40(8), suppl. 2, Jan. 7, 1992;.

AGES 15 TO 24

Homicide is the second leading cause of death

for U.S. residents aged 15 to 24 and accounts for

as many as 19 percent of males’ deaths and 12

percent of females’ deaths in this age group

(tables C-7 and C-8). In Canada, homicide

accounts for 3 percent of males’ deaths and 5

percent of females’ deaths in this age group. If

U.S. homicide rates were as low as Canada’s, the

U.S. overall death rate for young adult males

would be comparable to Canada’s (119.6 vs.

117.5 per 100,000).

AGES 25 TO 44

Death rates for this age group are 55 percent

higher for males and 35 percent higher for females

in the United States than in Canada (tables C-9

and C-10). Much higher rates of HIV and AIDS,

homicide, and chronic liver disease in the United

States account for the fact that its death rates are

higher than Canada’s. Homicide rates, for example, are five times as high for males in the United

States as in Canada.

AGES 45 TO 64

Death rates for this age group are 22 percent

higher for males and 26 percent higher for females

in the United States than in Canada. Much of the

difference can be accounted for by the higher rates

of heart disease in the United States than in

Canada. For men and women aged 45 to 64, the

rates of death from heart disease are 31 and 64

percent higher in the United States than in Canada

(tables C-1 1 and C-12).

AGES 65 AND OLDER

U.S. and Canadian death rates are comparable

for males in this age group, but U.S. rates are

about 12 percent higher than Canadian rates for

females (tables C-13 and C-14). Much of this

difference is explained by the higher rates of

death from heart disease in the United States.

SUMMARY

The United States ranks relatively poorly

among industrialized countries when general
58 I International Health Statistics: What the Numbers Mean for the United States

mortality measures are used as indicators. Age at

death is reliably reported in developed countries,

and the age-specific death rate is a useful mortality measure for international comparisons. Compared to the age-specific death rates of other

developed countries, U.S. rates are among the

highest through the age of 64, and then are

somewhat lower after the age of 65. These trends

generally remain the same when the other countries’ death rates are compared with the death

rates of only the white residents of the United

States. The high rates of death for members of

younger age groups mean relatively low life

expectancies at birth, and many years of potential

life lost. An analysis of age-specific death rates

since 1955 shows that the U.S. rates have been

persistently high and that reductions in mortality

have generally not been as great in the United

States as those observed in comparison countries.

An important exception to this trend is that

mortality rates have declined significantly for

U.S. men aged 45 to 54. The United States has

made the least progress, however, in reducing

mortality rates for men aged 25 to 34.

For people below the age of 35, accidents and

injuries are major causes of death, and the U.S.

rates of death from accidents and injuries are

among the highest for a developed country. The

rate of death from homicide and other violence is

at least twice as high for the under-35 age group

in the United States as in any of the comparison

countries. After the age of 35, cancer and heart

disease are the major causes of death in all the

developed countries. U.S. rates of death from

heart disease for both men and women aged 35 to

65 are among the highest, but U.S. rates of death

from cancer are not exceptionally high compared

with those of other developed countries.

If U.S. age-specific death rates were the same

as the Canadian rates, the United States would

have 9 percent fewer deaths (i.e., 192,200 U.S.

deaths would have been avoided in 1989). Most

of such excess deaths are concentrated in the 45

to 64 age group. Lower rates of heart disease in

Canada than in the United States account for most

of the disparities in the death rates for these age

groups.
Morbidity,

Disability, and

Quality-of-Life

Indicators 6

I

nternational comparisons of health status are usually

limited to mortality because of the lack of widely accepted

and uniformly measured morbidity or disability indicators. Morbidity comparisons could include the rates of

reportable diseases (e.g., acquired immune deficiency syndrome

(AIDS)), the incidence of diseases for which there are registries

(e.g., birth defects, cancer), and the prevalence of disabilities

reported in national surveys. This chapter reviews available

morbidity comparisons and current efforts to develop internationally useful measures of disability, quality-of-life, and healthy

life expectancy.

MORBIDITY, DISABILITY AND QUALITY-OF-LIFE

INDICATORS

As life expectancy in developed countries has increased,

interest in health indicators has shifted from mortality measures

to indicators of the consequences of living with chronic illnesses

and, to the extent that it can be measured, the maintenance of

good health. The World Health Organization (WHO) defines

health as “a state of complete physical, mental and social well

being and not merely the absence of disease and illness” (252).1

Although health is defined in a positive sense, most available

indicators measure the negative complement of health (198).

Three types of indicators can be used to describe health or its

absence:

1 The World Organization of NationaJ Colleges, Academies, and Academic Associations of General Fractitioncrs/Family Physicians (WONCA) has recommended that the

word “optimal” be substituted for “complete ‘‘ in the WHO deftitioq because few

people can achieve complete health as it has been defined (9). 59
60 I International Health Statistics: What the Numbers Mean for the United States

a Morbidity indicators are reports of diseases or . . Morbidity Indicators

conditions that can potentially impair, disable, REPORTABLE DISEASES

or handicap (e.g., the prevalence of arthritis, or

heart disease).

■ Impairment, disability, and handicap indicators, as defined by WHO, measure the

consequences of diseases and injuries and their

implications for the lives of individuals (box

6-A) (24,1 16,181,255).

■ Health-related quality-of-life indicators measure subjective judgments about states of health

or disease (19,115,116,134).2 An example of a

quality-of-life indicator is self-perceived

health. 3

Only three diseases-plague, cholera, and

yellow fever—require official notification under

WHO’s International Health Regulations, but

most developed countries have their own disease

surveillance systems. In the United States, for

example, physicians report to State or local health

officials, who in turn make weekly reports to the

U.S. Centers for Disease Control and Prevention,

when patients have any of 49 notifiable conditions (e.g., AIDS, hepatitis, rabies, and measles)

(211). In the United States, notification is not

mandatory, and the thoroughness of the reporting

z Sometimes health-related quality of life is defti more broadly to include all those things important to patients beyond traditional

outcomes of death and physiologic measures of disease activity (65).

g A question on self-perceived health appears on the U.S. National Health Interview Survey: “Would you say your health in general is

excellent very good, good, fair, or poor?” (232).
Chapter 6-Morbidity, Disability, and Quality-of-Life Indicators 161

varies with the seriousness of the condition.

Salmonellosis and mumps are, for example, less

likely to be reported than are plague and rabies.

Reporting is also influenced by the availability of

diagnostic facilities, infectious disease control

policies, and the vigilance of State and local

authorities involved in surveillance activities.

AIDS data are available from all developed

countries’ disease surveillance programs. As of

mid-1993, cumulative rates of the incidence of

AIDS4 were substantially higher in the United

States than in comparison countries (table 6-l).

Spain had the second highest rate (465 cases per

million), but it was less than half the U.S. rate

(1,268 cases per million). Japan’s rate is remarkably low, at only four cases per million.

Risk factors responsible for AIDS transmission

in the comparison countries vary substantially.

Homosexual or bisexual activity has been responsible for most of the cases in the United States,

intravenous drug use has caused most of the cases

in Italy and Spain, and contamin ated blood

products have been responsible for most of the

cases in Japan (98,237,274).

CHRONIC DISEASE

Incidence, prevalence, and mortality rates cannot adequately measure the extent and effect of

chronic conditions. Chronic diseases are often

variable in their onset, progress gradually, and

persist for months or years. International differences in chronic disease statistics may be misleading, if the disease entails any long asymptomatic period and is detected at different rates

during various stages. A country with an aggressive cancer screening program, for example,

might report a higher incidence of breast cancer

than a country without such a program would

report. To make international comparisons, cancer survival must be evaluated according to what

stage the cancer had reached at the time of

diagnosis. To evaluate the consequences of disTable 6-l--Cumulative AIDS Incidence Through

Mid-1 993, United States and Selected Countries

Cumulative

AIDS cases AIDS incidence

Country through mid-1 993 (per million)

United States 315,390 1,267.8

Australia 3,697 219.9

Canada 8,232 309.5

France 24,226 427.7

Germany a

9,697 123.3

Italy 16,860 293.1

Japan 543 4.4

Netherlands 2,575 171.0

New Zealand 360 106.2

Norway 319 75.4

Spain 18,347 464.7

Sweden 817 96.1

United Kingdom 7,341 128.3

aBased on data from the former Federal Republic of Germany.

SOURCES: Health end Welfare Canada “AIDS in Canada Surveillance

Update,” (Ottawa Ontario: Health and Welfare Canada, July

1993); U.S. Department of Health and Humeri Services,

Pubic Health Service, Centers for Disease Control end

Prevention, National Center for Infectious Diseases, Division

of HIV/AIDS Surveillance Report, Second

Quarter Edition, Volume 5, No. 2 (Atlanta, GA: U.S.

Department of Health and Human Services, July 1993);

World Health Organizaton, Regional Office for Europe, AIDS

Surveillance in Europe, Quarterly Report, No. 37

(Copenhagen, Denmark: World Health Organization, March

1993).

ease or disability, measures are needed that could

distinguish between, for example, a diabetic

individual with no complications and a diabetic

patient with heart, eye, and kidney diseases.

Disability Indicators

The World Health Organization has developed

a conceptual model describing the disability

process and has published the International

Classification of Impairments, Disabilities, and

Handicaps (ICIDH) to facilitate measuring the

consequences of diseases and injuries (box 6-A)

4 CurnulRtive AIDS incidence is the total number of AIDS cases reported to date (as of mid-1993), divided by the current estimate of the

mid-year population.
62 I International Health Statistics: What the Numbers Mean for the United States

(24,1 16,181,255). The United Nations Statistical

0ffice has compiled national statistics on disability from over 55 countries (187a). Although

disability-related statistics are often available

from national censuses or population surveys,

they are generally not comparable. Three factors

hamper efforts to make international comparisons

of disability: disagreement on what disability

means and on which states of health should be

measured; differences in how disability surveys

are conducted; and the need to interpret disability

statistics in a cultural and social context.

General disagreement on what disability means

has hampered attempts to standardize morbidity

and disability measures. The WHO classification

system has been adopted in Europe but, until

recently has not been widely accepted in the

United States.5 Critics of the WHO framework

state that the concepts of impairment, disability,

and handicap are ambiguous and result in problems of classification (24,25 .85).6 Some of the

problems identified in the ICIDH will likely be

resolved when the WHO clarification system is

revised in 1993 (181). A U.S. task force on

disability criteria recommended that the United

States adopt the ICIDH framework and participate in the ongoing revision of the ICIDH (201).7

The North American WHO Collaborating Center

for Health Related Classifications will participate

in revising the ICIDH and will coordinate its use

in the United States and Canada (74).8

National statistics on disability are generally

available from several sources, such as censuses,

surveys, and registration systems (e.g., administrative records from health or disability programs). According to a 1990 survey of data

collection policies in 14 countries, almost all

countries gather, as part of their population-based

surveys, information on the prevalence or incidence of chronic conditions,9 temporary and/or

long-term disability, and long-term incapacity to

work (44). But because countries differ in how

they conceptualize disability, the content of

disability-related questions on surveys varies so

widely that international comparisons cannot be

made (box 6-B). Furthermore, available surveys

sometimes include different populations; some

include institutionalized populations whereas others do not (14a).

There are numerous sources of data on disability in the United States,10 but even here the

content of disability surveys varies widely (124).

U.S. estimates of the prevalence of workdisability range from 9 to 17 percent based on

S An important U.S. civil rights law, tile Americans with Disabilities Act (ADA) (Public Law 101-336), dcfmcs disability broadly as “a

physical or mental impairment that substantially limits one or more major life activities, ” a record of such an impairment, or being regarded

as having such an impairment (61). This deftition outlines generally who is covered by the ADA but the final determination is made on a

case-by-case basis (242).

s &or@ to an ~te~tive Conceph al model proposed by S. Nagi, the term handicap is dropped and a dktindOn is de tien

functional limitations, which entail problems in performing simple actions and disabilities that entail problems in performing complex

activities. The WHO flamework was critilpmi, and the Nagi fimnework was adopted (but modified) in Disubifiry in America, an infhmtial

U.S. report published by the Institute of Medicine (IOM), The IOM and others have questioned the use of the term handicap because people

with disabling conditions in some countries perceive it as negative (85,1 13).

7 The U.S. Department of Health and %rnan Services’ Public Health Service Task Force on Improving Medical Criteria for Disability

Determination recommended a strategy to unprove the scientific basis for determining disabilities and developed a research agenda regarding

medical criteria for such deterrmna “ tions (201).

s The U.S. National Center for Health Statistics recently sponsored an international workshop on the collection of disability statistics in

population- based surveys (74).

9 The extent of self-reporting of medical conditions can vary with the format of the survey question. For example, the proportion of British

Oeneral Household Survey respondents reporting health problems rose ftom about o~rto~ost ~w~n~~eyfo~t

changed from being open-ended to including a checklist of medical conditions (13). Such variations support other evidence suggesting that

the prevalence of chronic diseases by dia~losis may not be reliably assessed through sehvports on natiomd health interview surveys (89).

10 me U.S. Na(io~ Cmter for Health Statistics is planning a supplement on disability as part of its National Health ~tCfiew smey in

1994-95 (169).
Chapter 6-Morbidity, Disability, and Quality-of-Life Indicators I 63

population-based surveys because of differences because its new data would not be comparable

in the purposes, context, and content of the

surveys (124).

A WHO working group has recommended

standardizing questions about disability to promote comparability of disability statistics (44,272).

Although having countries change the content

and wording of their population-based surveys to

promote international comparability might be

desirable, such changes would diminish each

country’s ability to monitor its internal trends

with its old data. Consequently, the changes

might be resisted.

But even if disability-related questions on

national surveys were standardized, difficulties

would remain in making international comparisons. Disability is commonly measured in terms

of “bed days, ’ “restricted activity days,” or

‘‘work-loss days. Restricted activity days might

be measured, for example, in terms of responses

to the question ‘‘Did you have to cut down on any
64 I International Health Statistics: What the Numbers Mean for the United States

of your usual activities about the house, at work,

or in your free time because of illness or injury?’

but the concept of usual activities is likely to vary

in different countries and to affect the responses

accordingly (13). Levels of work-related disability may measure unemployment and social security programs rather than the actual health of the

groups concerned. The increase in sicknessrelated absences from work in Europe since the

1950s has coincided with the growth of sickness

insurance plans and may not reflect true increases

in levels of disability (13).

Measuring handicap is inherently difficult

because it is defined in terms of societal accommodation of disability. A handicap exists when an

impairment or a disability is not environmentally

accommodated. Handicaps refly be absent in spite

of disabilities. A wheelchair-bound individual,

for example, might be considered disabled but

would not be considered to have a work-related

handicap if he or she were employed at a site with

adequate accommodations.11 Levels of handicap

among those with disabilities can be used to

measure progress toward accommodation of impaired and disabled people in the workplace and

elsewhere.

Trying to compare survey data on functional

limitations from the United States, Canada, and

Britain illustrates the difficulties in interpreting

international data on disability. A higher proportion of U.S. residents (21 percent)12 reported

having functional limitations than did Canadians

(15 percent)13 or Britons (14 percent),14 despite a

survey format that favored the reporting of

functional limitations in Canada and Britain.l5

Differences in health status, variations in the

environment, distinctions in how disability was

defined or measured, or survey error could

account for these international disparities (106).

Quality-of-Life Indicators

With attention increasingly focused on prevention and treatment for chronic illness, outcome

measures that describe the effects of treatment in

terms of both mortality and morbidity, and also

incorporate public values associated with various

outcomes, are potentially useful. Such interventions as heart transplants might increase life

expectancy but seriously compromise physical

independence, mobility, social activity, and other

factors that contribute to the quality of life.

Certain indexes try to capture, sometimes in a

single measure, dimensions of health that affect

its quality. Quality-of-life indicators are based on

health-state preferences, which are measures of

satisfaction or desirability that people associate

with the presence of symptoms and functional

limitations that can affect quality of life (50,51,

52,53). Health-related quality-of-life measures

are increasingly being considered for program

evaluation, population monitoring, clinical research, and policy analysis (134). Box 6-C shows

a selection of instruments for assessing functional

status. Some of these measurements are weighted

for quality-of-life factors.l6 WHO’s Quality-ofLife project is developing a survey instrument to

assess how patients in developing and developed

countries perceive the quality of their lives (33).

I I my~of ~e fidi~d~s x,3titthcy W- w&lciMWN@ said that they were limited in their ability to work according to

a 1978 survey by the U.S. Social Security Administration (124).

12 ~~~t~ 21 p=nt of ~ Uoso pop~tion@15 ~d Olda r~rt~ living with functiod limitations in 1984, according to the

Survey of Income and Program Participation (106),

13 ~Cd~H@~~~~i~Li~~tiOn survey es~t~bat in 1987 approtitely 15 percent of the adult population (age 15 and

older and including those residing in indutions) had a functional or activity limitation (106).

M ~cor~ t. aBri~ ~cy, abut 14 ~nt of adults S@ 16 or older were estimated to have a functional limitation in 1986 (106).

1S Bo~ ~ c~di~ ~d Briti~ survc ys @a more extensive list of functiod limitations ~ the U.S. Survey (106).

16 Some ~So~wi~ ~bifities f~(e-@~-of.Me qproachcs off~sive, kause tiq imply that a year of life with a disability

is less valuable than a year without a disalWy (74).
Chapter 6--Morbidity, Disability, and Quality-of-Life Indicators I 65

HEALTHY LIFE EXPECTANCY

Information on mortality and morbidity in a

population can be integrated to yield measures of

life expectancy adjusted for the prevalence of

impairment, disability, or handicap. WHO has

recommended that these healthy life expectancy

indicators be used to monitor the health of

populations (256). Healthy life expectancy differs

from life expectancy by referring to the number of

years someone of a particular age can, on average,

expect to live in a healthy state, in view of

prevailing age-specific rates of mortality and

morbidity (15). Evidence of widespread acceptance of the indicator is its incorporation into the

health objectives of various nations. One goal of

the United States, for example, is to increase the

years of healthy life from an estimated 62 years in

1980 to 65 years by the year 2000 (200). WHO’s

fourth European regional target toward “Health

for All’ calls for a 10 percent increase in healthy

life expectancy by the year 2000 (267).

A country’s life tables can be adjusted by using

information from population-based surveys to

estimate what portion of the residents’ life

expectancy is free from various types of impairments, disabilities, or handicaps (figure 6-l). An

I
66 I International Health Statistics: What the Numbers Mean for the United States

Figure 6-1--Survlval Curves for Australian Males and Females, 1988

Proportion surviving (percent)

100

so

60

40

20

0

100

80

60

40

20

0

Males

Severe-handicapfree

Female.

r 1 r 1 1 & T 1 T

00

0 10 20 30 40 50 60 70 80 90 100

Age

SOURCE: C. Mathers, Health Expectancies in Australia 1981 and 1988(Canbarra, Australia: Australian Government

Publishing Service, 1991).

international network of researchers called REVES17 free life expectancy exist for more than 30

is developing techniques and proposing standards countries (150),18 the estimates rely on different

to be used to calculate healthy life expectancy methods and disability data and cannot be com-

(113,150,151). These standards would be helpful pared (17). Some measures, for example, include

because although national estimates of disability- a quality-of-life adjustment. The World Bank has

17 ~~

name of the network on heslth expectancy and the disability process is R4scau E$p4rancc de Vie en Sant6. From 1989 to 1992,

the network has convened six international meetings and has published papers, bibliographies, and a world yearbook on statistical calculations

of healthy life expectancy (1 13).

16 ~el@~W~es for which esthnat.es are available ticlude: CSXMdiL ~~~and and Wales, France, Germany (the formex

Federal Republic of &xmany), Italy, the Netherlands, Spa@ Swede~ Switzerland, and the United States (1 13,180).
Chapter 6-Morbidity, Disability, and Quality-of-Life Indicators I 67

calculated ‘disability-adjusted life years, ’ which

include a weighting scheme reflecting relative

severity and burden of disabling conditions.

These weights were determined by a group of

experts (25 1). The U.S. measurement of years of

healthy life also includes a quality-of-life adjustment (200). However, some have suggested that

disability weights should not yet be used because

there is no consensus on how to measure quality

of life, and such adjustments obscure the ability

to monitor changes in a population’s health status

over time (15 1).

Most researchers agree on the need for longitudinal surveys to identify the incidence, duration,

and possible recovery from impairments and

disabilities. The United States has one of the few

national longitudinal data sets, the Longitudinal

Study of Aging (LSOA).19 Other countries are

beginning to mount such surveys, which will

allow international comparisons (153a).

SELF-PERCEIVED HEALTH

Population-based health surveys often include

questions on self-perceived health, but the responses to such questions may reflect social

perceptions that are culturally bound, making

them difficult to interpret and compare (68).

Furthermore, international comparisons are often

difficult to make, because the wording of survey

questions and responses varies by country .20

A standard question21 on self-perceived health

was included in a 1987 12-country study, “Europeans and Their Health. ” A full 79 percent of

Irelands’ residents rated their general state of

health as “good” or “very good” compared with

60 percent of residents of Italy (table 6-2) (28).22

The U.S. National Health Interview Survey

records responses to a question on self-perceived

health similar to the question used in the European survey, but the response categories differ

somewhat. 23 In the United States, most residents

(90 percent) reported themselves to be in “good,”

“very good, ’ or ‘‘excellent’ health in 1987

(214). This is higher than reports of “very good”

or “good” health in Europe in 1987, but the

difference in the response categories makes

comparisons difficult.

SELF-PERCEIVED STRESS

Perceptions of personal levels of stress are

sometimes intended to be a measure of mental

well-being. According to population-based surveys in the United States and Canada,24 a greater

proportion of adults (aged 18 and older) reported

‘‘very stressful” lives in 1985 in the United States

(18 percent of males and 23 percent of females)

than in Canada (10 percent of males and 8 percent

of females). In 1990 the report’s findings were

similar (20 percent versus 13 percent of males and

27 percent versus 12 percent of females) (162).

SUMMARY

There is no general consensus regarding disability measures, but they are important for determining whether gains in life expectancy have

come at the expense of quality of life. The WHO

IQ me LSC)A ~cludes ~~ on disability, instimtionalizatio~ and mortality for a sample of U.S. respondents, aged 70 or oldex, who were

originally interviewed in 1984 and then reinterviewed in 1986 and 1988 (152a).

zo WHO has re~mmended a standard self-perceived health question for survey U* (269).

21 me question on self-perceived health on the wey WaS ‘‘How would you describe your state of health in general now? Would you say

it is very good, good, reasonable, rather poor, very poor or you don’t know?” (28).

22 A standardized questionnaire related to cancer and its prevention was used as part of the sumey. Face-t-face interviews were conducted

within the homes of a representative sample of residents aged 15 and older within 12 countries. A total of 11,651 subjects were included in

the study (28).

23 ~ tie U.S. SUCY, the question is c$wo~d you say your hezdth ingeneraJ is “excellent,’ “verygood,” “good,” or ‘ffi or poor” (214).

24 me 1985 and 1~ H~~ ~motion Sumeys ~ Cmada and tie Natio~ Health ~temiew Survey Hdth PmmOtiOn ~d Disease

Prevention Supplements included comparable questions on self-perceived stress. In the United States, respondents were asked how much stress

they had experienced in the 2 weeks preceding the interview. In Canad% respondents were asked to assess the level of stress in their lives (162).
68 I International Health Statistics: What the Numbers Mean fort he United States

Table 6-2--Self-Perceived Health, United Statesa and Selected European Countries,b 1987

United States

European communityc

Belgium

France

Germany

Ireland

Italy

Netherlands

Spain

United Kingdom

21%

27

24

16

39

16

22

21

28

40.3%

44%

45

43

50

40

44

51

46

37

27.8% 22.40/Q 9.5%

28%

22

25

27

19

36

22

25

30

5%

4

7

4

2

4

3

6

4

1%

o

1

1

0

0

1

2

1

1%

2

0

2

0

0

1

0

0

aAs part of the U.S. National Health interview Survey, respondents were asked, “Would you say your health In general Is excellent, very good,

good, or fair to poor?"

bThe Commission of the European Communities survey respondents were asked, ‘How would you describe your state of health in general now?

Would you say it is very good, good, reasonable, rather poor, very poor or you don’t know?”

cWeighted average of 12 countries. Data from Denmark, Greece, Luxemburg, and Portugal are not shown.

SOURCE: Commission of the European Communities, Europeans and Cancer Prevention: A Study of Attitudes and Behaviour of the Public

(Brussels, Belgium: Commission of the European Communities, June 1988); U.S. Department of Health and Human Services, Public

Health Service, Centers for Disease Control, National Center for Health Statistics, Health United States: 1988, DHHS Pub. No. (PHS)

88-1232 (Hyattsville, MD: US. Department of Health and Human Services, March 1988).

International Classification of Impairments, Disabilities and Handicaps has been accepted by

many nations and used for clinical and health

services research, health services planning, and

population health monitoring (181,250,255). The

ICIDH framework has been criticized, but many

of the problems are likely to be resolved in the

planned revision of the classification scheme. In

view of differences in how health services are

delivered, internationally comparable data on

disability probably will come from populationbased surveys and not from administrative records. Achieving consensus on a disability classification would be a first step toward comparability

of information about disability on such surveys.

At present, both the content and methods of

surveys differ so widely that disability comparisons cannot be made.

Despite international disagreement over what

disability means, there is general agreement that

years of life without disability should be the focus

of public health efforts. An indicator that shows

great promise in monitoring health is a measure of

healthy life expectancy, which is the number of

years someone of a particular age can, on average,

expect to live without various impairments,

disabilities, or handicaps. Although the different

countries have not yet agreed on how to measure

healthy life expectancy, many of them have

included it as an indicator in their health goals,

and efforts are underway to measure and monitor

it. An international group of researchers (called

REVES) is working toward standardizing this

measure.
Health-Related

Behaviors 7

s

ome voluntary behaviors, such as smoking, drinking

alcohol, and driving recklessly contribute substantially

to the deaths and disabilities that result from chronic

diseases and injuries (200). Other behaviors—such as

using medical screening tests, getting immunizations, using

automobile seatbelts, and eating a healthy diet-can prevent

premature death and disability. Encouraging healthy lifestyles

has become a focus for public health in developed countries,

where targets are being used to monitor the success of health

education and promotion programs. 1 This chapter presents

information on health-related behaviors and selected preventive

health practices in the United States and other countries.

SMOKING AND ALCOHOL CONSUMPTION

It is difficult to accurately measure behaviors that may be

considered socially undesirable. National estimates of smoking

rates and alcohol consumption are available from surveys,2 but

these can be unreliable if heavy smokers or drinkers either don’t

participate in the surveys or underreport their smoking or

. . drinking. Large discrepancies between the amount of smoking

1 The WHO European Year 2000 target states that “there should be significant

increases in positive health behavior, such as balanced nutritiou non-smoking,

appropriate physical activity, and good stress management” and that ”.. there should be

significant decreases in health-damaging behavior, such as overuse of alcohol and

pharmaceutical products; use of illicit drugs and dangerous chemical substances; and

dangerous driving and violent sociat behavior” (256).

2 Other methods of measuring the consequences of alcohol consumption or smoking

include analyses of alcohol-or smoking-related mortality (e.g., liver cirrhosis, respiratory

cancer); admissions to general and/or psychiatric hospitals and to alcohol treatment

clinics; convictions for drunkenness or driving under the influence of alcohol; and the

number of trtilc accidents associated with alcohol use (270,271). 69
70 I International Health Statistics: What the Numbers Mean fort he United States

and “ drinking self-reported on surveys and the

amount of alcohol and cigarettes accounted for on

sales records provide indirect evidence of underreporting (270,271).

Smoking

Cigarette smokers die at twice the rates of

nonsmokers throughout middle age, and nearly

one in five deaths in developed countries can be

attributed to the effects of smoking (140). In the

United States, more than one-fourth of deaths

from cancer, nearly one-fifth of deaths from

cardiovascular disease, and one-half of deaths

from respiratory disease were attributable to

smoking in 1990 (for a total of approximately

419,000 deaths) (194,212a).

Comparable information on smoking in 12

European countries is available from a 1987-88

study, “Europeans and Cancer Prevention. ”3 In

Europe, smoking prevalence varied for males

from 40 percent (Ireland, Portugal, and the United

Kingdom) to 62 percent (Greece), and for females

from 11 percent (Portugal) to 44 percent (Denmark) (table 7-l).

A much smaller proportion of U.S. males (30

percent) than European males (45 percent)

smoked in the late 1980s, but the gap was less

significant between female smokers in the United

States (26 percent) and Europe (29 percent) (table

7-1) (28,228). The European and U.S. numbers

are not strictly comparable, because the European

definition included pipe and cigar smokers and

the U.S. definition referred only to cigarettes

(28,221). Almost all (94 percent) European smokers smoke cigarettes, however, so the comparison

is roughly accurate.4 In light of these differences,

the World Health Organization (WHO) has recommended that countries use a uniform set of

smoking questions on their surveys (44).

In Europe and the United States, in general,

more males than females smoke. But among those

aged 24 or younger, the rate for females is higher

in the United States, United Kingdom, the Netherlands, and Denmark (table 7-l).

According to comparable surveys from the

United States and Canada in 1985 and 1990,5

smoking prevalence was higher in Canada than in

the United States (30 versus 26 percent in 1990)

(table 7-2) (162). Higher rates for Canada were

most pronounced among women, especially those

aged 18 to 24 (162). In 1990, a greater proportion

of deaths in Canada (22 percent) than in the

United States (19 percent) were attributable to

smoking.6

Since the mid-1960s, smoking by males has

declined in the United States and selected European countries (table 7-3). The proportion of

females smokers has increased in some countries

where the rates used to be low (e.g., Belgium,

France) and declined in places where the rates

used to be high (e.g., United States, United

Kingdom). As a result, by the late 1980s, nearly

one-third of the women in the comparison countries smoked.

3 A standardized questionnaireeon caxer and its prewmtion was used as part of two sumeys conducted in 1987 and 1988. For each sumey,

face-to-face intemiews wereconducted within the homes of a representative sample of residents aged 15 and older within 12 countries. Smoking

data were aggregated from the two studios, which included more than 20,000 subjects in total. Survey respondents were asked to select which

of the following applied to them: “smoke cigarettes (including roll-your-own),” “smoke cigars or a pipe,” “used to smoke but you kve

stopped, ” or “you have never smoked, ’ Smokers were idcdficd as those reporting currently smoking cigarettes, cigars, or a pipe (28).

4 rfpipe ~d ciW s~kers wm raov~ ~m the European prevalence numbers, the Wp between U.S. ~d EWoPn ~es wo~d close

slightly, but the difference between U.S. and European females would likely remain the same, because most cigar and pipe smokers are males,

s In 1985 and 1990, the United Stites conducted the National Health Intaview Survey Health Promotion and Disease Prevention

Supplements, and Canada conducted Hwdth Promotion Surveys (162).

6 Estimates of mortality attributable to smoking in the United States and Canada were made by OTA using the Smoking-Attributable

Mortality, Morbidity, and Economic Costs computer program (SAMMEC 2.1) developed by the U.S. Centers for Disease Control and

Prevention’s Office on Smoking and Health (194).
Table-7-1-Smoking Prevalence by Age, Selected European Countries(1987-88)a and the United States (1988)

All Ages 15-24 25-39 40-45 55+ All Ages 15-24 25-59 40-54 55+

European Community

Belgium

Denmark

France

Germanyb

Greece

lreland

Italy

Netherlands

Portugal

Spain

United Kingdom

United States

45%

49

46

46

45

62

40

42

47

40

48

40

30

390/. 53%

4 9 5 5

3 7 53

5 5 58

3 4 61

6 2 72

3 5 41

32 49

38 51

52 60

52 62

30 48

18-24KE343&44

26 36 37

51%

56

51

46

51

69

39

4a

57

42

56

45

31

36%

41

4 4

3 2

3 9

4 5

4 0

34

49

30

34

37

65+

18

29%

30

44

31

31

27

31

27

40

11

24

30

26

3 1 % 41%

3 9 4 9

4 4 4 7

4 8 4 0

30 45

38 46

28 33

25 43

46 51

24 23

44 47

33 33

18-24544354 4

26 31 28

28%

29

48

25

33

20

32

26

39

8

11

41

28

18%

19

37

11

18

9

27

17

25

2

6

21

aFor European countries, smoking prevalence came from two surveys COnducted in 1987 and 1988 by the Commission of the European Communities (surveys ‘erg indudd ‘n 12

countries of the European Economic Community). Data from Luxemburg we not shown but are included in the total for Europe. These data refer to current smoking of cigarettes, cigars

or pipes. U.S. smoking data came from the 1988 U.S. Health Interview Survey. The data refer to current cigarette smokers (i.e., individuals who have smoked at least 100 cigarettes

and who now smoke; includes occasional smoking). bBased on data from the f

former Federal Republic of Germany.

SOURCES: Commission of the European Communities, Europeans and CancerPrevention: A Study of Attitudes and Behaviour of the Public (Brussels, Belgium: @remission of the

European Communities, June 1988); U.S. Depatment of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for

Health Statistics, Health, United States 1991 (Hyattsville, MD: U.S. Department of Health and Human Services, May 1992).
72 I International Health Statistics: What the Numbers Mean for the United States

Table 7-2--Cigarette Smoking by Adults (Age 18 and Older),a by Age, Sex, and Education,

United States and Canada, 1985 and 1990

 Current smokers (as a percent of population)

United States Canada

1985 1990 1985 1990

Total b

Men

Women

Age group

18-24

Men

Women

25-44

Men

Women

45-64

Men

Women

65+

Men

Women

Educational level

High school not completed

High school completed

College or university

30

33

28

28

30

38

32

33

30

20

14

35

34

23

26

28

23

27

23

33

27

29

25

15

11

32

30

18

35

36

33

38

41

40

37

36

30

20

18

39

39

28

30

32

29

31

31

36

34

30

26

18

14

36

34

23

aThe definition of a current smoker varied only slightly between the 1990 Canadian Health Promotion survey and the 1990 U.S. National Health

Interview Survey of Health Promotion and Disease Prevention. In the Canadian survey, a current smoker is anyone who currently smokes,

whereas in the U.S. survey, a current smoker is one who has smoked at least 100 cigarettes in hls or her Iifetime and smokes now. The effect

of this definitional difference should be minimal and would be most likely to reduce the rate for young people who have begun smoking but who

have not yet smoked 100 cigarettes.

bData for Canada includes persons 17 years of age. These persons are included in all totals Well as the age category 18 to 24 years for men

and women.

SOURCE: C.A. Schoenborn, “Health Status and Practices in Canada and the United States, 1985 and 1990,m Canada’s Health Promotlon Survey

1990: Technical Report, T. Stephens and D.F. Graham (eds.) (Ottawa, Ontario: Health and Welfare Canada, 1993).

Alcohol Consumption

At least 3 percent of all deaths in the United

States can be attributed to alcohol-related causes

(202). Excess and chronic consumption of alcohol

can lead to liver disease (e.g., cirrhosis), gastrointestinal cancers, and cardiovascular disorders.

Alcohol also contributes heavily to deaths and

disabilities related to injuries. As many as onehalf of all automobile crash fatalities are alcoholrelated. Furthermore, fetal exposure to alcohol is

a leading cause of mental retardation (202).

International comparisons of alcohol

difficult to make, because no standard

use are

criteria

have been used to assess alcohol use in populationbased surveys (270,271). The information about

alcohol consumption contained in populationbased surveys may include average occurrences

of drinking, amount of consumption, and frequency of intoxication. Drinking patterns, which

vary among the residents of different countries,

are important to distinguish, because the health

consequences of different patterns are likely to

vary. In wine-producing countries, for example,
Chapter 7–Health-Related Behaviors I 73

Table 7-3--Smoking Prevalence, United States and Selected European Countries,

Mid-1960s and Late 1980sa

Males Females

mid-1960s late 1980s mid-1960s late 1980s

United States 52%o 31% 34% 27%

Belgium 80 49 15 30

France 66 46 15 31

Germany b

70 45 16 31

Italy 50 41 27 27

Netherlands 82 47 32 40

United Kingdom 67 40 38 30

aEuropean statistics are for those 21 and older in 1963 and 1987-88. United States statistics are for those 18 snd older in 1965 and 1987.

bBased on data from the former Federal Republic of Germany.

SOURCES: Commission of the European Communities, Europeans and Cancer Prevention: A Study of Attitudes and Behavior of the Public

(Brussels, Belgium: Commission of the European Communities, March/April and June 1988); US. Department of Health and

Human Services, Public Health Service, Centers for Disease Control, National Center for Health Statistics, Health United States:

1988, DHHS Pub. No. (PHS) 88-1232 (Hyattsville, MD: U.S. Department of Health and Human Services, March 1988).

consumption tends to be regular whereas in other

countries consumption is more episodic. With

long-term moderate drinking, the risks of some

chronic diseases actually decline, but heavy binge

. . drinking is often associated with injury and

violence.

Uniform data on alcohol consumption are

available from 12 European countries.7 In these

12 countries, the prevalence of frequent8 drinking

ranges from a low of 11 percent of males and 2

percent of females in Ireland, to a high of 56

percent of males and 30 percent of females in Italy

(table 7-4). For the European Community as a

whole frequent drinkin g is reported more than

twice as often for males (38 percent) as for

females (16 percent) and infrequent alcohol

consumption is reported twice as often for females (55 percent) as for males (27 percent).

Information on alcohol consumption in the

United States is not directly comparable to the

European data because different consumption

categories are used.9 Within the United States,

“heavier” drinkin g is reported more frequently

by males (13 percent) than by females (3 percent).

Levels of alcohol abstention in the United States

are similar to levels of infrequent consumption in

Europe. In 1988, almost one-third (32 percent) of

7 The Commission on the European Communities included alcohol consum ption in a survey on cancer-related topics conducted in 12

countries in 1988. k identical questio maim was used to conduct 11,729 fac~to-face interviews among representative sample of respondents

aged 15 years or older (27a).

8 In the sunfey by the Commission on the European Communities, frequent consumption of atcohol was defiied as &inking wine or beer

daily and or spirits at least 3 or 4 days a week (28).

g The National Health Interview Survey aIcohol consumption categories are ‘‘abstaiq” which is consumption of less than .01 ounces of

alcohol per day; “light” which is commrnption of between .01 and .21 ounces of alcohol per day; “moderate,” which is consum ption of

between .22 and .99 ounces of alcohol per day; and “heavier,” which is consumption of 1.00 or more ounces of alcohol per day. One ounce

of atcohol is equal to approximately 2 average size drinks of beer, wine, or liquor (162,232).
74 I International Health Statistics: What the Numbers Mean for the United States

Table 7-4--Alcohol Consumption, Selected European Countriesa and the United States,b 

~~

1988

Infrequent Average Frequent Infrequent Average Frequent

European Community

Belgium

Denmark

France

Germanyc

Greece

Ireland

Italy

Luxemburg

Netherlands

Portugal

Spain

United Kingdom

United States

27%

33

24

24

24

27

41

25

29

31

22

30

33

Abstain

32

35%

33

56

29

50

36

48

19

40

41

21

23

47

Ligh t

30 25

36%

34

20

47

26

37

11

56

31

28

57

47

20

13

55%

52

50

51

54

64

72

51

60

59

53

56

60

53

29%

33

42

29

40

25

16

19

28

26

25

23

30

Ligh t

30 14

16%

15

8

20

6

11

2

30

12

15

22

21

10

3

aThe European Community data derived from a 1988 survey conducted by the Commission of the European Communities in 12 countries.

Infrequent alcohol consumption was d> fined as consumption of wine, beer, or spirits less often than once per week. Frequent alcohol

consumption was defined as consumption of wine or beer daily and/or spirits at Ieast 3 or 4 days per week. Average consumption was defined

as consumption falling between infrequent and frequent as defined above.

bThe U.S. data derived from the National Health interview Survey. Alcohol consumption status is defined in ounces (oz.) of absolute alcohol

(ethanol) consumed per day as follows: abstain-less than .01 oz.; light-.01 to .21 oz.; moderate-.22 to .99 oz.; and heavier-1.tl(l or more oz.

CBased on data from the former Federal Republic of Germany.

SOURCES: Commission of the European Communities, Europeans and Cancer Prevention: A Study of Attitudes and Behaviour of the Public

(Brussels, Belgium: Commission of the European Communities, June 1988); U.S. Department of Health and Human Services,

Public Health Service, Centers for Disease Control, National Center for Health Statistics, Health United States: 1988, DHHS Pub.

No. (PHS) 88-1232 (HyattsviIle, MD: U.S. Department of Health and Human Services, March 1988).

U.S. males and more than one -half (53 percent) of alcohol consumption as two or more drinks per

females were abstainers (table 7-4). day on average (162).11 In both years, a greater

Comparable data on alcohol consumption are proportion of Canadian than U.S. residents reavailable from 1985 and 1990 population-based ported drinking (in 1990, 81 versus 61 percent) .

surveys in the United States and Canada (162).10 (table 7-5). The overall prevalence of heavy

Both countries define a current drinker as some- drinkin g is similar in Canada (7 percent) and the

one who has had at least one drink of alcohol in United States (6 percent) .12

the year preceding the survey, and define heavy

10 h 1985 and lggtl, the united suites conducted the National Health Interview Survey Health PmmotiOn -DiSCSSC Revendon

Supplements, and Canada conducted Health Promotion Surveys (162),

1 I T)E ~cu~tionof ~vy &inking v ties slightly on the two surveys, with average conaum ptionbaaed on a 7-day recall period m Canada

and 14day recall period in the United States (162).

12 ~prcvd~w of heavy &inking ~Irnong drinkers in the United States and Canada WSS bme (9 p~t) in 1990, but the overall

prevalence of heavy drinking in 1990 ww slightly higher in Canada than in the United States, because the prevalence of &inking was higher

in Canada (table 7-5).
Table 7-5--Current Alcohol Consumption by Adults (Age 18 and Older), by Age, Sex, and Education, United States and Canada, 1985

and 1990

current drinkersa Cu ent d rr drinkers who drank heavily

United States Canada United States Canada

1985 1990 1985 1990 1985 1990 1985 1990

Total c

65% 61% 82% 81% 12% 9% 14% 9%

Men 76 72 87 86 17 14 23 16

Women 56 51 78 77 5 4 6 3

Age group

18-24

Men

Women

25-44

Men

Women

Men

Women

Men

Women

79

91

71

86

93

64

92

56

18

5

14

3

24

9

21

d -

79

59

16

4

13

3

23

4

15

2

e

83

63

92

86

90

83

14

4

e

72

53

68

48

80

73

84

73

18

7

15

4

23

7

1 2

e

d -

18

8

16

6

16

d -

58

34

55

31

7 3

5 2

66

58

Education leve l

High school not completed 47 4 2 7 1 7 2 1 5 1 3 1 3 1 1

High school completed6 6 6 0 8 6 8 5 1 2 1 0 1 6 1 0

College or university 7 7 7 1 9 0 8 8 11 8 1 4 8

aA current drinker is defined as a person who had at least one drink of any alcoholic beverage in the 12 months preceding the survey.

bHeavy drinking is defined as two or more drinks per day, on average, over the overall period (7-day recall in Canada; 14-day recall in the United States)”

CData for Canada includes persons 17 years of age. These persons are included in all totals as well as in the age category 18 to 24 years for both men and women.

dData suppresse d because of high sampling v~abil~.

eModerate sampling variability; read m ‘tiiM.

SOURCE: C.A. Schoenborn, “Health Status end Practices in Canada and the United States, 1985 and 1990,” Canada’s Health Promotion Survey 1990: Techncal Report, T. Stephens

and D.F, Graham (eds.) (Ottawa Ontario: Health and Welfare Canada, 1993).

—

-1

ul
76 I International Health Statistics: What the Numbers Mean for the United States

PREVENTIVE HEALTH PRACTICES

Death and disability associated with breast and

cervical cancer and hypertension can be reduced

by early detection and treatment. In the United

States women have about a 10 percent risk of

developing breast cancer and a 1 percent risk of

developing cervical cancer at some point during

their lives (164a). The use of the Pap test may

reduce the rates of mortality from uterine cervical

cancer by as much as 75 percent, however, and the

use of breast examination and mammography can

reduce mortality from breast cancer by 30 percent

for women aged 50 and (alder (200). Other

personal practices, such as use of seatbelts and

household smoke alarms can reduce the rates of

death and disability associated with automobile

crashes and household frees. For example, up to

one-half of the fatalities related to automobile

crashes in the United States could be prevented if

everyone used lap-shoulder belts (148).

Comparisons of the United States

and Canada

Information on preventive health practices in

Canada and the United States is available from

comparable population surveys conducted in

1985 and 1990 (162).13

BLOOD-PRESSURE CHECKS

In 1990, a similar proportion of the residents of

the United States (75 percent) and Canada (78

percent) had had their blood pressure checked

within the past year (table 7-6). For those aged 45

or older, who are at greater risk of heart disease,

the rates differed. Men aged 45 to 64, for example,

were more likely to have had their blood pressure

checked recently in Canada (80 percent) than in

the United States (74 percent) [162).

PAP TESTS

In 1985, Pap tests were used at similar rates in

the United States (78 percent) and Canada (76

percent). Between 1985 and 1990, the use of Pap

tests declined in Canada and increased in the

United States, so that by 1990 there was a clear

difference in usage in the United States (81

percent) and Canada (72 percent) (table 7-7).

Among women aged 65 and older, many fewer

women in Canada (44 percent) than in the United

States (63 percent) had had a Pap test within the

past 3 years (162).

BREAST SELF-EXAMINATION

In 1985, a greater proportion of women in

Canada (41 percent) than in the United States (32

percent) reported performing a monthly breast

self-examination (BSE) (table 7-7). By 1990,

however, monthly BSE rates had increased in the

United States (38 percent) and fallen in Canada

(27 percent) so that more U.S. than Canadian

women were engaged in this preventive health

practice (162).

SEATBELT USE

In 1985, regular use of seatbelts by residents of

the United States (36 percent) was less than half

that reported in Canada (79 percent) (table 7-8).

Between 1985 and 1990, regular use of seatbelts

increased in the United States from 36 to 67

percent, but such use remained substantially

higher in Canada (91 percent in 1990) (162).

OWNERSHIP OF SMOKE DETECTORS

Residents of the United States were less likely

than Canadian residents to have a home smoke

detector in 1985 (63 versus 77 percent) and 1990

(79 versus 85 percent) (table 7-8) (162).

13 blggs ti1990, ~e UniktjStIUCS conductd the National Health Interview Sumwys of Health Promotion and IXwasc RcvtWiOX4 ti

Canada conducted the Health Promotion SUIV9S (162),
Chapter 7–Health-Related Behaviors I 77

Table 7-6--Trends In Adults Having Recent Blood-Pressure Checks, by Age, Sex, and Education,

United States and Canada, 1985 and 1990

Had b ood pressu e chec I r ked in year preceding survey

es Canada

1885 1990 1985 1990

Total a

Men

Women

74%

68

79

75%

69

80

76”/’

69

83

78%

71

85

Age group

18-24

Men

Women

25-44

Men

Women

45-64

Men

Women

65+

Men

Women

62

79

62

82

51

78

57

79

63

76

64

78

68

81

67

84

73

78

74

80

77

85

80

87

89

92

82

86

84

85

86

92

Education level

High school not completed

High school completed

College or university

74

73

75

75

74

76

78

77

74

79

76

79

aData for Canada Include persons 17 years of age. These persons are included in all totals as well as the 18 to 24 age category for both men

and women.

SOURCE: C.A. Schoenborn, ‘Health Status and Practices in Canada and the United States, 1985 and 1990,” Canada’s Health promotion Survey

1980: Technical Report, T. Stephens and D.F. Graham (eds.) (Ottawa, Ontario: Health and Welfare Canada, 1993).

EXCESS BODY WEIGHT14

The proportion of men and women considered

overweight increased in both Canada and the

United States between 1985 and 1990 (figure 7-1)

(162). In 1990, similar proportions of men in the

United States (26 percent) and Canada (27

percent) were overweight, but substantially more

women were overweight in the United States (26

percent) than in Canada (18 percent) .15

REGULAR PHYSICAL ACTIVITY

Between 1985 and 1990, the proportion of

residents who engaged in regular physical activity

declined somewhat in Canada (from 53 to 47

percent) but increased slightly in the United

States (from 40 to 41 percent). Even so, relatively

fewer U.S. than Canadian residents reported

participation in regular physical activity in 1990

(table 7-9) (162). The elderly in Canada are much

14 B~~g ovemei~t cm S&ouSIy ~ecth~~ md longevity. Evidence suggests that the causes of OveWei@t Me m~~actori~ and refl~t

inherited, environmental, cultural, socioeconomic, and psychological conditions (123).

15 B@y.~s index (BMI) (weight in kilOgrSIIM dividd by the square of height in meters) is used to define overweight. The deftition Of

overweight used in the United States is somewhat more restrictive (BMI of 27.8 for men and 27.3 for women) than in Canada (BMI of 27 for

both sexes) (162).
Table 7-7-Trends in Women Having Had Pap Tests Within 3 Years of the Survey and Monthly Breast Self-Examination,b

by Age and Education, United States and Canada, 1985 and 1990

Had Pap smear within 3 years of survey Perform BSE monthly

United States United States Canada

1985 1990 1985 1990 1985 1990 1985 1990

Total c

78% 81% 76% 72% 32% 38% 41% 27%

Age group

18-24 78 80 75 66 24 28 38 16

90 90 88 83 34 39 40 26

76 78 73 72 37 42 46 36

57 63 51 44 29 36 37 28

Education level

High school not completed 68 70 68 62 29 33 38 28

High school completed 79 81 78 75 32 39 40 28

College or university 85 87 83 79 34 39 44 26

aThe Canadian Pap test question changed between 1985 and 1990, with the additionn of a screcreening question about ever having had a Pap smear and asking recently only of those who

reported ever having had one. The 1985 question simply asked respondents when they N their last Pap test, with “never being a response option. The U.S. questions did not change

between 1985 and 1990 and were more similar to the 1985 Canadian question, in that they asked when the respondent had her last Pap bet, to which she could respond with an interval

or “never.”

bThe context of the Canadin questions on BSE changed between the 1985 and 1990 surveys, The 1985 survey explained an introductory question regarding whether the woman had

ever been shown how to examine her own breasts. All women, regardless of the answer to the question, were then asked about their current BSE practices. The 1990 survey just asked

a direct question on frequency of performing BSE, without any introductory statement The question’s wording also changed from a more descriptive “know how to examine your own

breasts” in 1885 to “perform breast calf-exarnination” in 1990. The U.S. questions remained identicalin context and content between the two survey years, asking women if they knew

how to examine their own breast for Iumps and, for those who know how, *W how many times a year they did so.

cData for Canada include women 17 years of age. ~~ women are included in the total and in the age category 18 to 24 years.

SOURCE: C.A. Schoenborn, “Health Status and Pradices in Canada and the United States, 1985 and 1990," Canada’s Health Promotion Survey 1990: Technical R.T. Stephens

and D.F. Graham (eds.) (Ottawa, Ontario: Health and Welfare ~ 1993).
Table 7-8-Trends in Adults’ Regular Use of Seatbett# and Ownership of Smoke Detectors,b by Age, Sex, and Education,

United States and Canada, 1985 and 1990

Percent of m2p@tion who usual Iv wear seatbelts Percent of Population who own smoke detectors

United States ada United States a

1985 1990 1985 1990 1985 1990 1985 1990

Total c

Men

Women

Age group

18-24

Men

women

Men

Women

Men

Women

Men

Women

Education level

High school not completed

High school completed

College or university

36%

34

38

67%

62

71

79%

75

83

91%

87

95

63%0

63

63

79%

79

78

78

77

84

85

27

32

67

76

59

58

75

75

78

73

54

65

82

91

36

41

63

73

76

83

87

95

66

68

81

82

81

81

87

87

35

37

64

72

75

84

63

62

77

78

76

75

84

87

88

96

75

80

33

35

67

72

85

88

90

95

59

60

78

73

70

74

25

31

48

56

62

77

75

78

83

88

91

93

51

64

71

67

78

85

72

81

80

84

87

88

aThe Candian and U.S. questions regarding use of seatbelts remained unchanged between 1985 and 1990. There were some minor differences between the two surveys in terms of

response categories, but they should not affect results presented here.

bIn contrast to the 1985 Canadian question on smoke detection, which asked about having any smoke detectors in the home, the 1990 question asked about ‘ing ‘ke‘tdom”

The 1985 and 1990 U.S. questions asked first about ownership of any smoke detectors and subsequently about their working status. In order to be comparable * 1985 Canadian

results, previously published 1985 U.S. data presented ownership of any smoke detector, regardless of working status. The data presented in this table include 1985 and 1990 U.S. and

Canadian data on working smoke detectors only.

CData for Canada includes persons 17 years of age. These persons are included in all totals as well as the age cateegory 18 to 24 for both men and women”

SOURCE: C.A. Schoenborn, “Health Status and Practices in Canada and the United States, 1985 and 1990,” Canada’s Health Promotion Survey 1990: Techncal Rqxwf, T. Stephens

and D.F. Graham (ads.) (Ottawa, Ontario: Health and Welfare Canada 1993).

—

-J

co
80 I International Health Statistics: What the Numbers Mean for the United States

Canada

United States

Canada

United States

Figure 7-l—Trends in Overweight Proportion of Adult Population (Age 18 and Older),

Canada and United States, 1985 and 1990

I

I

o 5 10 15 20 25 30

Percent

SOURCE: C.A. Schoenborn, “Health Status and Practices in Canada and the United States, 1985 and 1990,” Canada’s Health Promotion Survey

1990: Technical Report T. Stephens and D.F. Graham (eds.) (Ottawa, Ontario: Health and Welfare Canada, 1993).

more likely to be engaged in physical activity

than their contemporaries in the United States

(162).

Comparisons Between Europe and

the United States

PAP TESTS

Women’s use of Pap tests appears to be much

higher in the United States than in Europe. In

1987, 88 percent of U.S. women reported ever

having had a Pap test and 75 percent reported

having had one within the preceding 3 years

(200). 16 By contrast, only 48 percent of women

surveyed in 12 European countries had ever had

a Pap test (table 7- 10).17 The lowest European use

was in Portugal (6 percent) and Greece (30

percent), and the highest was in France (70

percent) and the United Kingdom (67 percent).

Pap tests appear to be done less frequently in

Europe than is recommended. In France and the

United Kingdom, for example, where the proportion of women using the testis relatively high, a

significant proportion of them have the test

lb TIM U.S. Wk Fome on preventive Services reccxnmends regular Pap testing fOr all women starting at the onset of Sex@ activity, Witi

repeat tests every 1 to 3 years, at the physician’s discretion. Pap tests may be discontinued at age 65, if previous test results have been

cxmsistent.lynormal (238). Recommendationevary aomewhat in Europe, In Great Brita.@ for example, Pap tests are recommendd evuy 3 years

for all women beginning at age 20 and for younger women if sexually active. In Denmar& women up to the age of 70 are invited to be scree@

but those between the ages of 23 and 59 are targeted, and Pap tests every 3 years am recommended (192).

IT Wmen’s use of ~t=ts ~d mammography was assessed in 1988, A standardized questionnaire related to cancer and its prevention was

used as part of the survey. A total of 11,729 face-to-face interviews were conducted in the homes of a representative sample of residents aged

15 and oldex in 11 countries (27a).

1s ~ -e, 55 ~nt of women reported having Pap tests performed every year or every 2 to 3 Y-.III M Ulkd xdo~IX@ 32

percent of womea reported having the test repeated within 3 yews (table 7-10).
Chapter 7–Health-Related Behaviors I 81

Table 7-9--Trends in Adult Participation in Regular Physical Activity, by Age, Sex, and Education,

United States and Canada, 1985 and 1990

Regularly active I

a

United States Canada

1985 1990 1985 1990

Totalb

Men

Women

400/0

43

38

41%

44

38

53%

55

52

47%

49

46

Age group

18-24

Men

Women

25-44

Men

Women

45-64

Men

Women

65+

Men

Women

62

47

61

45

64

60

70

54

46

42

46

41

55

51

44

42

30

32

36

35

46

51

41

48

32

28

37

29

59

47

55

43

Education level

High school not completed

High school completed

College or university

24

38

53

26

37

52

45

55

59

44

49

49

aCanada: reported vigorous physical activity of at least 15 minutes’ duration three or more times weekly; United States: answered “yes” to “Do

you exercise or play sports regularly?"

bData for Canada includes persons 17 years of age. These persons are Included in all totals as well as the age categories 18 to 24 years for both

men and women.

SOURCE: C.A. Schoenborn, “Health Status and Practices In Canada and the United States, 1985 and 1990,” Canada’s Health Promotion Survey

1990: Technical Report, T. Stephens and D.G. Graham (eds.) (Ottowa, Ontario: Health and Welfare Canada, 1993).

performed less often than once every 3 years

(table 7-10).18

raries surveyed in 1988 had ever had a mammogram (table 7-11). Higher rates of ever having had

a mammogram were reported in Germany (35

percent), and lower rates were reported in the

United Kingdom (9 percent) and Ireland (6

percent).

MAMMOGRAPHY

Women aged 50 and older are somewhat more

likely to get mammograms in the United States

than in Europe. One-quarter of U.S. women in

that age group reported in 1987 that they had had

mammograms within the preceding 2 years (200),19

whereas 17 percent of their European contempoCHILDHOOD VACCINATION

Vaccinating children for diphtheria, pertussis,

and tetanus (DPT), as well as measles and polio,

19 me r~mm~ded age of onset and frequency ofmammography is in dispute within the United States and internationally (165), but within

the United States there is somewhat of a consensus concerning women aged 50 and older For those womew the Arnetican Cancer Institute

and the U.S. National Cancer Institute recommend annual mammograms; the U.S. Preventive Task Force recommends mammography every

1 to 2 years concluding at appro ximately the age of 75, urdess pathology has been detected (200,238). Mammography is recommended eve~

3 years for women aged 50 to 64 in the United Kingdom (165).
Table 7-10-Awareness, Use, and Frequency of Women’s Cervical Smear Test in Selected European Countries, 1988

Know Have shady Every Every 2 or 3 Every 4 or 5 Less

about it had one year years years Never

European Community 17% 12% 5% 14% 52%

country

Belgium

Denmark

Germanya

Greece

Frame

Ireland

Italy

Luxemburg

Netherlands

Portugal

United Kingdom

75

92

89

82

89

90

81

87

89

40

37

93

43

62

47

30

70

45

40

63

55

6

12

67

22

21

29

10

40

2

16

47

8

2

6

5

10

15

10

7

15

16

8

8

20

1

1

27

2

4

4

3

4

10

3

2

8

0

1

15

9

22

4

10

11

17

13

6

19

2

4

20

57

38

53

70

30

55

60

37

45

94

88

33

Age

15-24 72 25 13 6 1 5 75

87 63 30 18 6 9 37

40-54 83 59 20 18 9 12 41

55 and over 77 41 10 6 5 17 59

aBased on data from the former Federal Republic of Germany.

SOURCE: Commission of European Communities, Europeans and cancer prevention: A Study of the Attitudes and Behaviours of the Public (Brussels, Belgium: Commission of European

Communities, June 1988).
Chapter 7–Health-Related Behaviors I 83

Table 7-1 l--Mammography Use by Women Aged 50 and Older in Selected European Countries, 19888

Number of women Every

used as basis Every 2 or 3 Less Never

for percentages year years often had one

European Community

Belgium

Denmark

Germanyb

Greece

France

Ireland

Italy

Luxemburg

Netherlands

Portugal

Spain

United Kingdom

2,215

179

167

175

201

156

165

186

43

136

216

266

3%

6

3

7

NA

5

NA

(;

1

NA

2

NA

3%

4

2

10

1

1

2

(;

1

2

2

11?40

11

17

18

8

22

5

(23)

15

8

6

7

83%

79

78

65

91

72

94

(61)

83

91

90

91

KEY: NA = not available

aThe results for each country must be interpreted cautiously, because the number of women aged 50 and older in the sample Is relatively small.

bBased on data from the former Federal Republic of Germany.

SOURCE: Commission of European Communities, Europeans and Cancer Prevention: A Study of Attitudes and Bahaviours of the Public

(Brussels, Belgium: Commission of European Communities, June 1988).

is widely recognized as a simple, effective, and

inexpensive way to safeguard their health (247).

Immunization rates for these conditions among

preschool-age children are substantially higher in

most European countries than in the United States

(table 7-12).20 European immunization rates for

DPT, for example, are much higher than U.S.

rates (97 percent in France and the Netherlands

versus 65 percent in the United States).

Making international comparisons of the prevalence of infectious diseases is difficult, because

of marked differences in reporting practices

(248). Available evidence indicates that the

United States does not have greater rates of

infectious disease or the deaths attributed to them

than do selected European countries (table 7-13),

which is not surprising because U.S. immunization levels are sufficient to prevent many large

outbreaks of disease. But even a relatively small

number of outbreaks can result in many cases. For

example, a U.S. resurgence of measles during

1989-90 resulted from seven large outbreaks

among unvaccinated, preschool children in urban

areas (4). Insofar as a country’s level of childhood

immunization is an indicator of overall participation in well-child care, the United States appears

to lag behind most of Europe. Many other

developed countries provide universal insurance

coverage and actively promote preventive health

care for children (191).

SUMMARY

Smoking cigarettes and drinking heavily are

known to have both immediate and long-term

adverse effects on health. As many as 20 percent

of the deaths in developed countries can be

attributed to smoking alone. Available evidence

suggests that relatively fewer U.S. residents are

smoking than are residents of either Canada or

20 us.**tion rates are available for 1 to 4 year olds. In Europe, rates are presented for children underage 3 (table 7-12). By school

age, U.S. rates improve, beeause State laws mandate imrnunization of school children (247).
84 I International Health Statistics: What the Numbers Mean for the United States

Table 7-12--Completed Immunization Rates for Preschool Children, the United States and Selected

European Countries,

Most Recent Available Year

Country Year D T P

a,b Measlesc Polioa,d

United States

White

Ail other

Belglume

Denmark

England and Wales

Francee

Germanyh

Netherlands

Norway

Spain

Switzerland

(Different cantons)

1985

1987

1987

1987

1986

1987

1987

1987

1986

1986

64.9%

68.7

48.7

95.0

94.0f

87.Og

97.0

95.0

96.9

80.0

88.0

90-98

60.8%

63.6

48.8

90.0

82.0

76.0

55.0

50.0

92.8

87.0

83.0

60-70

553%

58.9

40.1

99.0

100.0

87.0

97,0

95.0

96.9

80.0

80.0

95-98

KEY: DTP= Diphtheria, tetanus, pertussis.

aThree doses or more.

bU.S. rates for children 1 to 4 years of age; European figures are for children under 3.

CU.S. rates are for children 1 to 4 years of age; European figures are for children under 2.

dU.S. rates are for children 1 to 4 years of age; European figures are for children 1 to 3 years of age.

‘Estimated.

fRate is for combined diphtheria, tetanus, and polio immunizations. Pertussis (coverage--89.0%) and oral polio vaccines are given at separate

visits; sequential immunization against polio by both injectable and oral vaccines is recommended.

gRate is for diphtheria and tetanus; rate for pertussis immunization is 73 percent.

hBased on data from the former Federal Republic of Germany.

SOURCE: B.C. Williams and CA. Miller, Preventive Health Care for Young Children: Findings From a 10-Country Study and Directions for

United States Policy(Arlington, VA: National Center for Clinical Infant Programs, 1991).

selected Western European countries. In the midto late-1980s, the proportion of men smoking was

30 percent in the United States and 36 percent in

Canada, and ranged from 40 to 62 percent in

Europe. Current smoking-related deaths can be

traced to smoking patterns that existed a decade

or more ago. In the mid-1960s, males were less

likely and females were more likely to smoke in

the United States than in Western European.

Relatively more Canadian than U.S. residents

drink alcohol, but the prevalence of heavy drinking is similar in Canada and the United States.

People appear to abstain from alcohol or to drink

infrequently at about the same rates in the United

States and Europe.

Certain preventive health services (i.e., mammography, Pap test) tend to be used more in the

United States than in Europe, and U.S. women are

more likely than Canadian women to participate

in cervical cancer screening and engage in monthly

breast self-examination. U.S. residents are less

likely than Canadians, however, to have their

blood pressure checked, to use seatbelts regularly,

and to have smoke detectors for their homes. U.S.

residents are more likely than Canadians to be

overweight and less likely to engage in regular

exercise, especially if they are elderly.

Childhood immunization is substantially more

widespread in Europe than in the United States,

which may reflect higher use of well-child care

associated with universal health insurance coverage and the promotion of preventive health

services for children.
Table 7-13--Reported Pertussis and Measles Morbidity, United States and Selected European Countries, 1980-86

Total deaths per

million population

Country 1980 1981 1982 1983 1984 1985 1988 1980-86a

United States

Denmark

England and Wales

France

Ireland

Netherlands

Norway

Spain

Switzerland

0.76

9.70

4.66

0.02

1.61

0.02

4.90

NA

0.02

0.54

8.52

4.33

0.01

2.90

0.04

4.92

NA

0.01

United States 5.96 1.36

Denmark 55.14 69.61

England and Wales 30.05 12.46

France 0.23 0.21

Ireland 3.25 3.12

Netherlands 0.13 0.05

Norway 3.24 11.19

Spain 38.71 38.86

Pertussis cases reported per 100,000 population

0.82 1.05 0.96

2.60

14.30

0.03

3.08

0.06

5.13

14.08

0.00

3.68

4,35

0.02

4.93

0.13

6.53

9.26

0.02

6.59

1.29

0.01

8.67

0.37

3.32

9.37

0.08

Measles cases reported per 100,000 population

0.74 0.64 1.10

30.59 65.00 41.45

21.30 23.15 13.59

0.15 0.16 0.18

5.45 17.62 16.22

0.07 0.31 0.08

26.67 14.97 42.21

4203 7.90 10.15

1.50

3.58

4.88

NA

10.42

1.05

2.95

15.73

0.10

1.18

25.79

20.99

NA

27.97

0.02

3.16

20.95

1.74

2.22

7.98

NA

NA

1.48

1.89

14.50

0.15

2.61

45.87

18.02

NA

NA

0.06

2.93

57.16C

0.18

0.59

0.76

0.49

2.86

0.07

0.00

0 . 3

b

0.16

0.11

n

1.76

2,03

KEY: NA = not available. g

aThe total number of reported deaths from 1980-88 divided by the mean annual population during this interval. E

b

1980-85 totals. z

Q

m

c1985 population ~ss d9n0minat0r.

SOURCE: B.C. Williams and C.A. Miller, Preventive Health Care for Young Children: Findings From a 10-country Study and Diredctions for United States Policy (Arlington, VA: National (D

Center for Clinical Infant Programsp 1991).

3

m

<
Appendix A:

Acknowledgments

OTA wishes to express appreciation to those who provided advice and information for this background

paper, International Health Statistics: What the Numbers Mean for the United States. These individuals and

organizations do not necessarily approve, disapprove, or endorse this report. OTA assumes full responsibility

for the report and the accuracy of its content.

Jan Barendregt

Erasmus University

Rotterdam, The Netherlands

Linda Bilheimer

Congressional Budget Office

U.S. Congress

Washington, DC

Margaret R. Bone

Social Survey Division

Office of Population Censuses and

Surveys

London, England

J.T.P. Bonte

Department of Health Statistics

Netherlands Central Bureau of

Statistics

Voorburg, The Netherlands

Hendriek C. Boshuizen

Netherlands Institute of Preventive

Health

Leiden, The Netherlands

Laurent Chambaud

National School of Public Health

Rennes, France

John Coombs

Statistics Canada

Ottawa, Ontario

Canada

Peter Davis

Department of Community Health

School of Medicine

The University of Auckland

Auckland, New Zealand

Elaine D. Eaker

Epidemiology Program Office

Centers for Disease Control and

Prevention

U.S. Department of Health and

Human Services

Atlanta, GA

Mark Eberhardt

National Center for Health

Statistics

Centers for Disease Control and

Prevention

U.S. Department of Health and

Human Services

Hyattsville, MD

Pennifer Erickson

National Center for Health

Statistics

Centers for Disease Control and

Prevention

U.S. Department of Health and

Human Services

Hyattsville, MD

Rosa Gispert

Institute of Health Studies

Barcelona, Spain

07
88 I International Health Statistics: What the Numbers Mean for the United States

Robert Hartford

National Center for Health

Statistics

Centers for Disease Control and

Prevention

U.S. Department of Health and

Human Services

Hyattsville, MD

Gerry Hendershot

National Center for Health

Statistics

Centers for Disease Control and

Prevention

U.S. Department of Health and

Human Services

Hyattsville, MD

Robert A. Israel

National Center for Health

Statistics

Centers for Disease Control and

Prevention

U.S. Department of Health and

Human Services

Hyattsville, MD

Vasantha Kandiah

Population Division

United Nations

New York, NY

Yoko Kanegae

Ministry of Health and Welfare

Tokyo, Japan

Kerry Kemp

Office of Technology Assessment

U.S. Congress

Washington, DC

Mansoor Khawaja

Population and Demography

Division

New Zealand Department of

Statistics

Christchurch, New Zealand

Kevin Kinsella

Center for International Research

Bureau of the Census

U.S. Department of Commerce

Suitland, MD

Jean Kozak

National Center for Health

Statistics

Centers for Disease Control and

Prevention

U.S. Department of Health and

Human Services

Hyattsville, MD

Julie Livingston

Office of Technology Assessment

U.S. Congress

Washington, DC

Alan D. Lopez

World Health Organization

Geneva, Switzerland

Iwao M. Moriyama

International Institute for Vital

Registration and Statistics

Bethesda, MD

Arun Nanda

Regional Office for Europe

World Health Organization

Copenhagen, Denmark

Janet O’Keefe

American Psychological Association

Washington, DC

Mary Patton

Health Section

Australian Bureau of Statistics

Belconnen, Australia

Constance Percy

National Cancer Institute

National Institutes of Health

U.S. Department of Health and

Human Services

Bethesda, MD

Eric Peterson

General Accounting Office

U.S. Congress

Washington, DC

Jose Q. Quevedo

National Institute of Statistics

Madrid, Spain

Richard G. Rogers

Population Program

Institute of Behavioral Science

University of Colorado

Boulder, Colorado

Jean-Marie Robine

INSERM

Montpelier, France

Harry M. Rosenberg

National Center for Health

statistics

Centers for Disease Control and

Prevention

U.S. Department of Health and

Human Services

Hyattsville, MD

Charlotte A. Schoenborn

National Center for Health

Statistics

Centers for Disease Control and

Prevention

U.S. Department of Health and

Human Services

Hyattsville, MD
Appendix A–Acknowledgments I 89

Tere Scotney

Health Information Services

New Zealand Ministry of Health

Wellington, New Zealand

Ken Shoendorf

National Center for Health

Statistics

Centers for Disease Control and

Prevention

U.S. Department of Health and

Human Services

Hyattsville, MD

Barbara Starfield

Department of Health Policy and

Management

School of Hygiene and Public

Health

Johns Hopkins University

Baltimore, MD

Thomas Stephens

Manotick, Ontario

Canada

Michel Thuriaux

World Health Organization

Geneva, Switzerland

Joan F. Van Nostrand

National Center for Health

Statistics

Centers for Disease Control and

Prevention

U.S. Department of Health and

Human Services

Hyattsville, MD

Judith Wagner

Office of Technology Assessment

U.S. Congress

Washington, DC

Russell Wilkins

Occupational & Environmental

Health Research

Canadian Centre for Health

Information

Statistics Canada

Ottawa, Ontario

Canada

Ron Wilson

National Center for Health

Statistics

Centers for Disease Control and

Prevention

U.S. Department of Health and

Human Services

Hyattsville, MD
Appendix B:

International

Comparability of

Cause-of-Death Data

nternational differences in medical training and

practices and in death certification procedures

are among the factors that affect the comparability of cause-specific mortality data. Withincountry studies indicate that from 12 to 29 percent of

death certificates do not correctly report the autopsyconfirmed underlying cause of death (97). International differences in the accuracy of death certificates

are likely because of differences in the use of

diagnostic tests,l the proportion of physicians who are

specialists, autopsy rates,2 and hospital use for terminally ill patients (table B-l). More diagnostic information, for example, is probably available for certifying

deaths that occur in medical facilities than for those

occurring at home or elsewhere. The proportion of

deaths occurring in hospitals or other medical facilities

varies substantially by country from a low of 30

percent in Spain to a high of 79 percent in Sweden. in

the United States, 60 percent of deaths occur in

medical facilities (264).3

Aspects of the health care delivery system could also

affect mortality reporting. Countries with national

health insurance systems, for example, are more likely

to have uniform medical records, which may enhance

physicians access to cause-of-death information. Greater

use of general practitioners and better continuity of

care within such systems may also increase the

likelihood of physicians’ being familiar with decedents’ medical histories.

There are documented international differences in

how physicians complete death certificates and how

countries code cause-of-death information (93,94,136).4

Predictably, the greatest differences are observed at the

level of specific diseases (e.g., site-specific cancers),

but international differences in reporting and coding

appear to exist even for broad categories of illness

(e.g., malignant neoplasms, cardiovascular system

diseases) (136). The Office of Technology Assessment

(OTA) adjusted U.S. and French male age-adjusted

I Technology use trends have recently been linked to mortality trends. Secular increases in rates of death from breast and brain cancer

probably stem from the increased use of noninvasive screening and diagnostic tests, especially among the elderly (47,1 18).

2 The proportion of deaths for which an autopsy is performed varies significantly fium a low of 4 percent in Japan to a high of 37 percent

in Sweden (table B-1) (264). In the United States, 12 percent of deaths sre autopsied. In U.S. teaching hospitals, between 20 and 30 percent

of deaths are autopsied (168).

3 Medical facilities do not include nursing homes.

4 One type of coding problem is the extent to which imprecise codes are used to identify the underlying cause of death on the death certifkate.

In 1988-89, the proportion of deaths with the underlying cause of death “signs, symptoms, and other ill-defined conditions” (ICD-9 codes

780-799) such as “senility without mention of psychosis’ (lCD-9 code 797) ranged from less than 1 percent of deaths in the United Kingdonq

to more than 6 percent of deaths in France (table B-1). In France and the Netherlands, as many as 8 percent of deaths in the age group 15 to

44 are assigned underlying caus~of-death codes representing ‘‘signs, symptoms, and other illdei”med conditions. ” Before malting

international comparisons, some analysts adjust mortality data by apportioning deaths attributed to nonspec~lc causes to other causes according

to age- and cause-specflc mortality patterns (1 12),

90
Appendix B–International Comparability of Cause-of-Death Data I 91

cancer mortality rates for international coding differences, to illustrate the extent to which they could affect

published cause-specific mortality rates.5 The published French male 1988 age-adjusted cancer rate is 22

percent higher than the U.S. rate (262.5 vs. 215.5 per

100,000), but when further adjusted for various coding

differences, the French rate could be from 11 to 26

percent higher than the U.S. rate.

It should not be surprising that there are international differences in how causes of death are recorded

on death certificates. The underlying cause of death

recorded on each death certificate is used for comparison, but identifying a single underlying cause of death

has become more difficult as an increasing proportion

of deaths occurs among the elderly, who are likely to

have more than one chronic illness contributing to

death.6 Even for younger decedents, deaths increasingly result from chronic diseases that often cannot be

well characterized by single causes (86).7

International comparability of data on causespecific mortality will likely improve as countries

adopt automated cause-of-death coding systems. Furthermore, physicians’ training regarding appropriate

methods for completing death certificates will improve

the quality of the data (170,229).

S OTA ~justed tie rates for difftiences in how physicians assign the underlying causes of death on death certificates nd for the tuw of

nonspecific cause-of-death codes (136).

s In most developed countries at least one-third of deaths occur among those aged 80 and older, and appro ximately 60 to 70 percent of deaths

are attributed to three chronic diseases: heart disease, cancer, and stroke.

T Some advocate analyzing all of the causes listed as contributing to death to better understand the contribution to death of conditions like

diabetes, which is rarely reported as the underlying cause of death on death certMcates (122). Such multipl~cause-of-death analyses provide

information on the prevalence of disease at death but are limited because of differences in the extent to which physicians list causes other than

the underlying cause of death on the certificate. There are probably international differences in the extent to which physicians list more than

one cause on the certificate, in part, because of differences in the format of death cea-titicates.
Table B-l-Background Information on Mortality Statistics, Circa 1989a

% deaths

% deaths among elderly

% deaths Followup attributed to (age 85 and

occurring in a inquiries ‘signs, over)

% hospital or % deaths in case symptoms attributed to

deaths other medical for which an of doubt and other illmedic- establish-

“senility

autopsy was about the Death Remarks on defined .

ally ment cause recorded Coding coverage of

country

mention of

certified Age % of death by dateo f: procedure mortality Age % psychosis”

WHO Region of the Amerlcas

United 100 60 0

states 1-14

15-44

65+

All ages

Canada 100 73b

France 100 50

o

1-4

5-14

15-44

65+

All Ages

46

45

15

16

5

12

62

55

49

56

29

13

20

No information

8

Yes, for Occurrence Coded by

about 10% of National center

deaths. for Health

Statistics or

under its

guidance.

Yes

Yes

Since, 1970,

only except

fordeaths)a

tabulated by

place or

occurrence.

All deaths

occurring in

counry;

dying abroad

Occurrence Descendmas

under guidance dyhgiilmd

Of Federal included;

. Statistical Office. Berm (west)

1-4 4 <1%

5-14 2

15-44 3

45-6 4

6 5 +

1-4 5 <1

5-14 3

15-44 3

45-6 4

6 5 +

1-4

5-14

15-44

1-4

5-14

1544

9

4

8

4

4

7

3

5

3

1

2

s

(B

Q’
Table B-l-Background Information on Mortality Statistics, Circa 1989a (Continued)

% deaths

% deaths among elderly

% deaths Followup attributed to (age 65 and

occurring in a inquiries “signs, over)

% hospital or % deaths in case symptoms attributed to

deaths other medical for which an of doubt and other ill- “senility

medic- establish- autopsy was about the Death Remarks on defined without

ally ment performed cause recorded Coding coverage of . . conditions mention of

country Ceftified Age % of death by date of: procedure mortality Age % psychosis”

Italy 100 37 No information Yes

Netherlands 100 44

100 30

100 79

United 100 57

Kingdom

and Wales

o 48 Yes

1-14 18

15-44 14

45-64 11

65+ 7

All ages 8

No Information Yes, in some

regions

o

1-14

15-44

All ages

0-14

15-44

65+

All ages

74 Yes, dXllA3%

66 Ofti

76

56

36

37

56 Yes, 2-3% of

62deat h

36

22

26

Occurrence CmtraHymded.

Occurrence Centraycoded.

1-4

5-14

15-44

1-4

5-14

15-44

1-4

5-14

15-44

1-4

5-14

15-44

65+

1-4

5-14

15-44

4 2

2

3

1

1

12

9

8

4

2

3

1

2

1

1

6

1

2

1

0

3

<1

<1

<1

<1

2

-.%

0
Table B1-Background Information on Mortality Statistics, Circa 1989a (Continued)

% deaths

% deaths Followup attributed to

occurring in a inquiries

% hospital or

“signs,

% deaths in case symptoms

deaths other medical for which an of doubt and other illmedic- establish- autopsy was about the Death Remarks on defined

ally ment performed =~ recorded Coding coverage of . .

country certified

conditions”

Age % of death by date of prooedure mortality Age %

% deaths

among elderly

(age 65 and

over)

attributed to

“senility

mention of

psychosis”

WHO Western Pacific Region

100 75d

o

1-14

15-44

All agese

Japan 100 67

New Zealand 100 63

0

1-14

15-44

Allages

o

1-14

15-44

65+

All ages

43 Yes, 9%0 of

68deah

70 certifiedd

29 queried h 1s.

12

21

19 No

12

8

7

3

4

74 Yes

71

71

35

18

26

Occurrance Demnhbd

with quality

control though

a system of

sample

checking at

state and

national levels.

Occurrence CerTmuy

coded.

A n *

occurring in

dying abroad

excluded .

1-4

5-14

15-44

65+

1-4

5-14

15-44

65+

1-4

5-14

15-44

3 <1

1

1

<1

<1

3

1

1

<1

1

5

3 <1

0

<1

<1

<1

aSatistics reflect situation around 1989.

bExcluding Quebec.

cBased on data from the former Federal Republic of Germany.

‘Based on data for New South Wales.

ebased on for WWWII AustraIia

SOURCES: World Health Organization, World Health Statistics Annual (Geneva, Switzerland: World Health Organization, 1969,1990,1991, and 1992); M. Chief, Demographer,

New Zealand Department of Statistics , Christchurch, New Zealand, personal communication, August 6, 1993.
Appendix C:

International

Mortality

Comparisons by Age:

Tables and Figures

95
96 I International Health Statistics: What the Numbers Mean for the United States

Table C-l-Trends In Age-Specific Death Rates (per 100,000), Males,

United States and Selected Countries, 1955-59 to 1980-84

country 1955-59 1960-64 1965-69 1970-74 1975-79 1980-84

Age 15-24

United States

Australia

Canada

France

Germanya

Italy

Netherlands

New Zealand

Norway

Spain

Sweden

United Kingdom

Age 25-34

United States

Australia

Canada

France

Germanya

Italy

Japan

Netherlands

New Zealand

Norway

Spain

Sweden

United Kingdom

161.1

159.4

144.1

123.3

161.9

127.2

186.9

85.7

152.1

113.7

129.9

107.1

98.9

180.9

171,6

170.0

204.6

187.4

169.4

262.6

106.7

165.1

136.9

201.7

132.5

122.6

150.2

140.2

139.6

115.8

154.6

127.2

145.1

87.0

128.3

106.6

105.2

100.8

100.0

189.5

159.2

156.8

186.8

171.8

159.2

211.3

106.5

145.4

131.1

167.7

120.6

113.0

174.7

151.6

151.3

131.2

144.8

110.6

116.0

97.0

146.6

101.6

106.0

100.0

97.8

207.4

154.2

158.1

177.3

162.5

132.6

170.7

104.2

152.4

126.1

157.6

128.6

104.8

186.6

167.0

172.8

148.1

157.9

108.4

113.7

104.7

159.9

111.1

102.0

103.2

96.4

211.4

143.3

155.6

163.9

166.2

119.3

140.7

96.9

141.1

119,1

143.0

123.5

102.0

169.7

159.6

165.3

147.0

146.1

98.2

88.7

89.8

168.4

104.3

99.0

97.8

93.9

190.6

135.2

150.8

153.7

149.8

105.7

106.8

86.8

137.8

106.4

128.0

126.8

99.1

151.7

135.6

135.5

140.3

119,6

99.3

77.4

74.0

152.1

107.1

92.4

78.7

83.4

183.0

128.8

134.3

161.4

129.3

103.5

84.8

85.1

139.2

104.7

118.5

116.3

93.2
Appendix C--international Mortality Comparisons by Age: Tables and Figures\ 97

Table C-l-Trends in Age-Specific Death Rates (per 100,000), Males,

United States and Selected Countries, 1955-59 to 1980-84 (Continued)

Country 1955-59 1960-64 1965-69 1970-74 1975-79 1980-84

Age 35-44

United States

Australia

Canad a

Franc e

German y

a

Italy

Japan

Netherlands

New Zealand

Norway

Spain

Sweden

United Kingdom

Age 45-54

United States

Australia

Canad a

Franc e

German y

a

Italy

Japan

Netherlands

New Zealand

Norway

Spain

Sweden

United Kingdom

373.9

291.4

288.4

364.9

297.9

292.8

386.0

194.3

256.4

217.3

325.7

216.4

254,9

975.1

782.9

763.1

922.1

764.1

740.9

876.6

545.3

684.4

534.7

755.0

527.4

762.9

374.4

296.7

282.9

347.3

284.4

285.7

325.7

197.4

261.6

233.2

287.0

210.2

250.0

973.2

801.1

749.6

865.0

768.7

740.3

772.7

573.8

731.9

547.4

676.0

514.2

752.6

397.6

310.0

284.4

354.4

293.4

282.6

298.0

208.9

277.6

239.3

285.7

229.6

244.3

971.9

820.7

751.0

832.3

748.8

719.2

678.3

599.4

759.7

587.0

634.5

533.1

732,1

384.5

286.2

289.6

346.5

304.2

257.4

283.6

202.9

275.9

236.6

266.2

234.3

233.4

926.1

796.3

736.9

797.6

720.9

687.5

578.2

598.1

734.3

605.1

632.4

560.1

737.1

321.2

247.3

263.0

317.9

290.4

231,9

230.5

180.1

250.4

208.9

246.7

235.4

213.5

819.6

713.5

705.8

821.7

724.6

698.9

529.1

568.2

728.1

599.6

610.4

574.5

708.7

280.9

196.2

213.5

278.6

269.3

205.7

191.6

163.6

211.6

185.8

217.0

202.0

184.5

721.7

593.0

592.0

768.7

676.4

624.8

517.2

510.7

609.2

565.1

558.5

521.4

609.6
98 I International Health Statistics: What the Numbers Mean for the United States

Table C-l-Trends in Age-Specific Death Rates (per 100,000), Males,

United States and Selected Countries, 1955-59 to 1080-84 (Continued)

Country 1955-59 1960-64 1965-69 1970-74 1975-79 1980-84

Age 55-64

United States

Australia

Canada

France

Germanya

Italy

Japan

Netherlands

New Zealand

Norway

Spain

Sweden

United Kingdom

Age 65-74

United States

Australia

Canada

France

Germanya

Italy

Japan

Netherlands

New Zealand

Norway

Spain

Sweden

United Kingdom

2283.2

2127.4

1955.3

2141.2

2011.8

1865.8

2165.7

1481.0

1891.1

1408.8

1809.0

14332

2231.3

4811.6

50822

4425.8

4827.9

4898.2

4342.8

5465.9

3635.7

4792.6

3436.2

4570.8

3764.7

5$472

2285.7

2135.8

1927.1

2114.0

2105.1

1926.3

2017.0

1598.8

1928.6

1514.6

1705.6

1441.6

2220.4

4954.5

5168.7

4380.7

4675.9

5013.8

4464.1

5122.2

3802.8

4787.6

3716.3

4355.2

3830.2

5454.4

2324.5

2176.9

1899.3

2078.3

2128.9

1915.8

1811.1

1694.6

2048.6

1547.9

1685.2

1407.9

2158.0

5080.9

5314.3

4358.9

4724.7

5267.2

4751.6

4731.3

4117.2

4897.5

3863.5

4169.8

3832.7

5386.9

2216.4

2133.5

1853.9

1861.5

2066.2

1824.6

1560.2

1721.7

2033.8

1556.2

1634.2

1416.4

2087.7

4765.5

5158.4

4257.9

4405.9

5237.8

4522.0

4247.3

4262.7

4601.3

4002.7

4202.8

3772.7

5263.5

1921.6

1827.8

1760.7

1743.3

1854.8

1770.5

1287.3

1610.5

1804.6

1520.0

1522.7

1427.4

1954.6

4234.9

4435.7

4027.2

4068.2

4936.0

4155.1

3542.1

4245.9

4633.7

3821.9

3931.0

3757.9

5013.4

1750.1

1569.1

1550.5

1623.4

1655.9

1643.7

1110.9

1489.1

1714.1

1488.0

1362.2

1367.6

1788.0

3953.1

3972.7

3735.9

3788.6

4572.6

4000.7

3093.7

4023.7

4297.4

3764.3

3384.3

3564.4

4636.2

aBased on data from the former Federal Republic of Germany.

SOURCE: World Health Organization, World Health Statistics Annual (Geneva Switzerland: World Health Organization, 1988).
Appendix C-International Mortality Comparisons by Age: Tables and Figures I 99

Table C-2--Trends in Age-Specific Death Rates (per 100,000), Females,

United States and Selected Countries, 1955-59 to 1980-84

Country 1955-59 1960-64 1965-69 1970-74 1975-79 1980-84

Age 15-24

United States

Australia

Canada

France

Germanya

Italy

Japan

Netherlands

New Zealand

Norway

Spain

Sweden

United Kingdom

Age 25-34

United States

Australia

Canada

France

Germanya

Italy

Japan

Netherlands

New Zealand

Norway

Spain

Sweden

United Kingdom

Age 35-44

United States

Australia

Canada

France

Germany a

Italy

Japan

Netherlands

New Zealand

Norway

Spain

Sweden

United Kingdom

65.1

56.5

56.8

59.3

61.9

67.0

132.5

41.3

61.2

38.4

85.0

46.0

46.8

108.6

89.5

92.1

108.6

112.5

111.5

211.6

71.2

91.8

68.7

148.4

73.4

88.0

232.0

199.1

186.5

217.1

211.4

204.1

308.1

155.5

200.7

142.1

242.5

161.7

192.2

61.0

55.3

54.4

54.6

56.6

56.3

83.9

34.9

54.4

35.1

56.9

42.1

41.6

106.4

83.9

79.4

91.9

92.6

93.8

143.5

61.2

83.9

56.1

111.4

68.9

74,8

228.0

189.9

168.8

188.7

193.3

178.7

230.7

136.8

188.2

132.1

189.5

140.3

181.3

65.3

57.0

53.0

57.1

55.5

48.0

58.2

39.8

50.9

36.9

48.1

43.7

41.6

104.3

80.2

75.4

83.6

81.7

76.6

104.6

58.6

83.2

47.7

86.5

64.2

66.2

235.1

190.2

167.8

178.4

187,4

164.4

185.2

140.3

190.9

126.1

166.9

144.3

175.1

66.1

57.8

58.1

58.6

58.4

44.6

52.8

42.0

59.8

33.3

44.3

42.3

40.9

96.5

73.3

73.8

75.8

78.8

65.5

83.2

55.7

75.7

49.4

73.9

58.7

59.4

220.1

178.8

165.6

166.8

172.0

142.7

156.1

132.6

194.1

118.8

150.1

135.6

162.7

58.9

52.1

53.1

54.7

55.9

37.2

38.6

35.8

59.9

35.3

37.6

41.4

38.4

78.8

61.1

64.1

68.5

72.7

53.3

63.1

53.1

74.4

44.4

60.2

58.7

57.9

175.4

146.6

145.3

148.5

152.2

122.4

124.3

119.4

175.1

102.9

126.6

128.5

148.3

52.9

45.1

43.2

51.1

44.5

33.2

30.5

31.9

62.7

31.7

35.0

31.1

33.0

71.6

53.5

56.3

67.8

62.3

47.8

53.3

47.7

67.9

41.0

50.2

53.5

52.2

148.2

112.2

123.1

131.6

140.6

109.8

105.1

105.7

142.6

98.8

102.1

109.7

123.8
100 I International Health Statistics: What t he Numbers Mean for the United States

Table C-2-Trends In Age-Specific Death Rates (per 100,000), Females,

United States and Selected Countries, 1955-59 to 1980-84 (Continued)

Country 1955-59 1960-64 1965-69 1970-74 1975-79 1980-84

Age 45-54

United States

Australia

Canada

Frame

Germanya

Italy

Japan

Netherlands

New Zealand

Norway

Spain

Sweden

United Kingdom

Age 55-64

United States

Australia

Canada

France

Germanya

Italy

Japan

Netherlands

New Zealand

Norway

Spain

Sweden

United Kingdom

Age 65-74

United States

Australia

Canada

France

Germanya

Italy

Japan

Netherlands

New Zealand

Norway

Sweden

Spain

United Kingdom

536.1

475.3

450.4

480.1

458.2

435.3

604.3

361.3

484.7

333.8

471.8

382.4

463.0

1216.6

1123.6

1121.1

1058.1

1121.0

1084.2

1361.9

920.3

1148.2

833.6

1093.7

972.9

1139.1

2944.8

3008.3

2899.4

2850.2

3432.2

3212.3

3741.9

2856.7

3004.3

2548.7

2950.2

3213.3

3198.6

522.0

459.2

418.4

429.8

449.8

416.0

506.0

339.4

454.0

307.0

411.6

360.3

452.1

1164.2

1081.2

1025.0

949.1

1059.5

1001.3

1177.3

837.2

1090.8

828.9

1000.5

873.9

1094.0

2828.6

2877,2

2698.8

2561.5

3120.1

2945.4

3312.4

2570.4

2871.1

2547.4

2691.9

2897.7

3048.9

517.5

474.3

408,6

403.8

438.8

394.6

421,1

338.8

480.3

303.8

369.4

331.8

443.6

1120.3

1081.5

962.4

892.3

1043.3

955.6

1015.7

821.7

1098.8

789.9

916.7

807.8

1054.1

2759.2

2876.8

2443.4

2396.9

3053.6

2837,0

2903.0

2430.5

2805.3

2383.9

2432.1

2657.0

2869.1

496.1

452.0

391.2

369.3

422.3

353.4

350

341.6

462.7

298.4

348.6

324.8

448.1

1078.2

1058.1

913.5

831.4

1006.6

890.8

866.3

779.4

1060.3

716.7

848.0

752.7

1053.0

2495.8

2735.4

2241.3

2131.7

2859.6

2517.1

2522.6

2272.8

2666.7

2224.7

2169.6

2506.6

2738.7

437.3

387.2

368.5

342.2

392.3

321.4

289.6

316.4

446.3

291.1

300.4

309.7

430.2

960.0

909.8

843.4

711.5

897.0

801.8

690.6

714.6

1020.1

698.5

744.3

708.5

1027.1

2151.0

2249.7

2059.9

1872.0

2538.4

2189.0

2028.6

2001.9

2517.5

1975.5

1980.7

2172.4

2600.3

393.5

321.4

319.9

306.8

331.3

284.6

249.9

287.6

402.4

266.2

253.9

280.7

375.2

921.4

780.5

772.5

629.8

793.1

710.3

572.4

671.4

941.7

671.8

613.1

676.2

981.5

2105.4

2000.8

1918.6

1709.1

2313.9

2044.5

1695.2

1799.2

2402.0

1818.2

1837.7

1790.3

2472.6

aBased on data from the former Federal Republic of Germany.

SOURCE: World Health Organization, world Health Statistics (Geneva, Switzerland: World Health Organization , 1988).
Table C-3a-Age- and Cause-Specific Death Rates (per 100,000), United States, 198@

Age O Age 1-4 Age 5-14 Age 15-24 Age 25-34 Age 35-44 Age 45-54 Age 55-64 Age 65-74 Age 75+

cause death death death

of death rate rate rate rate rate rate rate rate rate rate

Male

Total

Cancer

Heart

Accidents

Violence

lnfection

other

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

1099.0

2.3

29.7

26.5

8.9

18.1

1013.5

886.3

2.3

25.0

21.3

9.3

15.5

812.9

56.5

3.8

2.8

23.1

3.2

2.0

21.6

45.0

3.7

2.9

15.9

2.7

1.8

18.0

30.9

3.6

1.4

15.7

1.8

0.6

7.8

20.4

2.7

1.1

8.4

1.2

0.6

6.4

151.0

5.9

4.8

75.1

26.5

1.0

37.7

52.1

4.2

3.0

23.3

6.6

0.9

14.1

196.7

11.7

14.7

60.0

27.8

3.3

79.2

74.0

12.2

7.8

16.6

8.3

1.7

27.4

301.4

39.7

62.5

51.0

20.1

6.2

121.9

140.0

48.5

24.5

15.0

5.5

3.1

43.4

629.0

166.3

229.2

47.0

13.2

9.2

164.1

350.9

154.9

89.1

16.0

3.7

5.5

81.7

1606.9

526.7

676.1

51.2

9.6

18.9

324.4

904.7

376.6

296.2

20.7

3.1

13.0

195.1

3573.8

1072.7

1632.4

68.6

7.4

43.8

748.9

2056.1

659.2

871.4

35.4

3.7

29.3

457.1

10122.0

1985.8

5234.9

186.9

8.7

136.2

2569.5

7632.6

1064.4

4481.9

121.4

4.4

119.9

1840.6

- .

<
102 I International Health Statistics: What the Numbers Mean for the United States

Table C-3 b--Age- and Cause-Specific Mortality Rates of Selected Countries

Compared with U.S. Rates, 1988

Cause

~~~~

% different

from Death fro

% different

m Death fro

% different

m Death from

% different

Death from

~

of death rate U.S. rate rate U.S. rate rate Us. rate rate U.S. rate rate Us. rate

Australia

Males

Total

cancer

Heart

Accidents

Violence

Infection

Other

Females

Total

972.1

4.0

2.4

18.2

1.6

10.3

935.6

-1 1.5%

73.9%

-91.9%

-31.370

-82.O%

-43.1%

-7.7%

45.7

3.2

0.8

22.5

1.2

2.0

16.0

-19.1%O

-15.8%

-71 .4%

-2.6%0

-62.5%

0.0%

-25.9%

26.6

5.0

0.8

13.3

0.8

0.9

5.8

-1 3.9%

38.9%

-42.9%

-1 5.3%

-55.6%

50.O%

-25.6%

134.5

6.8

4.0

74.1

5.1

0.8

43.7

-10.9%

15.3%

-16.7%

-1.3%

-80.8%

-20.0%

15.9%

144.2

13.2

10.0

55.9

6.1

2.0

57.0

-26.7%.

12.8%

-32.0%

-6.8%

-78.1 %

-39.4%

-28.O%

754.4

0.8

5.0

20.8

5.0

9.2

713.6

-14.9%

-65.2%

-80.0%0

-2.3%

-46.2%0

-40.60/0

-12.2%

41.6

4.2

1.0

15.5

1.7

1.7

17.5

-7.6%

13.5%

-65.5%

-2.5%

-37.O%

-5.6%

-2.8%

16.5

2.3

0.7

6.7

0.7

0.7

5.4

-19.1 %

-14.8%

-36.4%

-20.2%

-41.7%

16.7%

-15.6%

47.5

3.7

2.2

21.3

3.3

0.7

16.3

-8.8%

-11.9%

-26.7%.

-8.6%

-50.0 %

-22.2 %

15.6%

53.3

10.8

5.8

12.6

3.1

0.1

20.9

-28.O%

-1 1.5%

-25.6%

-24.1 %

-62.7%

-94.1%

-23.7%

Cancer

Heart

Accidents

Violence

Infection

other

Age 35-44 Age 45-54 ~~ Age 75+

Y. different Y. different Y. different % different Y. different

Cause Death from Death from Death from Death from Death from

of death rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate

Australia

Males

Total

Cancer

Heart

Accidents

Violence

Infection

Other

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

185.4

35.8

45.3

33.1

5.3

2.7

63.2

-38.5%

-9.8%

-27.5%

-35.1 %

-73.6%

-56.5%

-48.2%

456.7

145.7

167.3

36.0

4.3

4.6

96.8

-27.4%

-12.4%

-27.0%

-19.1%

-67.4%

-50.O%

-41.0%

1359.7

495.6

556.6

43.9

4.5

5.0

254.1

-15.4%

-5.9%

-17.7%

-14.370

-53.1 %

-73.5%

-21.7%

3465.3

1096.6

1639.2

58.0

3.0

15.6

652.9

-3.0%

2.2$/0

0.4%

-15.5%

-59.5%

-64.4%

-12.8%

10023.4

2179.4

5146.6

178.2

3.5

56.5

2457.2

-1.0%

9.7%

-1.7%

4.7%

-59.8%

-57.0%

-4.4%

101.6

48.0

13.3

9.7

3.3

0.7

26.6

-27.4%

-1 .0%

-45.7%

-35.3%

-40.0%

-77.4%

-38.7%

270.0

144.2

51.9

15.5

2.9

2.0

53.5

-23.1 %

-6.9%

-41.8%

-3.1%

-21.6%

-63.6%

-34.5%

713.9

336.5

215.2

17.3

0.8

4.4

139.7

-21.1%

-10.6%

-27.3%

-16.4%

-74.25/0

-66.2%

-28.4%

1814.4

586.1

826.0

31.4

1.0

9.9

360.0

-11.8%

-11.1%

-5.2%

-11.3%

-73.0%

-66.2%

-21 .2%

7446.0

1088.6

4582.3

145.9

2.7

36.8

1587.7

-2.4%

2.3%

2.2%

20.2%

-38.6%

-67.6%

-13.7%
Appendix C-International Mortality Comparisons by Age: Tables and Figures I 103

Table C-3 b--Age- and Cause-Specific Mortality Rates of Selected Countries

Compared with U.S. Rates, 1988 (Continued)

~~ Age 5-14 Age 15-24 Age 25-34

% different % different % different % different % different

Cause Death from Death from Death from Death from Death from

of death rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate rate Us. rate

Males

Total

Cancer

Heart

Accidents

Violence

Infection

Other

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

803.9

1.6

10.4

12.5

3.6

6.2

769.6

631.7

2.7

4.9

16.9

2.7

4.4

600.1

-26.9%

-30.4%

-65.0%

-52.8%

-59.6%

-65.7%

-24.l%

-28.7%

17.4%

-80.4%

-20.7%

-71.070

-71 .6%

-26.2%

45.5

4.6

1.2

17.3

0.6

0.9

20.9

36.6

4.3

2.0

10.2

1.6

1.1

17.4

Canada

-19.5 % 28.9

21.1% 4.9

-57.1% 0.5

-25.1 % 14.2

-81 .3% 0.8

-55.0% 0.4

-3.2% 8.1

-18.7$70 17.1

16.2% 3.0

-31.0% 0.7

-35.8% 6.5

-40.7% 0.4

-38.9% 0.3

-3.3% 6.2

-6.5%

36.1%

#.3 %

-9.6%

-55.6%

-33.3%

3.8%

-16.2%

11.1%

-36.4%

-22.6%

436.7%

-50.O%

-3.1%

121.9

6.3

2.4

66.1

4.7

0.3

42.1

38.8

3.8

1.5

16.5

2.2

0.6

14.2

-19.370

6.8%

-50.O%

-12.0%

-82.3%

-70.O%

11,770

-25.5%

-9.5%

-50.0%

-29.2%

-66.7%

-33.3%

0.7%

132.0

10.7

7.7

49.9

7.6

0.9

55.2

50.2

12.4

4.5

11.5

3.3

0.6

17.9

-32.9%

-8.5%

-47.67.

-16.8%

-72.7%

-72.7%

-30.3%

-32.2%

1.6%

-42.3%

-30.7%

40.2%

64.7%

-34.7%

Age 35-44 Age 45-54 Age 55-64 Age 65-74 Age 75 +

% different % different % different % different

Cause Death from Death from Death from Death from Death from

of death rate U.S. rate rate U.S. rate rate U.S. rate rate Us. rate rate U.S. rate

Males

Total

Cancer

Heart

Accidents

Violence

Infection

Other

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

189.1

33.7

40.1

37.5

6.6

0.9

70.3

105.3

46.8

15.2

9.5

3.0

0.9

29.9

-37.3%

-15.1%

-35.8%

-26.5%

-67.2%

-85.570

-42.3%

-24.8%

-3.5%

-38.0%

-36.7%

-45.5%

-71.070

-31.1%

474.9

151.1

161.9

39.2

5.9

1.9

114.9

280,4

149.9

53.2

13.8

3.7

1,8

58,0

-24.5 %

-9.1%

-29.4%

-16.6%

-55.3%

-79.3%

-30.0%

-20.1 %

-3.2%

-40.3%

-13.7%

O.O%

-67.3%

-29.0%

Canada

1390.1

527.6

538.6

47.7

5.7

7.4

263.1

729.3

369.9

191.3

20.3

2.5

5.2

140.1

-1 3.5%

0.2%

-20.3%

-6.8%

-40.6%

-60.8%

-18.90/o

-19.4%

-1.870

-35.4%

-1.9%

-19.4%

-60.0%

-28.2%

3474.7

1183.2

1483.8

63.8

5.5

19.9

718.5

1771.1

669.5

681.6

33.6

1.7

12.0

372.7

-2.8%

10.3%

-9.1%

-7.O%

-25.7%

-54.6%

-4.1%

-13.9%

1.6%

-21.8%

-5.1%

-54.1%

-59.0%

-18.5%

10148.3

2275.1

4743.5

216.5

8.2

52.0

2853.0

7133.6

1179.3

3844.4

177.5

3.0

42.4

1687.0

0.3%

14.6%

-9.4%

15.6%

-5.7’%

-61.8%

1 1.0%

-6.5%

10.8%

-14.2%

46.2%

-31.8%

-64.6%

2.5%
104 I International Health Statistics: What the Numbers Mean for the United States

Table C-3 b--Age- and Cause-Specific Mortality Rates of Selected Countries

Compared with U.S. Rates, 1988 (Continued)

_4aQJL~ Age 5-1 4 Age 15-24 25-34

% different % different % different % different

Cause Death from Death from Death from Death from Death from

of death rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate

France

Males

Total

Cancer

Heart

Accidents

Violence

Infection

Other

Females

Total

Cancer

Head

Accidents

Violence

Infection

Other

892.9 -18.8%

4.3 87.O%

13.4 -54.9%

38.7 46.0%

3.8 -57.3%

18.5 2.2%

814.2 -1 9.7%

47.6

4.2

1.4

16.6

2.7

1.1

21.6

-15.8%

10.5%

-50.0%

-28.1 %

-15.6%

-45.0%

O.O%

24.7 -20.170

3.7 2.8%

1.0 -28.6%

10.4 -33.8%

1.2 -33.3%

0.7 16.7%

7.7 -1.3%

115.8

6.7

3.2

66.4

5.2

0.7

33.6

-23.3%

13.6%

-33.3%

-11.6%

-80.4%

-30.O%

-10.9%

163.2

11.9

10.2

55.2

8.0

0.9

77.0

-1 7.09/0

1.7%

-30.6%

-8.O%

-71.2%

-72.7%

-2.8%

668.4 -24.6%

4.5 95.7%

10.4 -58.4%

32.2 51.2%

4.8 48.4%

10.6 -31 .6%

605.9 -25.5%

37.3

4.1

1.9

11.1

2.2

2.1

15.9

-17.1 %

10.8%

-34.5%

-30.2%

-18.5%

16.7%

-11 .7%

17.4 -14.7%

2.4 -11.1%

1.0 -9.1%

6.5 -22.6%

0.7 -41.7%

0.4 -38.3%

6.4 O.O%

40.2

4.1

2.4

17.5

1.4

0.6

14.2

-22.8%

-2.4%

-20.0%

-24.9%

-78.8%

-33.3%

0.7%

60.9

11.8

5.0

12.6

2.5

0.8

28.2

-17.7%

-3,3%

-35.9%0

-24.1%

-69.9%

-52.9%

2.9%

Age 35-44 Age 45-54 55-64 Age 65-74 Age 75+

% different O/. different % different % different % different

Cause Death from Death from Death from Death from Death from

of death rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate

France

Males

Total

cancer

Heart

Accidents

violence

Infection

#her

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

272.3

58.0

40.1

47.0

7.7

2.4

117.1

-9.7%

46.1 %

-35.8%

-7.8%

-61.7%

-61.3%

-3.9%

640.8

254.0

116.6

56.6

7.7

5.6

200.3

1 .9%

52.7%

-49.1%

20.4%

-41 .7%

-39.1%

22.1%

-22.2$/0

-19.1 %

-62.4%

13.7Y0

8.l%

-60.0%

9.8%

1498.3

677.0

350.7

70.0

6,0

14.1

380.5

43.8%

28.5%

-48.1%

36.7%

-37.5%

-25.4%

17.3Y0

3004.1

1197.9

926.8

106.3

6.8

34.7

731.6

-15.9%

11 .7%

-43.2%

55.0%

-8.1%

-20.8%

-2.3%

9623.2

2371.1

3793.6

369.3

12.9

132.0

2944.3

-4.9%

19.4%

-27.5%

97.6%

48.3%

-3.1%

14.6Y0

-6.2%

2.9%

-27.3%

216.4%

50.0%

-18.8%

25.9%

119.7

42.3

12.0

14.0

3.3

1.1

47.0

-14.5%

-12.8%

-51.0%

6.7%

40.0%

-64.5%

8.3%

272.9

125.3

33.5

18.2

4.0

2.2

89.7

558.8

267.3

107.4

24.9

2.7

6.3

150.2

-38.2%

-29.0%

-63.7%

20.3%

-12.9%

-51.5%

-23.0%

1311.6

488.1

409.8

48,1

3.5

18.2

343.9

-36.2 %

-26.0%

-53.0%

35.9%

-5.4%

-37.9%

-24.8%

7157.4

1095.5

3256.7

384.1

6.6

97.3

2317.2
Appendix C-International Mortality Comparisons by Age: Tables and Figures I 105

Table C-3 b--Age- and Cause-Specific Mortality Rates of Selected Countries

Compared with U.S. Rates, 1988 (Continued)

Age O Age 1-4 Age 5-14 Age 15-24 Age 25-34

% different % different % different % different O/. different

Cause Death from Death from Death from Death from Death from

of death rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate

Germany

a

Males

Total

Cancer

Heart

Accidents

Violence

Infection

Other

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

866.9

2.9

5.5

17.8

4.8

10.9

825.0

-21 .1%

26.1 %

-81.570

-32.8%

-46.1%

-39.870

-1 8.6%

46.6

5.0

2.1

14.6

1.3

2.1

21.5

-1 7.5%

31 .60/0

-25.0%

-36.8%

-59.4%

5.0%

-0.5%

24.0 -22.3%

4.2 16.7%

0.9 -35.770

9.9 -36.970

0.8 -55.6%

0.7 16.70/’

7.5 -3.80/.

90.2

6.5

3.3

47.6

3.3

0.5

29.0

-40.3%

1 0.2%

-31 .30/.

-36.6%

-87.570

-50.0%

-23.1%

109.8

12.4

10,0

28.8

4.2

0.9

53.5

-44.2%0

6.0%

-32.0%

-52.0%

-84.9%

-72.7%

-32.4%

626.5

1.8

4.6

17,6

2.4

11.2

588.9

-29,3%

-21 .7%

-81.6%

-17.4%

-74.2%

-27.7%

-27.6%

37.5

3.6

0.8

9.9

1.0

2.4

19.8

-16.7%

-2.7%

-72.4%

-37.7%

-63.0%

33.3%

10.0%

16.1 -21.1%

3.0 11 .1%

0.6 -45.570

5.0 -40.5%

0.9 -25.0%

0.6 0.0%

6.0 -6.2%

50.7

13.9

5.8

6.4

2.1

0.6

21.9

-31,570

13.9%

-25.6%

-61.4%

-74.7%

-64.7%

-20.1%

34.4

4.3

2.2

12.7

1.7

0.4

13.1

-34.0%

2.40/o

-26.70/0

-45.5%

-74.2%

-55.670

-7.1%

Age 35-44 4554 - 64 Age 65-74 Age 75+

% different % different % different % different % different

Cause Death from Death from Death from Death from Death from

of death rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate

Germanya

Males

Total

Cancer

Heart

Accidents

Violence

Infection

Other

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

215.9

47.0

46.1

24.4

4.5

2.7

91.2

-28.4%

18.4%

-26.2%

-52.2%

-77.6%

-56.570

-25.2%

588.7

189.5

176.9

30.7

4.8

4.4

182.4

-6.4 %

14.0%

-22.8%

-34.7%

-63.6%

-52.2%

1 1.2%

1530.2 -4.8%

536.5 1 .9%

600.6 -11.2%

33.5 -346%

3.7 -61.5%

11.8 -37.6%

344.1 6.1%

3758.4

1167.3

1773.0

46.0

4.9

26.2

741.0

5.2%

8.8%

8.6%

-32.9%

-33.80/0

-40,2%

-1 .1%

11374.5

2516.6

6218.8

176.7

7.4

65.4

2389.6

12.4%

26.70/o

18.8%

-5.5%

-14.970

-52.0%

-7.0%

120.1

52.4

17.2

6.2

3.0

1.2

40.1

-14.2%

8.0%.

-29.8%

-58.770

-45.5%

-61.3%

-7.6%

287.1

146.2

49.8

9.1

2.4

2.3

77.3

707.1 -21 .8%

329.5 -12,5%

204.3 -31.0%

11.9 -42.5%

2.1 -32.3%

5.0 -61.5%

154.3 -20.9%

-7.4%

-1 .8%

-3.6%

-20.9%

-48.6%

-51 .20/0

-1 8.80/0

8220.7

1379.9

5066.5

180.7

4.7

49.0

1539.9

7.7%

29.6%

13.0%

48.8%

6.8%

-59.1%

-16.3%

-18.2%

-5.6%

-44.1%

-43.1%

-35.1%

-58.2%

-5.4%

1903.4

647.6

840.4

28.0

1,9

14.3

371.2
106 I International Health Statistics: What the Numbers Mean for the United States

Table C-3b--Age- and Cause-Specific Mortality Rates of Selected Countries

Compared with U.S. Rates, 1988 (Continued)

o Age 1-4 Age 5-14 Age 15-24 Age 25-34

% different % different % different % different % different

Cause Death from Death from Death from Death from Death from

of death rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate

Italy

Males

Total

Heart

Accidents

1015.4 -7.6%

4.0 73.9%

5.4 -81 .8%

14.1 -46.8%

1.0 -88.8%

6.7 -63.0%

984.2 -2.9%

35.4

5.0

2.3

9.4

0.1

1.3

17.3

-37.3%

31.6%

-17.9%

-59.3%

-96.9%

-35.0%

-19.9%

22.2

5.0

1.1

8.4

0.4

0.4

6.9

-28.2%

38.9%

-21.4%

-46.5%

-77.8%

-33.3%

-11.5%

89.1

7.4

4.9

48.6

4.2

0.5

23.5

-41.O%

25.4%

2.1%

-35.3%

-84.294

-50.0%

-37.7%

109.9

12.2

10.7

36.4

6.8

1.0

42.8

-44.1%

4.3%

-27.2%.

-39.3%

-75.5%

-69.7%

-46.0%

Infection

Other

Females

Total

Cancer

Heart

Accidents

Violence

Infection

other

818.0 -7.7%

2.9 26.1%

4.7 -81.2%

12.9 -39.4%

0.0 -100.0%

6.8 -56.1%

790.7 -2.7%

29.3

4.9

2.3

5.1

0.4

0.7

15.9

-34.9%

32.4%

-20.7%

-67.9%

-85.2%

-61.1%

-11.7%

15.1

3.7

1.4

4.0

0.3

0.5

5.2

-26.0%

37.0%

27.3%

-52.4%

-75.0%

-16.7%

-18.7%

29.4

5.9

2.3

10.6

0.9

0.3

9.4

-43.6%

40.5%

-23.3%

-54.5%

-86.4%

-66.7%

-33.3%

42.3

12.5

5.0

7.2

1.0

0.5

16.1

-42.8%

2.5%

-35.9%

-56.6%

-88.0%

-70.67.

-41 .2%

Age 35-44 Age 4554 - Age 55-64 Age 65-74 Age 75+

% different % different % different % different % different

Cause Death from Death from Death from Death from Death from

of death rate U.S. rate rate U.S. rate rate US. rate rate U.S. rate rate U.S. rate

Italy

Males

Total

Cancer

Heart

Accidents

Violence

Infection

Other

173.2

44.6

39.3

31.7

5.7

1.3

50.6

-42.5%

12.3%

-37.1%

-37.8%

-71.6%

-79.0%

-58.5%

490.4

200.4

130.0

40.5

4.8

3.1

111.6

-22.%

20.5%

-43.3%

-13.8%

-63.6%

-66.3%

-32.0%

1455.1

648.2

449.6

51.3

4.4

7.1

294.5

-9.4%

23.1%

-33.570

0.2%

-54.2%

-62.4%

-9.2%

3479.3

1301.3

1293.2

79.4

5.5

18.6

781.3

-2.6%

21 .3%

-20.8%

15.7%

-25.7%

-57.5%

4.3%

10393.2

2248.5

5133.2

258.2

8.8

34.0

2710.5

2.7%

13.2%

-1.9%

38.1%

1.1%

-75.0%

5.5%

2.9%

8.3%

1.3%

126.6%

13.6%

-80.9%

1.0%

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

96.3

49.5

15.3

6.4

0.9

0.6

23.6

-31 .2%

2.1%

-37.6%

-57.3%

-83.6%

-80.6%

45.6%

245.3

136.8

45.0

10.4

1.0

1.1

51.0

-30.1%

-11.7%

-49.5%

-35.0%

-73.0%

-80.0%

-37.60/0

622.2

297.1

162.6

16.2

1.2

3.3

141.8

-31.2%

-21 .1%

-45.1%

-21.7%

-61.3%

-74.6%

-27.3%

1705.2

568.8

681.1

37.8

1.7

7.7

408.1

-17.1%

-13.7%

-21.8%

6.8%

-54.1%

-73.7%

-10.7%

7856.2

1153.1

4541.6

275.1

5.0

22.9

1858.5
Appendix C-international Mortality Comparisons by Age: Tables and Figures I 107

Table C-3 b--Age- and Cause-Specific Mortality Rates of Selected Countries

Compared with U.S. Rates, 1988 (Continued)

Age 0 Age 1- 4 Age 15-24 Age 25-34

% different % different % different % different % different

Cause Death from Death from Death from Death from Death from

of death rate U.S. rate rate U.S. rate rate US. rate rate U.S. rate rate U.S. rate

Japan

Males

Total

Cancer

Heart

Accidents

Violence

Infection

Other

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

-53.7%

4.3%

-36.0%

38.1%

4.5%

-10.5%

-58.0%

72.0

5.6

5.5

39.4

2.3

0.7

18.5

-52.3%

-5.1%

14.6%

47.5%

-91.3%

-30.O%

-50.9%

80.8

11.5

13.8

19.4

2.6

1.0

32.5

-58.9%0

-1.7%

-6.1%

47.7%

-90.6%

-69.7%

-59.0%

508.8

2.4

19.0

36.6

9.3

16.2

425.3

50.9

3.9

3.5

18.1

2.1

2.5

20.8

-9.9%

2.6%

25.0%

-21 .6%

-34,4%

25.0%

-3.7%

20.1

3.7

1.4

7.3

0.8

0.5

6.4

-35.0%

2.8%

0.0%

-53.5%

-55.6%

-16.7%

-17.9%

27.2

4.2

2.6

7.1

1.1

0.6

11.6

-47.8%

O.O%

-13.3%

-69.5%

-83.3%

-33.3%

-17.770

43.2

12.8

6.4

3.3

1.2

0.8

18.7

-41 .6%

4.9%

-17.9%

-80.1%

-85.5%

-52.9%

-31.8%

443.0

2.3

15.3

29.6

8.5

11.6

375.7

-50.0%

0.0%

-38.8%

39.0%

-8.6%

-25.2%

-53.8%

39.7

3.8

2.5

10.4

2.1

1.9

19.0

-11.8%

2.7%

-13.80%

-34.6%

-22.2%

5.6%

5.6%

13.3

3.0

1.1

2.9

0.6

0.4

5.3

-34.8%

11.1%

0.0%

-65.5%

-50.0%

-33.3%

-1 7.29/0

Age 35-44 65-74 Age 75+

% different % different % different O/. different % different

Cause Death from Death from Death from Death from Death from

of death rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate

Japan

Males

Total

Cancer

Heart

Accidents

Violence

Infection

Other

161.1

38.3

41.0

20.9

4.4

2.6

53.9

-46.5%

-3.5%

-34.4%

-59.0%

-78.1%

-58.1%

-55.8%

430.6

139.7

115.5

35.9

6.1

6.5

126.9

-31.5%

-16.0%

-49.6%

-23.6%

-53.8%

-29.3%

-22.7%

1073.7

461.1

293.4

49.3

5.1

18.2

246.6

-33.2%

-12.5%

-56.6%

-3.7%

-46.9%

-3.7%

-24.0%

-46.3%

-42.3%

-54.6%

-33.3%

-35.5%

-40.0%

-43.5%

2661.6

1007.6

879.1

77.3

5.5

49.8

642.3

-25.5%

-6.1%

-46.1%

12.7%

-25.7%

13.7%

-14.2%

9361.4

1911.0

3979.8

177.8

9.3

134.8

3148.7

-7.5%

-3.8%

-24.0%

-4.9%

6.9%

-1.0%

22.5%

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

214.7

100.9

50.7

8.3

2.2

3.0

49.6

-38.8%

-34.9%

-43.1%

-48.1%

-40.5%

-45.5%

-39.3%

485.9

217.4

134.6

13.8

2.0

7.8

110.3

1350.4

445.8

521.9

31.0

3.3

20,9

327.5

-34.3%

-32.4%

-40.1%

-12.4%

-10.8%

-28.7%

-28.4%

6675.8

938.1

3389.3

105.8

7.1

65.5

2170.0

-12.5%

-1 1.9%

-24.4%

-12.9%

61 .4%

-45.4%

17.9%

91.8

42.6

16,7

4.7

1.9

1.3

24.6

-34.4%

-12.2%

-31.870

-68.7%

-65.5%

-58.1%

-43.3%
108 I International Health Statistics: What the Numbers Mean for the United States

Table C-3 b-Age- and Cause-Specific Mortality Rates of Selected Countries

Compared with U.S. Rates, 1988 (Continued)

~~ Age 5-14 Age 15-24 Age 25-34

% different % different % different % different % different

Cause Death from Death from Death from Death from Death from

of death rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate

Netherlands

Males

Total

Cancer

Heart

Accidents

violence

Infection

Other

Females

Total

Cancer

Heart

Accidents

Violence

infection

Other

798.1

4.2

11.5

10.5

1.0

11. 5

759.4

562.7

7.7

5.5

8.8

4.4

11.0

525.3

-27.4%.

82.6%

-61.3%

-60.4%

-88.8%

-36.5%

-25.1%

48.2

4.1

0.5

14.2

0.8

3.3

25.3

-14.7% 22.0 -28.8%

7.9% 4.1 13.9%

-82.1% 0.6 -57.1%

-38.5% 7.7 -51.0%

-75.0% 0.2 -88.9%

65.0% 0.6 0.0%

17.1% 8.8 12.8%

63.9

8.0

2.7

27.6

1.9

1.1

22.6

-57.7%

35.6%

-43.7%

-63.2%

-92.8%

10.0%

-40.1%

83.8

12.4

8.1

18.3

3.8

0.2

41.0

-57.4%

6.O%

-44.9%

-69.5%

-86.3%

-93.9%

-48.2%

-36.5%

234.8%

-78.0%

-58.7%

-52.7%

-29.0%

-35.4%

32.1

4.3

1.4

6.0

1.4

1.7

17.3

-28.7% 14.6 -28.4%

16.2% 2.7 0.0%

-51.7% 0.8 -27.3%

-62.3% 4.5 -46.4%

-48.1% 0.2 -83.3%

-5.6% 0.3 -50.0%

-3.9% 6.1 -4.7%

26.2

4.2

1.7

7.9

0.9

0.3

11.2

-49.7%

O.O%

-43.3%

-66.1%

-86.4%

-66.7%

-20.6%

45.4

13.0

6.0

3.7

1.4

0.6

20.7

-38.6%

6.6%

-23.1%

-77.7%

-83.1%

-64.7%

-24.5%

35-44 Age 45-54 55-64 Age 6574 . Age 75+

% different % different % different % different % different

Cause Death from Death from Death from Death from Death from

of death rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate

Netherlands

Males

Total

Cancer

Heart

Accidents

153.3

38.6

42.4

14.8

2.4

0.5

54.6

-49.1%

-2.8%

-32.2%

-71 .0%

-88.1%

-91.9%

-55.2%

435.9

154.0

161.0

19.6

2.2

1.8

97.3

-30.7%

-7.4%

-29.8%

-58.3%

-83.3%

-80.4%

-40.7%

1353.6 -15.8%

544.3 3.3%

531.6 -21.4%

21.1 -58.8%

2.2 -77.1%

5.9 -68.8%

248.5 -23.4%

3736.5

1402.2

1561.3

38.2

1.5

14.8

718.5

4.6%

30.7%

-4.4%

-44.3%

-79.7%

-66.2%

-4.1%

11182.0

2961.2

4881.9

207.5

2.9

48.4

3080.1

10.5%

49.1%

4.7%

11 .0%

-66.7%

-64.5%

19.9%

Infection

Other

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

103,3

51.4

13,7

4.9

0.9

0.8

31.6

-26.2%

6.0%

-44.1%

-67.3%

-83.6%

-74.2%

-27.2%

258.8

148.1

46.0

7.1

1.4

1.1

55.1

-26.2%

-4.4%

-48.4%

-55.6%

-62.2%

-80.0 %

-32.6%

648. 0 -28.4%

338.5 -10.1%

166.4 -43.8%

9.1 -56.0%

1.1 -64.5%

3.3 -74.6%

129.6 -33.6%

1674.1

622.2

643.1

26.4

0.7

10.4

371.3

-18.6%

-5.6%

-26.2%

-25.4%

-81.1%

-64.5%

-18.8%

7632.8

1343.9

3838.7

194.2

1.0

41.5

2213.5

0.0%

26.3%

-14.4%

60.0%

-77.370

-65.4%

20.3%
Appendix C--International Mortality Comparisons by Age: Tables and Figures I 109

Table C-3 b-Age- and Cause-Specific Mortality Rates of Selected Countries

Compared with U.S. Rates, 1988 (Continued)

Age O Age 1 -4 Age 5-14 Age 15-24 Aae2534 -

% different % different % different % different % different

Cause Death from Death from Death from Death from Death from

of death rate U.S. rate rate US. rate rate U.S. rate rate U.S. rate rate US. rate

New Zealand

Males

Total

Cancer

Heart

Accidents

Violence

infection

Other

1073.7

7.0

3.5

28.0

3.5

14.0

1017.7

-2.3%

204.3%

-88.2%

5.7%

-60.7%

-22.7%

0.4%

58.9

9.7

0.0

28.0

2.9

1.9

16.4

4.2%

155.3%

-100.0%

21 .2%

-9.4%

-5.O%

-24.1%

38.8

8.9

1.8

17.4

0.4

1.1

9.2

25.6%

147.2%

28.6%

10.8%

-77.8%

83.3%

17.9%

174.6

9.4

4.7

106.9

7.7

1.3

44.6

15.6%

59.3%

-2.1%

42.3%

-70.9%

30.0%

18.3%

153.1

15.1

13.2

70.3

6.8

1.9

45.8

-22.2 %

29.1 %

-10.2 %

17.2%

-75.5%

-42.4%

-42.2%

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

71.5

16.3

8.2

20.4

2.6

0.7

23.3

949

3.8

11.3

37.5

3.8

26.3

866.3

7.1%

65.2%.

-54.8%

76.1%

-59.1%

69.7%

6.6%

51.8

8.1

0.0

23.4

1.0

0.0

19.3

15.1%

118.9%

-100.0%

47.2%

-63.0%

-100.0%

7.2%

22.7

3.9

1.5

9.2

0.4

0.4

7.3

11 .3%

44.4%

36.4%

9.5%

-66.7%

-33.3%

14.1%

62.1

5.9

2.4

29.8

2.8

0.7

20.5

19.2%

40.5%

-20.0%

27.9%

-57.6%

-22.2%

45.4%

-3.4%

33.6%

5.1%

22.9%

-68.7%

-58.8%

-1 5.0%

35-44 Age 45-54 Age 55-64 Age6574- Age 75+

% different % different % different % different % different

Cause Death from Death from Death from Death from Death from

of death rate US. rate rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate

New Zealand

Males

Total

Cancer

Heart

Accidents

Violence

infection

Other

Females

Total

Cancer

Heart

Accidents

violence

Infection

Other

190.0

39.8

57.2

36.2

1,8

2.7

52.3

128.5

62.9

22.0

15.7

0.8

2.7

24.4

-37.0%

0.3%

-8.5%

-29.0%

-91.0%

-56.5%

-57.1%

-8.2%

29.7%

-10.2%

4.7%

-85.5%

-1 2.9%

-43.8%

562.3

148.8

260.5

41.4

5.6

1.2

104.8

385.9

185.4

90.8

15.1

3.2

1.9

89.5

-10.6%

-10.5%

13.7%

-11.9%

-57.6%

-87.0%

-36.1%

10.0%

1 9.7%

1 .9%

-5.6%

-13.5%

-65.5%

9.5%

1547.6

482.5

752.4

40.6

2.8

5.6

263.7

928.5

425.4

316.7

18.2

2.1

4.9

161.2

-3.7%

-8.4%

11 .3%

-20.7%

-70.8%

-70.4%

-18.7%

2.6%

1 3.0%

6.9%

-12.1%

-32.3%

-62.3%

-17.4%

4100.1

1197

2080.1

63.2

8.4

13.7

737.7

2338.2

753.2

1078.6

35.0

2.6

12.0

456.8

14.7%

11 .6%

27.4%

-7.9%

13.5%

48.7%

-1.5%

11066.8

2190.6

5556.0

196.5

2.0

47.2

3074.5

9.3%

10.3%

6.1%

5.I%

-77.0%

-65.3%

19.7%

9.7%

11 .8%

7.3%

79.6%

-72.7%

-58.6%

14.5%

13.7%

14.3%

23.8%

-1.1%

-29.%

-59.0%

-0.1%

8376.0

1190.3

4808.5

218.0

1.2

49.6

2108.4
110 I International Health Statistics: What the Numbers Mean for the United States

Table C-3b--Age- and Cause-Specific Mortality Rates of Selected Countries

Compared with U.S. Rates, 1988 (Continued)

~~ Age 5-14 Age 15-24 34

% different % different % different % different % different

Death from Death from Death from Death from Death from

of death U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate

Norway

Males

Total

cancer

Heart

Accidents

Violence

infection

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

919.5

0.0

3.4

3.4

0.0

17.0

095.7

-1 6.3%

-100.0%

-88.6%

-87.2%

-100.0%

-6.1%

-11 .6%

51.7

7.5

1.9

13.2

0.0

4.7

24.4

-8.5%

97.4%

-32.1%

-42.9%

-100.0%

135.0%

13.0%

26.1 -15.5%

5.4 50.0%

0.4 -71.4%

10.5 -33.1%

0.4 -77.8%

0.0 -100.0%

9.4 20.5%

97.8

3.2

3.5

48.0

3.2

0.0

39.9

-35.2%

-45.8%

-27.1%

-36.1%

-87.9%

-100.0%

5.8%

113.4

11.7

9.9

35.1

3.1

0.9

52.7

-42.3%

0.0%

-32.7%

-41 .5%

-88.8%

-72.7%

-33.5%

734.3

7.1

0.0

10.7

0.0

10.7

705.8

-17.1%

208.7%

-100.0%

-49.8%

-100.0%

-31.0%

-13.2%

38.5

3.0

0.0

9.9

0.0

6.9

18.7

-14.4%

-18.9%

-100.0%

-37.7%

-1 00.0%

283.3%

3.9%

10.6 -48.0%

3.4 25.9%

0.8 -27.3%

2.3 -72.6%

0.0 -100.0%

0.8 33.3%

3.3 -48.4%

30.2

2.5

2.2

10.8

0.6

0.9

13.2

-42.0%

4.5 %

-26.7%

-53.6%

-90.9%

0.0%

-6.4%

40.3

7.1

3.6

7.5

0.6

1.0

20.5

-45.5%

-41.8%

-53.8%

-54.8%

-92.8%

-41.2%

-25.2%

Age 35-44 Age 55-64 Age 65-74 75+

% different % different % different % different % different

Cause from Death from Death from Death from Death from

Of death rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate

Norway

Males

Total

Cancer

Heart

Accidents

Violence

Infection

Other

Females

Total

188.4

36.6

42.0

30.9

6.0

1.6

71.3

109.5

49.8

12.8

8.4

1.3

1.0

36.2

-37.5%

-7.8%

-32.8%

-39.4%

-70.1%

-74.2%

-41.5%

518.6

126.4

201.5

54.7

4.3

1.9

129.8

-1 7.6%

-24.0%

-12.1%

16.4%

-67.4%

-79.3%

-20.9%

1440.8

452.5

669.4

51.6

2.0

4.6

260.7

-10.3%

-14.1%

-1.0%

0.8%

-79.2%

-75.7%

-19.6%

3549.6

1035.5

1794.8

66.5

2.8

15.8

634.2

-0.7%

-3.5%

9.9%

-3.1%

-62.2%

-63.9%

-15.3%

11058.0

2135.6

5608.0

341.4

1.9

69.2

2901.9

9.2%

7.5%

7.1%

82.7%

-78.2%

-49.2%

12.99/0

8.0%

6.2%

-3.2%

174.7%

-88.6%

-48.3%

29.0%

-21.8%

2.7%

-47.8%

-44.0%

-76.4%

-67.7%

-16.6%

277.1

163.2

37.0

10.4

3.0

0.5

63.0

-21.0%

5.4%

-58.5%

-35.0%

-18.9%

-90.9%

-22.9%

681.5

347.6

194.4

10.2

0.5

3.4

125.4

-24.7%

-7.7%

-34.4%

-50.7%

-83.9%

-73.8%

-35.7%

1790.2

560.8

814.8

38.5

1.4

15.8

358.9

-12.9%

-14.9%

-6.5%

8.8%

-62.2%

-46.1%

-21.5%

8241.4

1130.6

4339.6

333.5

0.5

62.0

2375.2

Cancer

Heart

Accidents

Violence

Infection

Other
Appendix C-International Mortality Comparisons by Age: Tables and Figures I 111

Table C-3 b--Age- and Cause-Specific Mortality Rates of Selected Countries

Compared with U.S. Rates, 1988 (Continued)

Age O Age 1-4 Age 5-14 Age 15-24 Age 25-34

% different % different % different % different % different

Cause Death from Death from Death from Death from Death from

of death rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate

Spain

Males

Total

Cancer

Heart

Accidents

Violence

Infection

Other

1009.1

5.0

56.9

43.4

0.9

28.9

874

-8.2%

117.4%

91.6%

63.8%

-89.9%

59.7%

-13.8%

45.4

4.8

3.4

14.6

0.5

3.8

18.3

-19.6% 27.8 -10.0% 114.3

26.3% 5.4 50.0% 8.6

21.4% 2.0 42.9% 9.5

-36.8% 11.2 -28.7% 70.0

-84.4% 0.4 -77.8% 2.7

90.0% 1.0 66.7%. 1.5

-15.3% 7.8 0.0% 22.0

-24.3% 140.7

45.8% 14.4

97.9% 18.4

-6.8% 59.8

-89.8% 4.0

50.0% 2.6

-41.6% 41.5

-28.5%

23.1%

25.2%

-0.3%

-85.6%

-21.2%

-47.6%

-31 .6%

0.8%

1.3%

-33.1%

-80.4%

-17.6%

-37.6%

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

757.2

1.9

39.9

30.2

2.4

20.9

661.9

-1 4.6%

-1 7.4%

59.6%

41.8%

-74.2%

34.8%

-18.6%

39.2

4.7

2.0

11.1

0.5

3.7

17.2

-12.9% 17.8 -1 2.7% 41.5

27.0% 3.9 44.4% 5.5

-31 .0% 1.5 36.4% 4.7

-30.2% 5.1 -39.3% 17.6

-81.5% 0.3 -75.0% 1.1

105.6% 0.6 0.0% 1.1

-4.4% 6.4 0.0% 11.5

-20.3% 50.6

31 .0% 12.3

56.7% 7.9

-24.5% 11.1

-83.3% 0.8

22.2% 1.4

-18.4% 17.1

35-44 Age 45-54 Age 55-64 65-74 Age 75+

% different % different % different % different % different

Cause Death from Death from Death from Death from Death from

of death rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate

Spain

Males

Total

Cancer

Heart

Accidents

Violence

Infection

Other

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

223.5

54.0

50.3

50.7

3.0

4.3

61.2

101.2

45.5

17.5

9.4

1.2

1.9

25.7

-25.8%

36.0%

-19.5%

-0.6%

-85.1%

-30.6%

-49.8%

538.2

188.9

147.9

56.4

3.3

8.0

133.7

-14.4%

13.6%

-35.5%.

20.0%

-75.0%

-13.0%

-18.5%

1294.8

491.7

393.2

61.9

2.5

15.4

330.1

-19.4%

-6.6%

-41.8%

20.9%

-74.0%

-18.5%

1.8%

3151.4

1053.3

1138.2

74.8

2.6

31.8

850.7

-11.8%

-1 .8%

-30.3%

9.0%

-64.9%

-27.4%

13.6%

8644.2

1916.7

4484.5

141.5

4.7

86.0

3000.8

-4.7%

-3.5%

-14.1%

-24.3%

-48.0%

-36.9%

16.870

0.6%

-14.3%

-1.6%

-39.0%

-40.9%

-50.3%

15.6%

7587.9

912.2

4412.2

74.1

2.6

59.6

2127.2

-27.7%

-6.2%

-28.6%

-37.3%

-78.2%

-38.7%

-40.8%

237.8

119.5

47.8

13.4

1.0

2.3

53.8

-32.2%

-22.9%

-46.4%

-16.3%

-73.0%

-58.2%

-34.1%

553.5

231.6

152.1

21.0

1.0

7.3

140.5

-38.8%

-38.5%

-48.6%

1.4%

-67.7%

-43.8%

-28.0%

1582.9

444.3

657

35.9

1.3

16.8

427.6

-23.0%

-32.6%

-24.6%

1.4%

-64.9%

-42.7%

-6.5%
112 I International Health Statistics: What the Numbers Mean for the United States

Table C-3 b--Age- and Cause-Specific Mortality Rates of Selected Countries

Compared with U.S. Rates, 1988 (Continued)

~~ Age 514 . Age 15-74 Age 25-34

% different % different % different % different % different

Cause Death from Death from Death from Death from Death from

of death rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate

Sweden

Males

Total

Cancer

Heart

Accidents

Violence

Infection

Other

657.2

1.7

5.2

8.6

3.5

5.2

633.0

-40.2 %

-26.1%

-82.5%

-67.5%

-60.7%

-71.3%

-37.5%

30.9 -45.3%

2.4 -36.8%

0.0 -100.0%

7.3 -68.4%

2.5 -21.9%

1.0 -50.0%

17.7 -18.1%

20.3 -34.3%

3.5 -2.8%

1.0 -28.6%

9.4 40.1%

0.4 -77.8%

0.2 -66.7%

5.8 -25.6%

81.0

5.4

3.3

35.5

6.9

0.3

29.6

-46.4 %

-8.5 %

-31.3%

-52.7%

-74.0%

-70.0%

-21.5%

114.8

12.3

9.4

31.6

12.0

0.0

49.5

-41 .6%

5.1%

-36.1%

-47.3%O

-56.8%

-100.0%

-37.5%

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

501.3

3.7

11.1

1.8

0.0

5.5

479.2

-43.4%

60.9%

-55.6%

-91.5%

-100.0%

-64.5%

-41.1%

26.4 -41.3%

2.1 -43.2%

1.0 -65.5%

5.2 -67.3%

0.0 -100.0%

1.6 -11.1%

16.5 -8.3%

12.3 -39.7%

2.3 -14.8%

0.8 -27.3%

4.3 -48.8%

0.2 -83.3%

0.4 -33.3%

4.3 -32.8%

34. 0

4.0

1.7

10.7

2.5

1.0

14.1

-34.7%

-4.8%

-43.3%

-54.1%

-62.1%

11.1%

0.0%

51.3

12.1

4.3

6.7

4.1

0.7

23.4

-30.7%

-0.8%

-44.9%

-59.6%

-50.6%

-58.8%

-1 4.6%

~ ~ ~

. 4 75+

% different % different % different % different % different

Cause from Death from Death from Death from Death from

of death rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate

Sweden

Males

Total

Cancer

Heart

Accidents

Violence

Infection

Other

195.5

26.3

39.0

29.4

16.8

1.4

82.6

-35.1%

-33.8%

-37.6%

-42.4%

-16.4%

-77.4%

-32.2%

438.9

106.8

150.7

34.1

18.3

1.0

126.0

-30.2%

-34.6%

-34.2%0

-27.4%

38.6%

-89.1%

-23.2%

1256.1

362.5

610.4

39.2

13.3

8.0

222.7

-21.8%

-31.2%

-9.7%

-23.4%

38.5%

-57.7%

-31.4%

3265.4

896.6

1747.5

57.0

11.1

17.3

533.9

-8.6% 10832.3

-16.2% 1906.0

7.1% 6191.9

-16.9% 234.7

50.0% 9.5

-60.5% 80.1

-28.7% 2410.1

7.0%

-4.O%

18.3%

25.6%

9.2%

-41.2%

-6.2%

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

115.1

49.3

13.7

6.2

6.5

1.8

37.6

-17.8%

1.6%

-44.1%

-58.7%

18.2%

-41.9%

-13.4%

264.8

132.8

44.8

10.6

6.9

1.9

67.8

-24.5%

-14.3%

-49.7%

-33.8%

86.5%

-65.5%

-17.0%

635.5

311.3

181.0

14.3

6.2

4.5

118.2

-29.8%

-1 7.3%

-38.9%

-30.9%

100.0%

-65.4%

-39.4%

1726.5

594.8

762.1

29.2

5.8

17.0

317.6

-16.0% 8071.8

-9.8% 1096.6

-12.5% 4648.4

-17.5% 196.4

56.8% 4.1

-42.0% 59.7

-30.5% 1866.6

5.8%

3.0%

8.2%

61.870

-6.8%

-50.2%

1.4%
Appendix C-International Mortality Comparisons by Age: Tables and Figures I 113

Table C-3 b--Age- and Cause-Specific Mortality Rates of Selected Countries

Compared with U.S. Rates, 1988 (Continued)

Age O Age 1-4 Age 5-14 Age 15-24 Age 25-34

% different % different % different % different % different

Cause Death from Death from Death from Death from Death from

of death rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate rate US. rate

Males

Total

Cancer

Heart

Accidents

Violence

Infection

Other

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

1019.2

2.5

9.7

15.4

5.7

12.9

973.0

767.9

3.9

8.3

13.3

3.1

11.4

727.9

-7.3%

8.7%

-67.3%

-41 .9%

-36.0%

-28.7%

-4.0%

-13.4%

69.6%

-66.8%

-37.6%

-66.7%

-26.50/,

-10.5%

44.7

4 . 6

1.2

9.7

1.8

3.7

23.7

38.1

4 . 8

1.5

7.6

1.5

2.9

19. 8

United Kingdom

-20.9% 24.8 -19.7%

21.1% 4.4 22.2%

-57.1% 0.9 -35.7%

-58.0% 10.3 -34.4%

-43.7% 0.6 -66.7%

85.0% 0.7 16.7%

9.7% 7.9 1.3%

-15,3’-% 15.1 -26.0%

29.7% 3.5 29.6%

-48.3% 0.7 -36.4%

-52.2% 3.7 -56.0%

-44.4% 0.6 -50.0%

61 .1% 0.5 -16.7%

10.0% 6.1 -4.7%

80.3

6.9

3.1

36.4

7.2

0.8

25.9

30.9

5.2

2.4

7.7

2.7

0.8

12.1

-46.8%

16.9%

-35.4%

-51 .50/o

-72.8%

-20.0%

-31 .3%

-40.7%

23.8%

-20.0%

-67.0%

-59.1%

-11.l%

-14.2%

94.2

12.4

10.0

26.1

9.2

1.1

35.4

46.0

15.0

5.0

6.1

2.8

0.9

16.2

-52.1 %

6.0%

-32.0%

-56.5%

-66.9%

-66.7%

-55.3%

-37.870

23.0%

-35.9%

-63.3%

-66.3%

-47.1 ”/0

-40.9%

Age 35-44 Age 45-54 55-64 Age 65-74 75+

% different % different % different % different % different

Cause Death from Death from Death from Death from Death from

of death rate US. rate rate U.S. rate rate U.S. rate rate U.S. rate rate U.S. rate

United Kingdom

Males

Total

Cancer

Heart

Accidents

Violence

Infection

Other

Females

Total

Cancer

Heart

Accidents

Violence

Infection

Other

174.4 -42.1% 511.9

38.6 -2.8% 154.0

50.3 -19.5% 235.4

23.1 -54.7% 24.0

8.6 -57.2% 8.4

2.2 -64.5% 2.7

51.6 -57.7% 87.4

117.7 -1 5.9% 315.4

61.4 26.6% 174.1

17.3 -29.4% 69.5

6.4 -57.3% 7.6

3.8 -30.9% 4.4

0.8 -74.2% 1.7

28.0 -35.5% 58.1

-18.6%

-7.4%

2.7%

-48.9%

-36.4%

-70.7%

-46.7%

-10.1%

12.4%

-22.0%

-52.5%

18.9%

-69.1%

-28.9%

1595.2

538.5

781.7

26.3

7.5

7.0

234.2

921.1

426.6

305.3

13.0

4.3

4.8

167.1

-0.7%

2.2%

15.6%

-48.6%

-21.9%

-63.0%

-27.8%

1.8%

13.3%

3.1%

-37.2%

38.7%

-63.1%

-14.4%

4123.9

1282.7

2046.1

37.5

7.2

16.2

724.2

2320.0

761.5

1064.2

26.0

4.9

8.7

454.7

15.4%

20.5%

25.3%

-45.3%

-2.7%

-63.0%

-3.3%

12.8%

15.5%

22.1%

-26.6%

32.4%

-70.3%

-0.5%

11121.2

2455.5

5363.9

118.0

10.7

39.1

3134.0

8440.6

1315.5

4541.7

127.7

5.6

26.3

2423,8

9.9%

23.7%

2.5%

-36.9%

23.0%

-71.3%

22.0%

10,6%

23.6%

1.3%

5.2%

27.3%

-78.1%

31 .7%
114 I International Health Statistics: What the Numbers Mean for the United States

gj
Appendix C-international Mortality Comparisons by Age: Tables and Figures I 115
116 I International Health Statistics: What the Numbers Mean for the United States
Table C-5-Trends in Age-Standardized Death Ratesa (per 100,000) for Selected Cancer Sites,

United States and Selected Countries, 1950-54 to 1980-94 (Continued)

1950-54 1955-59 1960-64 1965-69 1970-74 1975-79 1980-84

Age-Standardized Death Rates (per 100,000)

Breast cancere

United States

Australia

Canada

France

Germanyc

Italy

Japan

Netherlands

New Zealand

Norway

Spain

Sweden

United Kingdom

30.4

29.3

32.3

19.5

22.1

18.6

5.4

33.4

32.6

24.9

8.0

25.6

33.2

30.5

28.2

32.3

22.1

22.9

19.9

5.3

33.7

31.2

24.7

9.0

26.7

33.3

30.5

27.8

33.6

23.0

24.4

21.4

5.2

35.4

32.0

24.3

12.7

28.3

34.3

31.4

27.8

33.9

24.8

26.6

23.6

5.5

38.5

33.5

26.0

13.5

26.4

35.4

31.6

29.0

33.9

25.3

28.3

25.7

6.3

39.0

35.4

25.2

15.6

28.6

37.8

31.0

28.0

33.1

26.2

29.5

26.2

7.0

37.4

35.0

26.6

18.3

27.4

39.2

31.4

28.5

33.0

27.2

30.8

28.2

7.6

37.6

36.5

25.3

19.9

26.6

40.3

.—.

n

Cg

z

u ) —
118 I International Health Statistics: What the Numbers Mean for the United States

-ii
Table C-7--Comparison of U.S. and Canadian Death Rates (per 100,000) for the Five Leading U.S. Causes of Death,

Males, Age 15 to 24,1989

27,165

12,647

100.0%

46.6

142.4

66-3

2348

1,240

100.0% 117.5

621

21.1%

6.8

9,429

3,218

34.7

11.8

49.4

16.8

38.5

14.3

45.3

l & 8

9.1

0.6

5,112 26.8 82 3.5 4.1

4,106

1,074

15.1

4.0

2-15

5.6 131 5.6

26.4

6.6

-18.6

-142

2 2

13.4

3.1

19.1

44 1.9

13.8

2 2

162

40.4

17.9

is

o

s

A

A

w
5

&

-.

0

z

Table C-8--Comparison of U.S. and Canadian Death Rates (per 100,000) for the Five Leading U.S. Causes of Death,

Females, Age 15 to 24,1987

-

9,323 100.0% 50.9 791 100.0% 41.2 23.6%

. .

4,081

3,512

43.9

37.7

22.3

19.2

379

317

47.9

40.1

19.7

16.5

13.2

16.4

579 6.2 3.2 62 7.8 3.2 0.0

1,073 11.5 5.9 42 5.3 2.2 167.8

764

4.2

4.2

77

91

9.7

11.5

4.0

4.7

5.8

-12.0

8.3

8.2

2270

3.7

24.3

1.9

124

20

182

2.5

23.0

1.0

9.5

82.4

30.8 q’

s

CD
Table C9--Comparison of U.S. and Canadian Death Rates (per 100,000) for 10 Leading U.S. Causes of Death,

Males, Age 25 to 44,1989

Us. and

Us. Canada rate

cause of United States ~dfl~e~a

death rank Cause (ICD-9 Codes) Number Percent Rate (per 100,000) Number Percent Rate (per 100,000) (percent)

All causes

Accidents and adverse effects

(E800-E949)

Motor vehicle accidents (E810-E825)

All other accidents and adverse

effects (E800-E807,E826-E949)

Human immunodeficiency virus

infection (042444)

Diseases of heart (390-398, 402,

404-429)

Malignant neoplasms, Including

neoplasm of lymphatic and

hematopoletic tissues_ (140-208)

Suicide (E950-E959)

Homicide and legal intervention

(E960-E978)

Chronic liver disease and drrtmsis

(571)

Cerebrovascular diseases (430-438)

Pneumonia and influenza (480-487)

Diabetes mellitus (250)

All other causes

99,482

21,889

100.0%0

22.0

251.2

55.3

7040

2024

100.0%

28.8

161.7

46.5

55.4%

1 18.9

12,169

9,720

12.2

9.8

30.7

24.5

1108

916

15.7

13.0

25.4

21.0

20.9

16.7

2

3

4

14,646 14.7 37.0 8.3 13.4 175.7

11,204 11.3 28.3 11. 0 17.8 59.4

9,522 9.6 24.0 959 13.6 22.0 9.2

5

6

9,442

8,797

9.5

8.8

23.8

22.2

1181

160

16.8

2.3

27.1

3.7

-12.1

504.5

7 3,388 3.4 8.6 138 2.0 3.2 169.9

8

9

10

1,730

1,454

1,302

16,108

1.7

1.5

1.3

16.2

4.4

3.7

3.3

40.7

130

54

48

1.8

0.8

0.7

14.0

3.0

1.2

1.1

22.7

46.3

196.0

198.2

79.1

KEY: ICD = International Classification of Diseases-9 code.

aThe rate difference represents how much greater or smaller the U.S. rate is relative to Canada’s rates. It is calculated as the U.S. rate minus the Canadian rate, divided by the Canadian

rate.

SOURCES: Statistics Canada health Reports 3(1) (suppl.) (Ottawa, Ontario: Statistics Canada 1991); U.S. Department of Commerce, Bureau of the Census, Cument Population

Reports, U.S. Population estimates by Age, Sex, Race, and Hispanic Origin: 1980 to 1991, Pub. No. F’XP1095 (Washington, DC: U.S. Government Printing Office,

FebruaIy 1993; U.S. Department of Health and Human services, Centers for Disease Control end Prevention, National Center for Health Statistics, unpublished tables,

Hyattsville, MD, 1993.
Table C-10--Comparison of U.S. and Canadian Death Rates (per 100,000) for the 10 Leading U.S. Causes of Death,

Females, Age 25 to 44,1989

us. and

U.S. Canada rate

Cause of ~ Canad a

a

deat h Cause (ICD-9 codes) Percent Rate (per 100,000) Number Percent (per 100,000) (percent)

All Causes 41,9611 100.0% 104.8 3,411 100.0% 77.7

1 Malignant neoplasms, including

34.9%

neoplasms of lumphatic and

hematopoietic tissues (140-208) 11,534 27.5 28.8 1,250 36.6 28.5 1.1

2 Accidents and adverse effeects

(E800-949) 6540 15.6 16.3 17.7 13.7 18.9

Motor vehicle accidents (E810+E825) 4,40 2 10.5 10.9 11.5 8.9

All otheraccidents and adverse

effects (E800-E807,E826-E949) 2,138 5.1 5.3 211 62 4a 10.4

3 Diseases ofheart (390-398, 402, “

404-429) 4,040 9.6 10.1 214 6.3 4.9 106.9

4 Suicide (E950-E959) 2,454 5-8 6.1 10.4 8.1 -24.0

5 Homicide and legal intervention

(E960-E978) 5.6 5.9 80 23 1.8 223.0

6 Human immodeficiency virus infection

(042444) 1,676 4.0 42 28 0.8 0.6

7 Cerebrovascular diseases (430-438) 1,537 3.7 3.8 139 4.1 32 212

8 Chronic liver disease and cirrhosis

(571) 1,196 29 3.0 48 1.4 1.1 173.1

9 Pneumonia and influenza (480-487) 20 21 44 1.3 1.0 109.8

10 -

Diabetes mellitus (250) 817 1.9 20 43 1.3 1.0 108.3

All other causes 8,968 21.4 22.4 17.8 13.8 61.7

Key: ICD = International Clasification of ~ Diseases-9 code.

aThe rate difference represents how much grear3eater or smaller the U.S rate is relative toCanada's rates. It is calculated as the U.S. rate minus the Canadian rate, divided by the Canadian 

rate..

SOURCES:
Appendix C-International Mortality Comparisons by Age: Tables and Figures I 123

1! .
—

Table C-12-Comparison of U.S. and Canadian Death Rates for the 10 Leading U.S. Causes of Death, Females, Age 45 to 64,1989

Us. and

Us. Canada rate muse of United States ~differ-a

death rank Cause (ICD-9 Codes) Number Percenlt Rate (per 100,000) Number Percent Rate (per 100,000) (percent)

All causes

Malignant neoplasms, including

neoplasms of lymphatic and

hematopoietic tissues (140-208)

Diseases of heart (390-398, 402,

404-429)

Cerebrovascular diseases (430-438)

Chronic obstructive pulmonary

disease and allied Conditions

(490-496)

Diabetes mellitus (250)

Accidents and adverse effects

(E800-E949)

Motor vehicle accidents (E810-E825)

All other accidents and adverse

effects (E800-E807,E826-E949)

Chronic liver disease and cirrhosis

(571)

Pneumonia and influenza (480-487)

Suicide (E950-E959)

Nephritis, nephrotic syndrome and

nephrosis (580-589)

All other causes

143,892 100.0% 603.3 12,332 100.0 % 478.8 26.0%

1

61,951 43.1 259.8 6,325 51.3 245.6 5.8

2

3

4

32,987 22.9 138.3 2,172 17.6 84.3 64.0

6,994

5,893

4.9

4.1

29.3

24.7 341

4.9

2.8

23.3

13.2

25.9

86.6

5

6

4,788

4,240

3.3

2.9

20.1

17.8 429

1.9

3.5

9.3

16.7

116.3

6.7

2,349

1,891

1.6

1.3

9.7

7.8

231

198

1.9

1.6

9.0

7.7

7.8

1.3

7 3,581 2.5 15.0 2.1 10.3 46.5

8

9

10

2,036

1,763

1,108

1.4

1.2

0.8

8.5

7.4

4.6

145

237

74

1.2

1.9

0.6

5.6

9.2

2.9

51.6

-19.7

61.7

18,551 12.9 77.8 1,506 12.2 58.5 33.0

KEY: ICD. International Classification of i Dsesses ads.

aThe rate difference represents how much greater or smaller the U.S. rate is relative to Canada’s rates. It is calculated as the U.S. rate minus the Canadianrate, divided by the Canadian

rate.

SOURCES: Statistics Canada, Health Repott 3(1) (suppl.) (Ottowa, Ontario: Statistics Canada 1991); U.S. Department of Commerce, Bureau of the Census, Current Population

Reports, U.S. Population Estimates age,sSex, race, and Hispanic origin: 1980 to b 1991, Pub. No. P25-1095 (Washington, DC: U.S. Government Printing Office, Febrary

1993; U.S. Department of Health and Human Services , Centers for Disease Control and Prevention, National Center for Health Statistics, unpublished tables, Hyattsville, MD,

1993.
Table C13-Comparison of U.S. and Canadian Death Rates (per 100,000) for the 10 Leading U.S. Causes of Death,

Males, Age 65 and Over, 1989

Us. and

U.S.

cause of united -

death rank Cause (ICD-9 Codes) Number Percent Rate (per 100,000) Number Percent Rate (per 100,000) (percent)

All causes

Diseases of heart (390-398, 402,

404429)

Malignant neoplasms, including

neoplasm of Lymphatic and

hematopoietic tissues (140-208)

Cerebrovascular diseases (430-438)

Chronic obstructive pulmonary

disease and allied conditions

(490-496)

Pneumonia and influenza (480-487)

Accidents and adverse effects

(E800-E949)

Motor vehicle accidents (E81O-E825)

All other accidents and adverse

effects (E800-E807,E826-E949)

Diabetes mellitus (250)

Nephritis, nephrotic syndrome and

nephrosis (580-589)

Artherosclerosis (440)

Septicemia

Ail other causes

—70,261

23,609

100.0%

33.6

5,671.2

1,905.6

3.1 %

17.6

720,811

276,328

100.0%

38.3

5,844.6

1 2,240.6

2 178,430 24.8 1,446.8 19,055 27.1 1,538.1 -5.9

7.4

6.4

421.7

362.9

-9.2

-9.9

3

4

47,202

40,304

6.5

5.6

382.7

326.8

5,224

4,496

6.2

-8.1

5

6

29,972

13,525

4.2

1.9

243.0

109.7

2,836

1,479

4.0

2.1

228.9

119.4

0.6

1.5

31.6

87.8

1.6

-14.6

4,051

9,474

32.1

75.0

391

1,088

-1. 0

-8.2

7

8

13,399

8,187

1.9

1.1

108.6

66.4

1,359

896

1.9

1.3

109.7

72.3

831

10,267

67.1

16.9

828.7

-19.6

201.9

-1.6

9

10

6,652

6,281

100,531

0.9

0.9

13.9

53.9

50.9

815.1

1.2

0.3

14.6

KEY: ICD. International Classification of Diseases-9 code.

aThe rate difference represents how much greater or smaller the U.S. rate is relative to Canadas' rates. It is calculated as the U.S. rate minus the Canadian rate,

rate.

SOURCES: Statistics Canada Health Reports 3(1) (suppl.) (Ottawa, Ontario: Statistics Canada, 1991); U.S. Department of Commerce, Bureau of the Census, Current Population

Reports, U.S. Population Estimates by Age, Sex, Race, and Hispanic Origin: 1980 to 1991, Pub. No. P25-1095 (Washington, DC: U.S. Government Printing Office, February

1993; U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, unpublished tables, Hyattsville, MD,

1993.
Table C-14-Comparison of U.S. and Canadian Death Rates (per 100,000) for the 10 Leading U.S. Causes of Death,

Females, Age 65 and Over, 1989

—

All causes

. Diseases of hea@ (390-398, 402s

404-429)

Malignant ~ne)

neoplasms and Iymphaicmd

hematopoiec tkslms (14CH08)

Cerebrovascular (’K-’-V

Pneumonia and influenza (460-487)

Chronic obstructiv e

disease amdauedandibom

(490-496)

Diabetes mellitus (250)

.

Accidents and adverse effects

(E800-E949)

Motor vehicl e (E81O-E825)

All other axMantsadadvefse

effects (E800-E807,E82&E949)

Artherosclerosis (440)

Nephritis nephrdc syndrome @

nephrosis (~)

816,977

327,640

100.0%

40.1

4,4524

1,785.6

68,545

23,215

100.0%

33.9

3974.3

1,346.0

120%

1 327

2 157,776 19.3 859.9 15,591 227 804.0 -4.9

3

4

5

---

79,458

37,423

29,661

9.7

4.6

3.6

433.0

204.0

161.6

7511

3211

11.0

4.7

3.3

435.5

186.2

133.0

-0.6

9.5

21.6

6

7

21,399

13,307

2 6

1.6

116.6 1767

1,537

2 6

2 2

1025

89.1

13.8

-18.6

3,200

10,107

0.4

1.2

17.4

55.1 1,283

0.4

1.9

14.7

74.4

18.4

-25.9

8

9

11,761

9,321

1.4

1.1

64.1

50.8

1,434 21

1.3

83.1

51.7

-229

-1.8

10 9,147

120,084

1.1

14.7

49.9

654.4

216

11,132

0.3

16.2

125

645.4

298.0

1.4
Appendix C–International Mortality Comparisons by Age: Tables and Figures I 127

Figure C-1—Age-Specific Death Rates (per 100,000), Males, United States and Selected Countries,a 1987-88 b

Age 1-4

—. —.. -.— . ——... —. . . ...— .. —-- ——. - .—— — .—

Under age 1

1200 — 60

50

40

30

20

10

0

1000

800

800

400

200

T . . 1 -1 u s France Italy Spm Drnlnmh Swsdm N*w ZMand us Franm Italy SfMn DwuT18* Sw*don NW Z*a!md Cnnada Qemmny Nethefiands U K Norway Austmtia Japnn Canada c3Wnmny kethmlands U K Norway AWtmtia Japan

Age 5-14

40 .

Age 15-24

200

r

— . -. — .— -.. ——.—

1

30 4

20

1

10 i

I

nl , .

us ‘ Frmnc:

l-h

Italy S@n

1Dbfnurk 1 Swwd.n I N*w Zealk

Canada Germany Nwthwtands U K Norway Au9tr818 Japan u s France Italy spm D*lnu61 SwsdM N*w Z.aland

Canada Germany Ntihedmnds U K NOrWy Au*traN8 Japan

,4ge 25-34

?nn T — .—-—

Age 35-44

350 —-- -— ----- --—–-—— –--– - – -—–—- -–

T

I

3(XI

19

. . . 1 u us Fmnci My Spain Dsnmsk Swdsn k Znkd

C8nads O.rnwny N@thwtands U K Norway Auotlnla Japan us Franc. Italy Spain Dwwwk Swdm Now Zealand

Canada Germany Netherlands U K Ncfwy AustraNs Jsp8n
128 I International Health Statistics: What the Numbers Mean for the United States

Figure C-1—Age-Specific Death

700

MO

500

400

300

200

100

0

Rates (per 100,000), Males, United States and Seiected Countries,a 1987-88b

(Continued)

Me 45-54

T T

CaM& Gornuny kthdmds U K Norway ALmtmm Japan

Age 65-74

5000

4000

3000

2000

100U

o

us Frmco Its& ‘Spain &nm& &m& &v Zoalhd

cm-da Gummy Nctklands U K Mafvmy Ausbmua J8pan

2000

1500

1000

500

0

12000

1000O

aooo

6000

4000

2000

0

Age 55-64

————

us i Italv fLnnwk Sweden NW Z. And

Canach ‘Germany ‘&thetin~- U K

- t4cmway Austraha Japan

Age 75 and older

-----

France

Canadm Gefma

Italy

ny Netheria

Spm

nds UK

hvluk Swedeil N& Z*8 Norway Austraka

Iu?d

Japan

a Data f~ Germany from former Federal Republic Of Germany.

b Rates are for 1988, except for Italy, New Zealand, and Spain where 1987 rates are shown.

SOURCE: world Health Organization, l%ddlhdth Statlstlcs Annua/(Geneva, Switzerland: Worfd Health Organization, 1989, 1991, 1992).
100a

800

800

400

200

0

Appendix C-international Mortality Comparisons by Age: Tables and Figures I 129

Figure C-2—Age-Specific Death Rates (per 100,000), Females, United States

and Selected Countries,

a 1987-8 8b

Under age 1

,! ,,

us 1 France Italy r‘Spain Derwu& Swadm New Zaaknd

Canada Germany Netherlands U K NOfWmy Austmha JaPa

Age 1-4

60 T ---

50

40

30

20

10

0

Age 5-14

,,T ---- -

– ‘-1

I

v ‘us ‘ kranci ‘ Italy ‘spat. ’ Demnark SW& NO& Zealand

Caruda G-ny Netherlands U K Naway Auatl-aks Japan

Age 25-34

80 . ‘ 1

6 0 -

40-

20-

J

u sFrance naty ‘Spain D-ti SWadafl Naw Z**land

Canada Germany Na4hwiaMa U K NW-way Au8tm6a Japan

us ‘ France ‘ Italy .spmn Dwvnak SWdaA Naw Zedkd

Canada Germany Na(herfands U K Norway AuaVakz Japar

Age 15-24

,0 ~— – — – –..

‘7

50 I m

u s

Canada

France

Gumany

,.

tlaly

Nathedands

Sgwn

 U K

Darmnati

Ninny

SWOdan

)watmka

 New Zealand

Japan

1

Age 35-44

,~ ~. -. —

‘

-

‘ T

140 -

120-

100-

8 0 -

6 0 -

40

20 I

“

u s Franc, Raly Spa. Dumu& Svmdan NW Zoahnd

Cmada GamIw Nathadand8 U K Mc+Way Alatrab Japan
130 I International Health Statistics: What the Numbers Mean for the United States

Figure C-2—Age-Specific Death Rates (per 100,000), Females, United States

and Selected Countries,a 1987-88 b (Continued)

400

300

200

100

0

Age 45-54

—

2500

2000

1500

1000

500

0

u s Fmnco ‘ m+ ‘ ‘Smh’ Dmril Awdon N& zmhnd

Canada Qwwmny Nothwhnd; U K Nonv8y &18irlKa Jspan

Age 65-74

I

I

II

I

u s Frond ‘ ndy ‘Spain’ kk &vod&l I& Zodkd ‘

Canada &rrnany Nothwland# U K Nolway ALl@trDBa Jap@n

1200

1000

800

600

400

200

0

Age 55-64

u s FmlCo 1 WV S@ Dmmart( Swodon Now Zosland

Canada Qofmwry Nothorhnds U K Norimy AIJstrana Japw!

Age 75 and older

8000

ooOO

4000

2000

n

“ us hwwo

Gomu~n%thodsn~sh

Dofwnsrk Sweden Now ZOdand

C#M& UK Norvny AustrBla JaPmI

● Data for Qormany from former Federal Republic of Qormany.

b Rates aro ~r 1088, ● xcopt for Italy, New Zealand, and Spain whoro 1987 rate$ aro shown.

SOURCE: World Health Organization, 14bdd Health StafJstb Anrtual(Gonova, Swltzorland: World Health Organization, 1989, 1991, 1992),
Appendix C-International Mortality Comparisons by Age: Tables and Figures I 131

Figure C-3—Age-Specific Death Rates (per 100,000) for Accidents,a Males, United States

and selected Countries,b 1987-88c

Under age 1 Age 1-4

50 — 30

25

20

15

10

5

0

—. —-. . — ——.—.. . —. —.. —

40

30

20

10

0 L-I-l l-l .,, , .

‘Fmnco ‘ Italy ‘ (J8 ‘Frlnm It,ly S@. Nofw9y Almtrana J&pan

Canada Oumany Ntihwlands U K Swsdon Now Zdmd Canada (hnnany Notho!lands U K Sweden Nw Zdand

Age 5-14 Age 15-24

80 I I

“

u s

C8nada

Fmnoi

many

I

Raly

Nothutands

‘*aIn’

 U K

Nofwy

8w9don IL19trD18 Now Zo,hnd

‘Japan “ ‘us ‘ ‘Fmrl,

l-l

My Spah Nofwy J1A,mtralt Jspan

cIM& Oonnmy Ndhwimdt U K Swbdon NW Zmknd

&e 25-34 Age 35-44

I

11-1 -f 11 “ ‘us ‘ imnw IWy Spain NoIwy AU@f818 Jqon

CSMdS Gummy Nothorhndc U K -dsn Now Zmbnd u s Fmncc my/_&@n -Y Awtfala Japan

C*Mda tM-many UK SwQdml Now Zo,kd
132 I International Health Statistics: What the Numbers Mean for the United States

Figure C-3-Age-Specific Death Rates (per 100,000) for

and Selected Countries,b 1987-88 C

Accidents, a Males, United States

(Continued)

Age 45-54 Age 55-64

60

50

40

30

20

10

0

70

ao

so

40

30

20

10

0

T- - ‘--

u s Franco Imy

.

spat.

1.

Norw3y Auatraiia ‘Japar

I Canada Gefmany Nathedanda U K %aden Naw Zealand

u s France Italy Spa,n NOmmy Auatraba Japan

Canada Gemmny Natheriands U K Sweden New Zealand

Age 65-74 Age 75 and older

120

lca

80

60

40

20

0

400

300

200

100

u s Fratnx Italy

1

.5pm N0rw8y Auatrafia J81 0 I1 r I Canada Gannany Nathadanda U K SWadan w Zoabnd u s Francc Italy ‘ span Nuway AAlairaba

Canada

JaFW

Gafmarry Natheriands U K Swaden Naw Zealand

a l~A~dents~~ indu~s Intermtionalcl~fi~tion of Diseases-9 basic tabulation list AM E47-E53, ~CkntS and adverse eff~ts.

b Data for GerMny from former Federal Republic of Germany.

c Rat= are for 1888, ex~pt for Italy, New Zealand, and Spain where 1987 rates are shown.

SOURCE: Worid Health O~nizatlon, Wddl-/ea/th Stat/st/ca Annua/(Geneva, Switzerland: Mbld Health Organization, 1989, 1991, 1992).
Appendix C-international Mortality Comparisons by Age: Tables and Figures I 133

Figure C-4—Age-Specific Death Rates (per 100,000) for Accidents,” Females, United States

and Selected Countries,b 1987-88 C

Under age 1 Age 1-4

40 ——

30

20

10

0

25

20

15

10

5

us France Illnaty

.

Spa,n

1

NCRWBy Almtra#a Japan 0 11111111.1 I Canada Germany F4efhertands U K Sweden New Zeahnd

u s Frww Itatj Spa. Nowmy AIIwatia Japan

Canada (3Wmany Nethatinda U K Sweden New Zealand

Age 5-14

]0 ~ . -— - —––~

Age 15-24

30 ~——— -

.

8

6

4

2

0

:11177

I

9

I

T T I u s Franc. Wy Spare NOmvay Alntwa II

Japan

Canada 5elmany Nathetlmd, U K Swden New Zaabnd u s France naly .spam Not-way Auatraa8 Japan

Canada Germany Nather!ande U K Sweden Naw Zdand

Age 25-34 Age 35-44

25

20

15

10

5

0

16

~4

12

10

8

6

4

2

0

—

u s Fmnc: r Italy ‘ 1 .spam’ by

I

Cana&

kmtrk ‘Japa n

Germany Nethefhde U K Swad,n Mew Zoabnd

us

 r

‘FrwIce ‘ Italy ‘ ‘Spare krwj LStA ‘Japan

C-M& Germany Nctherhndo U K ~dan Mow Zoabnd
134 I International Health Statistics: What t he Numbers Mean for the United States

Figure C-4--Age-Specific Death Rates (per 100,000) for Accidents,a Females, United States

and Selected Countries,b 1987-88 c (Continued)

20

15

10

5

0

Age 45-54

. —. —— —— - . —.- — .— -—- — . —

us Fmrwo

Cmuda Wfrnany

My r Nothwla

IUK

kofwmy

$iwodon

Au8d

 Now Zdand

‘J8PCI 1

Age 65-74

50 -l–– .——.——————— -

I

40 1 1. I

30.

20-

10 q

o I us Prsnoo my Spsh Mmny ALIUmlm Japan

Cwlada Oww!y NUhwhds U K Swdon NW Zoalsnd

25

20

15

10

5

0

Age 55-64

.—.—

1 ‘T

us Ff8fuo My~h,dandpah M?+My hlmtralh

Canada w’nwly

Japsn

UK Sweden NW Zealand

Age 75 and older

400 T—–——- -- - — -– — -- –- -------

300

200

100

0

4

IL

‘ u s. r1‘Fmnai1‘“

Canadn M’lmwly

bItaty Spakl

Neth.risnds 1UK

-b-m

I

1

. . ..-,swA- Now ZMlmd

a 1iAodd*nt~17 Includes Intornatlonalcla~ifl~tjon of Dlseasw-Q baelo tabulation 11.t OOdea E47-E53, tiden~ and adverse Qffwts.

b Data for Gorrnany from formor Federal Ropubllo of Qormany.

o Rat- aro for 19s8, ● xoept for Italy, New Zealand, ● nd Spain whoro 1987 ratoe aro shown.

SOURCE: World Health Organlzatlon, bMWHoa/fhSt8tktti Annua/(Qonova, Switzerland: World Health Organlzatlon, 1989, 1991, 1992),
Appendix C-international Mortality Comparisons by Age: Tables and Figures 1135

Figure C-5—Age-Specific Death Rates (per 100,000) for Homicide and Other Violence,a Males,

United States and Selected Countries,b 1987-88 C

Under age 1 Age 1-4

35

3

2 5

2

1 5

1

05

0

10

8

8

4

2

0 -T I.—

u s

-.I Frmm’ I

nmly Spare N-Y Auetraka Japan

Canada Germany Netherlands u K Sweden NOW Zeabnd

u s Franco ndy Spwn Nwway ANatraia Japan

Cmati Germany Netherlands U K Swmdon New Zealand

Age 5-14 Age 15-24

2T . 3 0

1

- -

1

15

1

05

0

I

h.dldll [

UK

u s

Canada

Franrx

Gefrnany

tlsly

Netherlands U

Spare 

K

&way AJJatmia ‘Japan

Ihb9 Swaden Naw Zaalati

.

u s Franc; Italy .spam

Canada Germany $Hherfands

&-way huatraka Japan’

Sweden New Zealand

Age 25-34 Age 35-44

30 - —-—- ——--- ––

“—-~ 25 ~ -

---1

11

I

.

u s

C8nada

France

Germany

I@ty

Nathertands

Spain 

 U K

Nmvay

SW.*

hatrala

 New Zealand

‘Japan us Franco ILB.Italy spin NOrwmy &latraLl L-dJapan

Canada Gafmany Nathafland8 U K *clan New Zcabnd
136 I International Health Statistics: What the Numbers Mean for the United States

Figure C-5--Age-Specific Death Rates (per 100,000) for Homicide and Other Violence,a Males,

United States and Selected Countries,b 1987-88 C (Continued)

20

15

10

5

0

Age 45-54

—

u s ‘France ndy .spam k-way ktmk ‘JaPan

Cmwda G-ny Netherlands U K Sw*d.n NOW Zealand

Age 65-74

12

T

-.

– “--—7

u s France naty

dSfmm N0rw8y

1 AMtraba 1

Japan

Canada G-ny Natheriands U K SWadan New Zealand

14

12

10

8

6

4

2

0

Age 55-64

.—

I

u ST k-ic e Italy Spain Nfxwmy Auatra8a Japao

Caluti Germany N@thertands U K Swadan *W Zaahnd

Age 75 and older

10 I

I

8

6

4

2

n 1

I

I

“ ‘us ‘ ‘Frmca Italy spa,. my Amtralia l-l

Japan

Canada Germany Netherlands U K Sweden Naw Zaa19nd

a *cHOmi~de and Other Mole~e” i~{ud~ International cl~fi~tion of Diee~es.9 basic tabulation list -sE5$E~.

b Data for Germany from former Federal Republic of Germany.

c Rat= are for 1 ~8, exapt for ~aly, New Zealand, and Spain where 1987 rates are shown.

SOURCE: World Health Organization, H4wldHea/th Stat/stks Annuad(Geneva, Switzerland: World Health Organization, 1989, 1991, 1892),
Appendix C-International Mortality Comparisons by Age: Tables and Figures I 137

Figure C-6-Age-Specific Death Rates (per 100,000) for Homicide and Other Violence,a Females,

United States and Selected Countries,b 1987-88 C

Age 1-4 Under age 1

3

2 5

2

15

1

05

0

10

8

6

4

2

0 III Ill 11 1. T

hah ‘Japar

den New Zealand us ‘ France Italy Spare

Canada Germany Nefher!ands

Nmvay

us France Italy Spain Norway UK Swa huetraha Japan

Canada Germany Netherlands U K Sweden New Zea!and

Age 5-14

1 4 - 1

7

Age 15-24

———

IJMUI

6

5

4

3

2

1

0

12

1

0 8

0 6

04

02

0 ,T,hl — 1 -9

Norway

-..wAuetraka Japar

Sweden New Zealand u s France ttaly spa,.

Canada Germany Netheriande &y AIJetraka Japan

Sweden New Zembnd u s France

Canada Germar

Italy spa,.

JY Nettwriands UK UK

Age 25-34 Age 35-44

~ o . – —- — –—- - 1

7 i

--

‘

- “—-–7

I

I

Iu s

I I

1

4

3 !

-T1[1 TUI France Italy Spain

Canada Garmany Netherlands

Norway Almlr81a Japan

“us’ France ‘naly Spa,n NmWay Swdorl NWzoabnd Auairaka Japan

Canada G9rlnany Neiheriatis U K SWW% New Zealand UK
138 I International Health Statistics: What the Numbers Mean for the United States

Figure C-6-Age-Specific Death Rates (per 100,000) for Homicide and Other Violence,a Females,

United States and Selected Countries,b 1987-88 C (Continued)

7

6

5

4

3

2

1

0

Age 45-54

I

us ‘ ‘Franc.’ ‘ nab ‘ ‘Spaklr kvay Al-al; ‘JaPan

Caluda Germany N.thwianti U K Sumdul New Zealand

Age 65-74

6—-, —1

2

1

0 I

u s 1 Fmna Italy Spain NOwmy Mfala JaPen

Canada Gununy Nothertands U K SwOdon New Zsaland

7

6

5

4

3

2

1

0

Age 55-64

—

l_l_h IJS Ftmncn m

ItalyNdh=*n&y -Y Alntmla Japan

Cmada Gwnuny UK Swdml Now Zdm-ld

Age 75 and older

, ~____ –

‘“–— ----- -

4-

2-

Ot

us Ffanco Italy

1

Spain Norway Awhtim JaPUI

C8nad9 Germany Nothedands U K Swvdon Now Zoalmd

a wHOmld& and Other ~O~~e” l~{ud~ [nt~rnatlon~ c[~sif{~tlon of D{seage~9 ~lc tabulation list ~s E5~E~m

b Data for ~r~ny from former Fedeml Republic of Germany.

c Rat- are for 1988, except for Italy, New Zealand, and Spain where 1987 rat- are shown.

SOURCE: World Health Organization, Wbrfd Hea/th Statistks Annual (Geneva, Switzerland: World Health organization, 1989, 1991, 1992).
Appendix C-international Mortality Comparisons by Age: Tables and Figures I 139

Figure C-7—Trends In Age-Standardizeda Death Rates (per 100,000) for Injury and Violence,b - . Males,

1*

130-

12G

110-

10(3

90

m

7G

6 0

5 0

United States and Selected Countries,c 1955-84

. . . . . . . . . . . .. . . . . . . . .. . . . . . . . . .........-...... -.-.— -----------

..-............ .-. .”.”.-.—---. .-.-----’-’ . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . ..

—.

I . . . . . . . . . . . . . . ..

I

1955-59

-64

/ 1970-7 4

v1975-79

I 1 I I

Japan New Zealand UK 1 Spare ‘ ‘ Norway

... -, - I-.. .A. Qwfwien Itidv Netherlands
140 I International Health Statistics: What the Numbers Mean for the United States

Figure C-7—Trends In Age-standardizeda Death Rates (per 100,000) for Injury and Violence,b Females,

United States and Selected Countries,c 1955-84 (Continued)

60

55

5 0

4 5

40

35

30

25-

20

15

/

/

/

/

/

!

‘./ /’

4

/

;

~

,/

/

,;/

/

/

—/

1955-59

-64

Iermany ‘ Japan ‘ ‘Australia’ Nbw Zeala;d ‘ Sweden ‘ Spain ‘ 1 Norway

France u s. Canada UK Italy Netherlands

a The Eum~an standard population is used to age adjust rates.

b ~lnjuv and ~olewe~” lnd~e= [international c~=ifi=t{on of D~~ses.9 b~k tatilation Ilst (x)&s E47-E56, whbh include acddents (E47-53),

suidde and eelf-inflicted injuries (E54) and homicide and other violence (E55 and E56).

c Data for Germany from former Federal Republic of Germany.

SOURCE: Worict Health Organization, Wbdd Hea/th Staflstics Anrwal(Geneva, Switzerland: World Health Organization, 1989, 1991, 1992).
Appendix C-international Mortality Comparisons by Age: Tables and Figures I 141

Figure C-8-Age-Specific Death Rates (per 100,000) for Cancer,a Males Age 45 and Older, United States

and Selected Countries,b 1987-88 C

Age 45-54

m ~—-—––

7

250 1

200

150

100

50

0 Ius France Italy Spare

Canada Gannany ~~ UK

l-l

‘Lwa; Auetraih Japan

Sweden New Zea!and

leoo

1400

1200

1000

eoo

m

400

200

0

us

Age 55-64

700 T————————”—- .- ‘– -1

600

500

400

3oil

200

100

0

u s France Italy Spare

Canada Germany Nather!an& u K

Age 65-74

2500

2000

150a

1000

500

0

Frmce Italy SQaIn

Canada Germany Nathadands UK

NOr&-ay Australia Japal

Swwdao New Zealand

i40fway Auatrah; Japan

Sweden New Zealand

Age 75 and over

3m ~ ----- - ■ ✍

‘us France Italy Spain

Cam& Germany Netherlands UK

NoWay M8tda Japan

Sweden Nawzealand

a ~~rlnd~a International Classification of Diseases-9 basic tabulation list ~des o~l 4.

b Data fw @rmany from former Federal Republic of Germany.

C Rates are for 1888, except for Italy, New Zealand, and Spain where 1987 rates are sh~n.

SOURCE: World Health Organization, Mrld Health Statistics Annual (Geneva, Switzerland: World Health Organlzatlon, 1989, 1991, 1992).
142 I International Health Statistics: What the Numbers Mean for the United States

Figure C-9—Age-Specific Death Rates (per 100,000) for Cancer, Females Age 45 and Older, United States

and Selected Countries,a 1987-88 b

Age 45-54

——1~

Age 55-64

200

1s0

100

so

o

400

300

200

100 1. -r -r -1 n

u s Franc. naty Spain Norway Auatrala

Canada

Japan -

Germany Netheflw?ds U K SWadefl Flaw Zealand

us France’ Italy ‘S@n &v AUatrali JaDan

Camda Germany iWhadanda U K -SWadon F&w Zealand’

Age 65-74 Age 75 and over

800 T-- ‘— ——– 1

14~ ~—. — 1

I

1200

1000

m

800

400

203

0

+

1

I

600

400

200

0

I

u s franc: ttdy ‘ ‘ Spain

Canada G9fmany Pktheftmds

iwway AIstrank ‘Japan

UK Swaden Naw Zaalmd

us ‘ ‘Franca’ Italy ‘S@n

Canada Germany Notblanda

i&rwey AJetrad ‘Japan’

UK Swadan Maw Zealand

a Data for Germany from former Federal Republic of Germany.

b Rates are for 1988, except for Italy, New Zealand, and Spain where 1987 rates are shown.

SOURCE: Wodd Health Organization, Wr/d/-fea/th Stat/sks Anrwa/(Geneva, Swhzerland: Wodd Health Organization, 1989, 1991, 1992).
Appendix C-international Mortality Comparisons by Age: Tables and Figures I 143

Figure C-10--Trends in Age-standardizeda Death Rates (per 100,000) for Circulatory System Disease,b

United States and Selected Countries,c 1955-84

Males

—_ ——___.._.-”....—.-....-...-..-.-.—.——— ... -__.,. _.-_ -. .". -....-.-....-. -..." ------------------

8s3

8oo750-

7(2G

65G

600

550

500 /

450 / :

400 /

350

u s

1955-59

-64

Iv’r

1975-70

1960-84

‘ UK ‘ N&w Zeala~d ‘Germany’ “ France Spain Norway

Australla Canada Sweden Japan Italy Netherlands
144 I International Health Statistics: What the Numbers Mean for the United States

Figure C-l O-Trends in Age-Standardizeda Death Rates (per 100,000) for Circulatory System Disease,b

United States and Selected Countries,c 1955-84 (Continued)

Females

A

5

ScKb

4!$O4m35ch

300_

/

.’<

2*/:,$

/

//

‘ us ‘ “ U.K. ‘ ‘ Canada’ ‘Germany’ ‘ France ‘

Australia

‘ Spain ‘ ‘ Norway ‘

New Zealand Sweden Japan Italy Netherlands

lm5-5s

-s4

, , f’

a The ~m~an standard population is used to age adjust rates.

b ‘Cim[atw s~tem disease” inducfes International Classification of Diseases-9 basic tabulation ikd COdSS 25-W.

C Data for &rmany from former Federai Republic of Germany.

SOURCE: Wodd Health Organization, bWdd/-/ethth StatMcsAnnu a/(Geneva, Switzedand: Wodd Health Organization, 1989, 1991, 1992).
Appendix C--International Mortality Comparisons by Age: Tables and Figures I 145

Figure C-11—Age-Specific Death Rates (per 100,000) for Circulatory System Disease,a Males Age 45 and

Older, United States and Selected Countries,b 1987-88 C

Age 45-54 Age 55-64

.—— 800

600

400

200

0

30a

250

200

150

1C43

50

0

u s Fmnce My ‘Spar ?Wwmye AustmRa ‘Japan

I u s France 1 -1

Italv

T

%81n NOrTnY Almtmaa 1

Japar)

cm-lads Gem-my “kthertati” U K -Sweden Now Zealand Canada Gemm-fy Nethedands U K NW Zealand

Age 65-74 Age 75 and older

2500

2000

1500

1000

500

0

7000

6000

5ooa

4000

3000

2000

lm I 1, o

us ‘ kc; r my ‘

)!

‘Spare NOfvm~ ktrala ‘Japa n

Canada Germany Nathdm& U K SwWJen New Zealand

u s Franc* My Spain NOfwmy *I* Japan

Canada Gemwny PWherlands u K swwden New Zealand

a ~fc}rw/atq SPtm d~~e” ind~es International Classification of Di*-es-9 k$k tabulation l~t*S25_~.

b Data for Germany from former Federal Republic of Germany.

c Rat= are for 1988, except for Italy, New Zealand, and Spain where 1987 rates are $hHn.

SOURCE: Wodd Health Organization, Mdd Hea/th Stat/stlca Armua/(Geneva, Switzerland: Wortd Health Organization, 1989, 1991, 1992).
146 I International Health Statistics: What the Numbers Mean for the United States

Figure C-1 2—Age-Specific Death Rates (per 100,000) for Circulatory System Disease,a Females Age 45 and

Older, United States and Selected Countries,b 1987-88 C

100

m

eo

40

20

0

1200

1000

600

600

400

200

0

Age 45-54

us Ftancc naly Spain Norway tili ‘Ju18n

Cmad~ Genmny Matherhnds U K -~ NW Z,almld”

Age 65-74

-r

u s Francs Italy Spain -y AWtfali

Canada

‘JaPM

Gwmany Mthorlands U K SWdan Now Zoalmd

350

300

250

200

160

100

50

0

Age 55-64

u s Fm’nx Italy S9dn NOwav AUtnh I.lanal

Cmda Gonnany ‘kthorlmds U K

-—r—

-Swden New Zealand

Age 75 and older

6000

4000

3000

20W

1000

0

us ‘ Fmwo Italy “Spain N0fw8y I kmtdI

‘Japan

Canada C3urnany Nathodands U K SW8den New Zoalwld

a $~c{mlatq gwtm d~~e” Indudeg international Clasalficatbn of Diaeaaea-9 kio tabulation Ikt ~s 2=.

b Data for Germany from former Federal Republic of Germany.

c %t~ are for IW8, except for Italy, New Zealand, and Spain where 1987 rates are shown.

SOURCE: World Health Organization, 144w#Hea/th Stat/st/u Anrwa/(Geneva, Switzerland: World Health Organization, 1989, 1991, 1992),
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