Cripplers and killers : a profile of Georgia

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TO THE PEOPLE OF GEORGIA FOR WHOM PLANNING IS ESSENTIAL

CRIPPLERS AND KILLERS A PROFILE OF GEORGIA
A Publication of The Department of Human Resources Division of Physical Health
G. E. Alan Dever, Ph.D., Consultant Georgia State University
William S. Barton, Research Assistant Georgia State University
Michael R. LaVoie, Research Assistant Department of Human Resources
Charles M. Plunkett, Research Assistant Georgia State University

TABLE OF CONTENTS

Section I Introduction .

.pa~e

Section II

Infant Deaths.

8

Section III

Heart Disease and Cerebrovascular Disease Mortality.

19

Section IV Cancer Mortality.

. . . . . . . . . . . . . . . 34

Section V Accidental Deaths.

. . . . . . . . . . . . . . . 50

Section VI

Venereal Disease Morbidity

57

Section VII

General Index of Health Status

64

ii

LIST OF TABLES

Table

Page

1. Total Infant Mortality by Service Area, 1969-1972 . . . 12

2. Non-White Infant Mortality by Service Area, 1969-1972 . 13

3. White Infant Mortality by Service Area, 1969-1972 . . 14

4. Total Neonatal Mortality by Service Area, 1969-1972 . 16

5. Non-White Neonatal Mortality by Service Area, 1969-1972 . 17

6. White Neonatal Mortality by Service Area, 1969-1972 . 18

7. Hypertensive Disease, Age-Sex Adjusted Death Rates

by Service Area, 1969-1972 . . . . . . . . . .

24

8. Acute Myocardial Infarction, Age-Sex Adjusted Death Rates

by Service Area, 1969-1972 . . . . . . . . .

26

9. Ischemic Heart Disease (Excluding Acute Myocardial Infarction), Age-Sex Adjusted Death Rates by Service Area, 1969-1972 . . . . . . . . . . . 28

10. Other Forms of Heart Disease, Age-Sex Adjusted Death

Rates by Service Area, 1969-1972 . .

30

11. Cerebrovascular Disease, Age-Sex Adjusted Death Rates by Service Area, 1969-1972 . . . . . . . . . . . 33

12. Malignant Neoplasm of the Stomach, Age-Sex Adjusted

Death Rates by Service Area, 1969-1972 . . . .

37

13. Malignant Neoplasm of the Large Intestine, Age-Sex Adjusted Death Rates by Service Area, 1969-1972. 40

14. Malignant Neoplasm of the Rectum, Age-Sex Adjusted Death Rates by Service Area, 1969-1972 . . . . . . 42

15. Malignant Neoplasm of the Trachea, Bronchus, and Lung, Age-Sex Adjusted Death Rates by Service Area, 1969-1972. . . . . . . . . . . . . . . . . . . . . . 44

iii

List of Tables (Continued)

Table

16. Malignant Neoplasm of the Breast, Age-Sex Adjusted Death Rates by Service Area, 1969-1972 . . . . . 47

17. Malignant Neoplasm of the Cervix Uteri, Age Adjusted Death Rates by Service Area, 1969-1972 . . . . . 49

18. Motor Vehicle Accidents, Age-Sex Adjusted Death Rates by Service Area, 1969-1972 . . . . . . . . . . 54

19. Accidental Deaths (Excluding Motor Vehicle Accidents)

Age-Sex Adjusted Death Rates by Service Area,

1969-1972. . . . . . . . . . . . . . .

56

20. Primary and Secondary Syphilis, Morbidity Rates

by Service Area, 1967-1972

.

61

21. Gonorrhea, Morbidity Rates by Service Area, 1967-1972 . . 63

22. General Index of Health Status Ranked by Service Area,

1972 . . . . .

. . .. ....

. 67

23. Correlation Matrix

.

. 69

24. Sum of Correlation Coefficients .

71

iv

LI ST OF FI GURES

Figure

Page

1. Infant Mortality, 1969-1972 . .

11

2. Neonatal Mortality, 196901972 .

15

3. Hypertensive Disease, 1969-1972

23

4. Acute Myocardial Infarction, 1969-1972.

25

5. Ischemic Heart Disease, 1969-1972

Excluding Acute Myocardial Infarction.

27

6. Other Forms of Heart Disease, 1969-1972 . .

29

7. Cerebrovascular Disease, 1969-1972.

32

8. Cancer of the Stomach, 1969-1972 . . .

36

9. Cancer of the Large Intestine, 1969-1972 . .

39

10. Cancer of the Rectum, 1969-1972 . . . . .

41

11. Cancer of the Trachea, Bronchus, and Lung, 1969-1972 . . 43

12. Cancer of the Breast, 1969-1972 .

46

13. Cancer of the Cervix, 1969-1972

48

14. Motor Vehicle Accidents, 1969-1972.

53

15. Accidental Deaths, 1969-1972

Excluding Motor Vehicle Accidents . .

55

16. Syphilis, 1967-1972

Includes Primary and Secondary Cases .

60

17. Gonorrhea, 1967-1972 . .

62

18. General Index of Health Status.

66

19. Georgia Service Areas . . . .

73

v

Preface
For decades, communicable diseases -- tuberculosis, smallpox, polio, whooping cough -- virtually staggered populations. But with the advent of vaccines, antibiotics and modern medicine there was a dramatic down swing of these types of diseases. Now, and probably in future decades, new disease patterns have emerged for which there are no present cures or vaccines. For instance, cancer, heart disease and stroke currently are the diseases which cripple and kill Georgia's population.
In this monograph, selected data are used to present these new disease patterns in the state of Georgia. The resulting patterns reflect high and low risk areas that must subsequently be investigated. Although this is a county and service area analysis, it must be recognized that further differences exist at intra-urban and intra-county levels.
This monograph could not have been completed without the assistance of many friends and colleagues, specifically my research assistants Scott Barton, Michael LaVoie and Charles Plunkett. It was these individuals who labored and provided valuable input to the project. I would like to give a special thanks to Edward Bistany who gave freely of his time and comments. Further there are many individuals too numerous to mention who retrieved and coded the original data from the counties. The individuals in the Vital Records section and the Biostatistics unit are very much a part of such a project. Nevertheless, the author alone is responsible for any insufficiencies or inaccuracies in the design and execution of this monograph.
1

INTRODUCTION
Presently the United States is experiencing a series of epidemics which cause crippling and killing and an overall destruction to our society. Unlike infectious disease patterns and epidemics in the early 1900's, this present crisis is a result of various life-styles which reflect non-infectious disease patterns. Typical examples are heart disease, cancer and stroke.
Georgia, a fast-growing primarily rural southern state, certainly is not excluded from this disease crisis that is expanding within the United States. The epidemic related to the cripplers and killers is really not well understood and basic informative disease patterns have been lacking. The ldentification of the various disease patterns is essential to the growth, development, policy formulation and planning of various human,resource activities.
The major objective of this monograph is to illustrate the disease patterns of the crippers and killers in Georgia for a four-year period: 1969 to 1972. Maps showing the disease patterns may be viewed at the county or service area level. These pictorial descriptions will aid the local and state health agencies to identify target areas of high and low risk. A further objective of this study is to provide a health base-line by which future changes in the disease patterns may be evaluated. A final objective is to develop a general index of health status. This index and the maps are based primarily on mor-
3

tality data with some morbidity data on various venereal diseases. Obviously there are difficulties in using mortality data for the development of an index but in the absence of meaningful morbidity data the mortality data are utilized. Frankly, if mortality data are acquired, utilized, manipulated and mapped r~pidly, it provides a significant input due to minimal time lag. Many researchers seek an optimal solution where merely good ones will suffice. In social planning it clearly is evident that we will not attain a 100 percent explanation. However, future efforts in health care should consider the development of a morbidity reporting system. In the interim, therefore, hospital admission and release diagnosis of patients could serve as a beginning morbidity reporting system.
This monograph also represents an initial base which must be updated, improved and continually evaulated. The target areas identified in this report are subject to further data resolution for a more complete and specific assessment of need. Methods employed for further assessment include sampling (usually stratified according to meaningful relationship to the functional impact on the disease pattern), surveys (primarily questionnaires or some other form of solicitation), and surveillance techniques. Obviously, these methods are not mutually exclusive processes. Utilizing anyone or all of the above methods (depending on intent of evaluation) one may select a previously determined target area and begin subsequent identification of population groups for a more detailed assessment. At this point, the assessment should include data related to sociodemographic, economic, attitudinal, behavioral and perceptual characteristics of individuals to the specific programs in question.
4

Mapping of Disease

The mapping of disease patterns has been of historical value.

Future disease patterns will continue to be of major importance be-

cause of their utility for evaluation purposes. In this monograph,

seventeen maps display the various crippler and killer patterns in

the state of Georgia. Each map contains a legend indicating four

levels of disease rates. The disease rates were age- and sex-adjus-

ted using the 1970 Georgia population as the Standard Million.*

Further, on each map there is a graph or frequenc~ distribution which

reflects standardized scores. Accordingly, the average is set equal

to zero and the standard deviations range from greater than a plus

one (1) to less than a minus one (1). These standardized values be-

come z-scores. A z-score is a transformation of the original data

such that its average or mean becomes zero and its standard deviation

becomes, unity. This transformation is important for a meaningful

interpretation and comparison among county disease variations. For

example, zl = Xl - j
S

(1) where:

zl = the transformed standard score for county 1 Xl = the original value for county 1 X = the average or mean of the disease rate for the
state

S = the standard deviation of the disease rate for
the state

Therefore, in the case of cancer of the cervix for Appling county we

*The age-sex-race adjusted death rates are not provided in this volume but they are available from G. E. Alan Dever, Division of Physical Health, Department of Human Resources, Atlanta, Georgia.

5

develop:

XApp1ing - XState

ZApp1ing = county

county

Sstate

(2)

Substituting:

Z

_ 5.75 - 4.55

(3)

Appling - 4.12

county

Thus, the z-scare for Appling county is .291. On each map the zero

(0)' ref~ects the state average and the values above and below this

average are displayed in such a manner that the reader may see if

there are more counties above or below the state average.

A map outlining the 23 Service Areas and identifying the 7 Standard Metropolitan Statistical Areas in the State may be found on the last page of this monograph. The map clearly defines each service area from which the reader will be able to make visual comparisons with other areas. The map further aids the reader in identifying specific target areas which should necessitate further investigation.

Tabular Display of Data Accompanying each map is a Table which depicts a rate and a pro-
portional value which is derived from the state average. The tables further reflect values for the service areas which are aggregations from the county data. Implicit in each table is a ranking of the service areas which indicates areas that are above or below the state average. The state average for each table is set equal to 100 and the values calculated for each service area provide interesting comparisons. The rate as a proportion of the state average(when the state average was set equal to 100)is calculated in the following manner. For instance,

6

(4)

where:

Xl = rate as a proportion of the state average

Rl

= rate
rate

(depending on could be only

the one

disease category of the following

the three:

[1] age-sex adjusted death rate; [2] infant

mortality rate; and [3J morbidity rate) of the

service area.

Ms = the average rate for the state 1969 - 1972
= multiply

Therefore, in the case of infant mortality for servi ce area 19 we

develop:

Rlnfant Mortality Rate

Service Area 19
XService =

100 ( 5)

Area 19 Mlnfant Mortality Rate

State Average

Substituting:

XService -- ~ 23.5 100

(6)

Area 19

Thus, the rate as a proportion of the state average for service area

19 is 111.9 (see Table 1). The monograph incorporates 21 such tables

that are constructed uniformly for comparative purposes.

7

INFANT MORTALITY
This section displays the infant and neonatal mortality rate for 1969 - 1972. Their respective averages for this period are 23.5 and 14.6 peaths per 1000 live births. The map on infant mortality clearly depicts that the majority of the high risk areas (counties) are in the southern half of the state. Further inspection of the non-white infant mortality rates clearly shows the impact of this group on the state average. In fact, all service areas show nonwhite infant mortality rates higher than the state average while the white infant mortality rates reflect an opposite situation with the exception of service area 11. The rates range from 28.3 to 73.7 for the non-white and 12.1 to 24.7 for the white rates (Tables 2, 3).
In comparison to the infant mortality rates, the neonatal mortality rates reflect a somewhat different pattern. (There are more service areas found above the state average which indicates that infant deaths within the first 27 days is a more serious problem than those deaths up to one year.) For instance, service areas 2, 6 and 12 are below the state average for infant deaths but well above the state average for neonatal deaths. The non-white neonatal death rates for the majority of the service areas are above the state average. There are moderate shifts in some of the service areas demonstrating the importance of race as a target area variable. In contrast, the white neonatal rates for the service areas are almost all below the state average. Specifically, service areas 2, 3, 9, 11
9

and 23 are the five above the state average. Interestingly, areas 3, 9 and 23 cluster in the southern portion of the state. The rates for non-white and white neonatal deaths range from 12.8 to 27.6 and 8.3 to 18.8 per 1000 births respectively.
Identifying these infant and neonatal disease patterns will aid health officials in planning and improving the delivery of infant health care. Subsequent investigation of these identified target areas should lead to more accessible and available family planning services and care for infants and mothers. Hopefully, the results of this section will provide the local health officials insights into their relative ranking in the state in terms of service areas and further will demonstrate the problem counties within the service area. Utilizing these two indicators in association with morbidity, a planner will be able to effectively evaluate his program and provide health services in specific geographic areas. Failure to act in these directions will lead to eventual death and retardation for the babies of Georgia.
10

INFANT MORTALITY, 1969-72

.:::::::::::::::::::::"

DEATHS PER 1000 LIVE BIRTHS
D 4.2-16.2 Eillill 16.3-21.8
~ ~ 21.9-29.5
29.6-52.2

-.75 SD 0 +.75 SD

Healthier

Unhealthier

TABLE 1. --TOTAL INFANT MORTALITY BY SERVICE AREA, 1969-1972

Service Area

Rate Per 1000 Live
Bi rths

Rate as a Proportion of State Average
(State Average = 100)

21

27.8

11

27.6

9

27.0

23

26.6

19

26.3

Above

17

26.0

State

18

25.8

Average

15

25.3

3

25.0

13

24.8

22

24.4

16

23.6

118.3 117.4 114.9 113.2 111. 9 110.6 109.8 107.6 106.4
105.5 103.8 100.4

------------------------------------------------------ -------~------------

State Average

23.5

100.0

_____________________________________________________________ w-

-.-- __ -

14

23.4

99.6

10

23.3

99. 1

20

23.3

99.1

6

22.2

94.5

Below

2

22.0

93.6

State

12

21.9

93.2

Average

1

18.7

79.6

8

17.2

73.2

4

15.8

67.2

7

15.6

66.4

5

15.3

65. 1

Source: Author.

12

TABLE 2.--NON-WHITE INFANT MORTALITY BY SERVICE AREA, 1969-1972

Servi ce Area

Rate Per 1000 Live
Bi rths

Rate as a Proportion of State Average
(State Average = 100)

2

73.7

15

38.2

21

38.2

7

36.7

8

35.4

9

35.4

22

35.0

17

34.8

4

34.7

11

33.7

Above 19

32.5

State 3

32.4

Average 13

32.3

5

32.2

18

32.0

23

31.0

1

30.9

10

30.8

20

30.8

14

29.2

313.6 162.6 162.6 156.2 150.6 150.6 148.9 148. 1 147.7 143.4 138.3 137.9 137.4 137.0 136.2 131.9 131.5
131. 1 131.1 124.3

16

28.9

12

28.5

6

28.3

123.0 121. 3 120.4

------------------------------------------------------------------------

State Average

23.5

100.0

------------------------------------------------------------------------

Source: Author.

13

TABLE 3.--WHITE INFANT MORTALITY BY SERVICE AREA,1969-1972

Service Area

Rate Per
1000 Li ve Bi rths

Rate as a Proportion of State Average
(State Average = 100)

11

24.7

105.1

--------------------------------------------------------------------------

State Average

23.5

100.0

--------------------------------------------------------------------------

9

3

2

22

10

23

15

19

1

20

Below

12

State

16

Average

6

21

13

4

8

14

17

5

7

18

21.2

90.2

20.9

88.9

20.8

88.5

19.3

82. 1

19.2

81. 7

18.9

80.4

18.3

77.9

17.9

76.2

17.6

74.9

17.6

74.9

16.9

71.9

16.7

71.1

16.4

69.8

16.2

68.9

15.3

65. 1

15.2

64.7

~lS,~

64.7

14.9

63.4

13.9

59.1

13.8

58.7

13.6

57.9

12. 1

51. 5

Source: Author.

14

NEO-NATAL MORTALITY, 1969-72
DEATHS PER 1000 LIVE BIRTHS
D 0.0-9.3
I::::.:J 9.4-12.9
~!!f!!!lll 13.0-18.9 ~.m..i.i..m..i 19.0-47.4

-.75 SD 0 +.75 SD

Healthier

Unhealthier

............

\.::::::::::::::::: :.:.~.~.~.~.~.~.~.~.!.~.:.
.::::::::::::::::::::ggoo':::::::

'.. .
l::...

~.. .1

llili!!ii!l!ill'ii!!!!!i !!!;:.", II I' '(' ,
1IIIn"""'.ll!!!!!!!!'IIIIIIIIIIII,III~~ 1'1::I~I: I ,II~II .::::::::::::::' 1..,..:::::::::::::::::::::: ::::::::::::::::::::
.:.,:::::::::::::::::::::::::::::::::::::::::"::i,:':,1'I'I'I'I'I'i1,'1i,1'i1,'1,'i1i,1'i.,8'i8ji8::8g888g8g8m88m88::::::::::::::::::::::::::::::::::::::::

1:""H,~~~i!~~:::;~i: I ' ::::::::::::::::::::::::::: 1II1J1IIIIIIIIIUII:gllmmmm

... ....

:.::::::::::::::::::::::g:g:g:g.g.g..g.g.g.g.g,g..g.:.g.g.g,g.g.g..g.g.g.g..g.g.g.g.g..g.g.g.g.gi

II IIIII:I!III:III!::::::::

....................................

TABLE 4.--TOTAL NEONATAL MORTALITY BY SERVICE AREA. 1969-1972

Servi ce Area
9 15 6 3 11 17 2 Above 23 State 13 Average 21 22 16 12 19
State Average
1 10 8 Below 14 State 20 Average 18 4 5 7
Source: Author.

Rate Per 1000 Live Bi rths
20.4 17. 1 17.0 16.8 16.5 16.5 16.4 16.2 15.9 15.2 15.0 14.9 14.7 14.7
14.6
13.7 13.2 13. 1 12.9 12.9 12. 1 11.3 10.5 10.4

Rate as a Proportion of State Averaqe (State Average ='100)
139.7 117. 1 116.4 115.0 113.0 113.0 112.3 111.0 108.9 104. 1 102.7 102.1 100.7 100.7
100.00
93~8
90.4 89.7 88.4 88.4 82.9 77 .4 71.9 71.2

16

TABLE 5.--NON-WHITE NEONATAL MORTALITY BY SERVICE AREA, 1969-1972

Servi ce Area

Rate Per 1000 Li ve
Bi rths

Rate as a Proportion of State Average
(State Average = 100)

9

27.6

8

24.2

15

21.6

17

21.6

6

21.5

2

21.0

7

20.3

Above 21

19.0

State 4

18.3

Average 13

18. 1

3

18.0

22

17.6

1

17.5

19

16.9

12

16.4

16

16.2

189.0 165.8 147.9 147.9 147.3 143.8 139.0 130. 1 125.3 124.0 123.3 120.5 119.9 115.8 112.3 111.0

State Average

14.6

100.00

------------------------------------------------------------------------

14

14.4

98.6

18

13.8

94.5

Below 10

13.7

93.8

State 5

13.5

92.5

Average 23

13.3

91.1

11

13.0

89 .0

20

12.8

87.7

Source: Author.

17

TABLE 6.--WHITE NEONATAL MORTALITY BY SERVICE AREA, 1969-1972

Service Area

Rate Per 1000 Li ve
Bi rths

Rate as a Proportion of State Average
(State Average = 100)

II

18.8

128.8

Above

3

16.2

111.0

State

2

15.7

107.5

Average

9

15.2

104.1

23

15.2

104.1

_________________________________________________ w

-

w

.--

State Average

14.6

100.0

15

14.4

98.6

22

13.9

95.2

1

13.6

93.2

12

13.6

93.2

19

13.4

91.8

13

13.3

91.1

16

13.0

89.0

10

12.9

88.4

Below

20

12.7

87.0

State

6

12.6

86.3

Average 14

12.1

82.9

8

11.8

80.8

4

11.4

78.1

21

11. 3

77 .4

17

10.7

73.3

5

10.3

70.5

7

9.5

65. 1

18

8.3

56.8

Source: Author.

18

HEART DISEASE
Heart disease is the leading cause of death in the United States and also ranks number one in Georgia. Heart disease includes several cateqories: hypertensive disease, acute myocardial infarction, ischemic heart disease and other forms of heart disease. These diseases reflect a mode of living that is difficult to alter but which, hopefully if changed, might result in a subsequent decline of this major crippler ~nd killer.
Death due to hypertensive heart disease in Georgia is concentrated in two major areas. The map indicates a continuous high-risk belt that extends from south-east Richmond county to Chatham county and south along the coast. A second high-risk concentration is clustered in the central and western portion of the state. The rates for this disease of rather low incidence range from 2.38 per 100,000 in service area 7 to 30.5 per 100,000 in service area 3. It is evident from Table 7 that there are more service areas below the state average.
The outcome of an acute myocardial infarction, more commonly known as a heart attack, can be said to be subjective to the quality of the emergency medical system. It has been estimated that 20 percent of all fatalities due to heart attack could have been prevented with prompt and efficient medical service. This means that possibly 200 lives could have been saved in service area 17 during the 1969-1972 period. These and other possibilities might be deserving of attention.
20

nne major high-risk area exists in the southern section of the state while seconda~y high-risk areas occur in an apparently random pattern. Likewise, the pattern for low-risk areas is sporadic. The prevention of this form of heart disease is dependent upon the alterati on of an indivi dua l' s 1ife-s tyl e; the survi va 1 of a vi ctim may be deoendent upon the efficiency of the emergency medical service.
Ischemic heart disease, unlike acute myocardial infarction, is a chronic disease that results from arteriosclerosis or a narrowing or occlusion of the coronary arteries. The developing imbalance between blood supply and cardiac muscle gives rise to ischemia or damage. The rates for this form of heart disease range from 19.5 to 194.8 per 100,000. The map clearly depicts counties and service areas that are high-risk. These target areas could serve as pilot program areas to further identify high-risk populations. The county disease pattern shown on the map of ischemic heart disease reflects random variation. Table 9 shows that 13 of the 23 service areas are above the state average. The western portion of the state, specifically service areas 1, 2, 5,11,18,19 and 21, reflect rates lower than the state average.
Finally, the category of other forms of heart disease is strongly skewed in favor of lower rates. Thirteen of the 23 service areas are below the state ~verage (Table 10). The pattern for these forms of heart disease is quite definitive. The coastal counties and a small core of counties encompassing service area 19 show rates well above the state averaae.
The four patterns of the different tyoes of heart disease clearly suggest that health planners cannot allocate resources on the basis of
21

a category called "total heart disease". The patterns exemplified in this section should extend the planners' awareness that the various forms of heart disease have quite dissimilar qeoqraphical distributions. For this reason, resource allocation programs should account for these geographical inequities that exist in the state of Georgia.
22

HYPERTENSIVE DISEASE, 1969-72

AGE-SEX ADJUSTED DEATH RATES PER 100,000

D 0.0-3.3
C12J 3.4-14.0

14.1-24.8

::::::::. 1.11110
.....on.

249-860

STATE AVERAGE -14.3

-150 0 +150

Healthier

Unhealthier

.......

'.'

0000000000000000000

:::.. ::i.:.:'!!!llll!!l!llllllill ::::::::::::::!~.

ggggggo a ::::::::::::::::: ::::~~~~~~~~:

TABLE 7.--HYPERTENSIVE DISEASE, AGE-SEX ADJUSTED DEATH RATES BY SERVICE AREA, 1969-1972

Servi ce Area

Age-Sex Adj usted Death Rate Per 100,000

Rate as a Proportion of State Average
(State Average = 100)

S
9
21 Above 18 State 13 Average 19
16 14 23

30.50 25.96 24.62 21.38 20.32 18.38 18.07 17.43 14.32

213.74 181. 92 172.53 149.82 142.40 128.80 126.63 122. 14 100.35

State Average

14.27

100.00

------------------------------------------------------------------------

22

20

11

12

17

6

Below 15

State

5

Average 1

10

4

2

8

7

13. 12 12.97 12.85 11.69 11.42 10.75 10.25 9.88 9.35 8.75 7. 10 5.96 5.62
2.38

91.94 90.89 90.05 81.92 80.03 75.33 71.83
69.24 65.52 61.32 49.75 41.77 39.38 16.68

Source: Author.

24

ACUTE MYOCARDIAL INFARCTION, 1969-72
AGE-SEX ADJUSTED DEATH RATES PER 100,000
D 43.0-132.0
/:::::::1 132.1-177.5
177.6-220.3
........
iii:::::: 220.4-304.8
STATE AVERAGE - 1783

~lSD

0

+lSD

Healthier

Unhealthier

TABLE 8.--ACUTE MYOCARDIAL INFARCTION, AGE-SEX ADJUSTED DEATH RATES BY SERVICE AREA, 1969-1972

Service Area

Age-Sex

Adjusted Death

Rate Per 100,000

Rate as a Proportion of State Average
(State Average = 100)

17 22 7 23 Above 19 State 15 Average 16 1 10 5
State Average
14 8 12 11 2 13 Below 4 State 21 Average 9 18 20 3 6

230.25 221. 94 215.00 203.72 191. 69 188.62 186.50 184.40 181 .68 179.75
178.27
177.68 175.25 172.91 172.40 166.54 166.28 162.40 160.91 156.58 153.97 153.00 152.00 129.75

129. 16 124.50 120.60 114.28 107.53 105.81 104.62 103.44 101. 91 100.83
100.00
99.67 98.31 96.99 96.71 93.42 93.27 91. 10 90.26 87.83 86.37 86. 11 85.26 72.78

Source: Author.

26

ISCHEMIC HEART DISEASE, 1969-72
EXCLUDING ACUTE MYOCARDIAL INFARCTION
AGE-SEX ADJUSTED DEATH RATES PER 100,000
D 19.5-57.8
L2] 57.9-90.0
90.1-121.5
1111110
ii::::::: 121.6-194.8

-150 0 +150

Healthier

Unhealthier

..':.:.:..:::::::::::::::::::::::::::::::::::::::::::
...:...:...:...:....:....:....:.....:....:....:....:...:....:....:....:....:...:.,..:...:...:...:...:...:...:...:....:...... ..........................................

TABLE 9.--ISCHEMIC HEART DISEASE (EXCLUDING ACUTE MYOCARDIAL INFARCTION), AGE-SEX ADJUSTED DEATH RATES BY
SERVICE AREA, 1969-1972

Service Area

Age-Sex Adjusted Death Rate Per 100,000

Rate as a Proportion of State Average
(State Average = 100)

6
3 14 17 8 13 Above 12 State 15 Average 22 20 10 23 16

134.00
122.25 103. 11 101. 67 100.50 97.57 97.38 95.88 95.22 95.06 94.92 94.75 93.14

148.76 135.71 114.46 112.87 111. 57 108.31 108.10 106.44 105.71 105.53 105.37 105. 18 103.40

------------------------------------------------------------------------

State Average

90.08

100.00

4

89.21

99.03

5

89. 12

98.93

9

88.00

97.69

18

84.88

94.23

11

84.70

94.03

19

81.91

90.93

21

81.07

90.00

1

78. 10

86.70

7

75.25

83.54

2

54.21

60. 18

Source: Author.

28

OTHER FORMSOF HEART DISEASE, 1969-72
AGE-SEX ADJUSTED DEATH RATES PER 100,000
D 0.0-9.8
L2J 9.9-27.5
27.6-44.8 :..:..:....:..:..:..:..:: 44.91- 26.3
STATE AVERAGE - 27.6

Healthier

+ISD Unhealthier

.. This Category Excludes Acute Myocardial Infarction, Hypertensive Disease, and Ischemic Heart Disease

TABLE 10.--0THER FORMS OF HEART DISEASE, AGE-SEX ADJUSTED DEATH RATES BY SERVICE AREA, 1969-1972

Servi ce Area

Age-Sex
Adjusted Death Rate Per 100,000

Rate as a Proportion of State Average
(State Average = 100)

19

46.50

168.42

9

43.00

155.74

23

37.88

137.20

Above 3

37.50

135.82

State 13

36.21

131. 15

Average 18

32.28

116.91

22

31.69

114.78

20

31.58

114.38

1

28.68

103.88

15

28.28

102.43

------------------------------------------------------------------------

State Average

27.61

100.00

------------------------------------------------------ -----------~------

11 14 21 12 16 Below 6 State 2 Average 17
10
8 7 5 4

25.45 25.43 24.68 24.53 23.07 22.75 21. 75 21.62 20.58 16.00 13.38 13.00 12.48

92. 18 92.10 89.39 88.84 83.56 82.40 78.78 78.30 74.54 57.95 48.46 47.08 45.20

Source: Author.

30

CEREBROVASCULAR DISEASE Stroke or cerebrovascular disease is the third leading cause of death in the United States. In Georgia, however, it appears to alternate year by year with cancer as the second ranking disease. The disease pattern on the map projects I'many counties in the southern portion of the state that are above average. However, there are only seven of the 23 service areas that are above the state average (Table 11). The high-risk areas identified on the map should be utilized to implement prevention programs. Stroke is largely the result of high blood pressure and therefore can be reduced significantly through screening programs concentrated in the high-risk areas.
31

CEREBROVASCULAR DISEASE, 1969-72
AGE-SEX ADJUSTED DEATH RATES PER 100,000
D 42.5-92.3
C2J 92.4-129.0
129.1-165.5
HIII"1
f:i:::::: 165.6-264.0
STA TE AVERAGE - 1295

Healthier

Unhealthier

::: ~oooooooooogggggggggggggggg
,. . II~I~I""

TABLE 11.--CEREBROVASCULAR DISEASE, AGE-SEX ADJUSTED DEATH RATE BY SERVICE AREA, 1969-1972

Servi ce Area

Age-Sex Adj usted Death Rate Per 100,000

Rate as a Proportion of State Average
(State Average = 100)

17
11 21 Above 18 State 20 Average 13 23 12
State Average
19 9 15 22 10 14 3 Below 16 State 1 Average 8 6 2 5 7 4

161. 38 154.70 154.21 149.94 149.30 137.68 134.80 134.53
129.48
129.41 129.25 128.81 128.03 124.55 119.46 116.62 115.00 114.80 111.00 109.75 109.62 108.12 96. 12 94.10

124.64 119.48 119.10 115.80 115.31 106.33 104.11 103.90
100.00
99.95 99.82 99.48 98.88 96. 19 92.26 90.07 88.82 88.66 85.73 84.76 84.66 83.50 74.24 72.68

Source: Author.

33

CANCER
Epidemiological studies may contribute to the prevention of cancer in many ways. One method is to demonstrate differences in the incidence of cancer in different counties or service areas and subsequently correlate them with differences in socioeconomic, demographic and behavioral characteristics. The potential value of these distributional patterns of cancer is recognized as a new source of hypotheses for further investigation. In cancer program planning it is essential to know as much as we ~ossibly can about conditions in the population associated with high or low risk areas. Other characteristics of the population are equally important to the planning and operation of cancer control programs. A few of these include public knowledge or awareness, basic professional resources, and the knowledge of the economics of medical care. Finally, all public health programs require evaluation and re-evaluation to determine if needs for the program have changed and to what extent the program is effective in meeting those needs. The evaluative process, however, is relatively embryonic and tools are in the early stages of development.
This section maps six major categories of cancer ---- stomach, large intestine, rectum, lung, breast and cervix. Notably, cancer of the lung and the breast are the two leading causes of death for males and females respectively. Cancer of the stomach mortality rates range from 3.0 to 9.67 per 100,000 (Table 12). The only major urban area that is of highrisk is Atlanta or service area 6. Three other principal clusters are: (1) along the coast in service areas 3 and 9; (2) the southwestern por-
35

CANCER OF THE STOMACH, 1969-72

................................................................................................................... "'i!l!l!i:::!!!!::!!:;:::!!:!!'!:::!!!!:!::::
.: :~~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~ ~ ~:~; ~; ~. ~ ~ ~ ~~.;;;: ~ ~ ~~~ ~~~ ~ ~
:::!!::!I:I:I":II:
~ :::::::::::::::::::::ji:::::::..... :::::::::::'::::: :::::::::::::.

AGE-SEX ADJUSTED DEATH RATES PER 100,000
D 0.0-1.3
!illillJ 1.4-5.3
5.4-9.3
Iini.
=i::: 9.4-19.5
STATE AVERAGE - 5.4

-ISD 0 +1SD

Healthier

Unhealthier

TABLE 12.--MALIGNANT NEOPLASM OF THE STOMACH, AGE-SEX ADJUSTED DEATH RATES BY SERVICE AREA, 1969-1972

Service Area

Age-Sex Adjusted Death Rate Per 100,000

Rate as a Proportion of State Average
(State Average = 100)

9

9.67

179.07

3

8.50

157.41

Above 14

8.43

156. 11

State 18

7.25

134.26

Average 21

6.84

126.67

23

6.53

120.93

6

6.25

115.74

------------------------------------------------------------------------

State Average

5.40

100 .00

10

5.38

4

5.27

2

4.92

7

4.88

16

4.86

12

4.69

13

4.68

Below 1

4.53

State 20

4.47

Average 17

4.17

19

4.06

11

4.00

15

3.88

8

3.75

22

3.25

5

3.00

99.63 97.59
91. 11 90.37 90.00
86.85 86.67 83.89 82.78 77 .22 75. 19 74.07 71.85 69.44 60.19 55.56

Source: Author.

37

tion of the state service areas 18, 21 and 23; and (3) service area 14 -- the central portion of the state. Interestingly, the highest rates of stomach cancer are located adjacent to the Atlantic Ocean.
Cancer of the large intestine accounts for twice as many deaths as cancer of the stomach in the state of Georgia. The rates range from 7.25 to 16.38 per 100,000 (Table 13). Again, like stomach cancer this category reflects increased risk at locations adjacent to the Atlantic Ocean. Service area 9 ranks first in both of these categories while service area 3 ranks fifth for cancer of the intestine and second for cancer of the stomach. The urban area of Atlanta also ranks high for this category, which includes service areas 6 and 8 or Fulton, Dekalb and Clayton counties.
Ranging from 1.09 to 3.75 per 100,000 population, cancer of the rectum represents the lowest incidence of the six selected categories (Table 14). There is an apparent shift in the distribution of this cancer when compared with the two previous types. The majority of high-risk areas are located principally in the northern section of the state -- service areas 1, 2, 4, 6, 8 and 11. Service area 9 which ranked first in the t~10 previous categories ranks fourth in mortality from cancer of the rectum. It appears that service area 9, a coastal location, may be a major foci for these types of digestive cancers. World distribution of cancer of the stomach also appears to favor coastal regions, for example, Japan and Chile.
Lung cancer ranks number one in deaths for males (white and nonwhite) in the United States; likewise, it ranks number one in Georgia. With the exception of service area 9 the distribution of this type of
38

CANCER OF THE LARGE INTESTINE, 1969-72
AGE-SEX ADJUSTED DEATH RATES PER 100,000
D 0.0-5.0 Ld 5.1-10.0
10.1-15.3 =::=::-:.::":: 15.4-31.8
STATE AVERAGE 10.3

-150 Healthier

tlS0 Unhealthier

"00000 0 0000"0"0"00 ooooonoooooooooo QOOOOOOoooooooooo 00000000000000"0<1" 000"000000000000000
0000000000000000000 00000000000000000000 00000000000000000000
00000000000000000000 , 000000000000000000000

..................

..

0 <

00000000

..Iiiiii::";:iiil:,

TABLE 13.--MALIGNANT NEOPLASM OF THE LARGE INTESTINE, AGE-SEX ADJUSTED DEATH RATES BY SERVICE AREA, 1969-1972

Servi ce Area

Age-Sex Adjusted Death Rate Per 100,000

Rate as a Proportion of State Average
(State Average = 100)

9 8 12 Above 17 State 3 Average 6 20 1 21
State Average
11 10 14 16 7 23 Below 13 State 19 Average 22 18 4 5 15 2

16.38 13.00 12.91 12.58 12.50 12.50 12.39 11.50 11.29
10.25
9.85 9.83 9.82 9.68 9.63 9.50 9.25 9.19 8.88 8.78 8.29 7.88 7.50 7.25

159.80 126.83 125.95 122.73 121.95 121.95 120.88 112.20 110.15
100.00
96. 10 95.90 95.80 94.44 93.95 92.68 90.24 89.66 86.63 85.66 80.88 76.88 73.17 70.73

Source: Author.

40

CANCER OF THE RECTUM, 1969-72
AGE-SEX ADJUSTED DEATH RATES PER 100,000
D NONE E2J 07-17
1.8-3.5
iiiiiiii: 3.6-6.5

-lSD 0 +lSD

Healthier

Unhealthier

TABLE 14.--MALIGNANT NEOPLASM OF THE RECTUM, AGE-SEX ADJUSTED DEATH RATES BY SERVICE AREA, 1969-1972

Service Area

Age-Sex Adjusted Death
Rate Per 100,000

Rate as a Proportion of State Average
(State Average = 100)

6

3.75

11

3.10

8

2.75

9

2.71

Above

15

2.56

State

17

2.46

Average

4

2.37

2

2.29

23

2.28

1

1.98

State Average

1.81

7

1. 75

3

1.63

5

1.63

20

1. 58

12

1.53

Below

14

1.46

State

18

1.44

Average

16

1. 39

13

1. 36

10

1. 28

21

1. 20

22

1. 16

19

1.09

207.18 171. 27 151.93 149.72 141.44 135.91 130.94 126.52 125.97 109.39
100.00
96.69 90.06 90.06 87.29 84.53 80.66 79.56 76.80 75.14 70.72 66.30 64.09 60.22

Source: Author

42

CANCER OF THE TRACHEA, BRONCHUS, AND LUNG, 1969-72
AGE-SEX ADJUSTED DEATH RATES PER 100,000
D 0.0-17.3 L2l 17.4-26.5
26.6-35.0
........
iii:::::: 35.1-56.0
STATE AVERAGE . 26.5

-ISD Healthier

+lSD Unhealthier

TABLE 15.--MALIGNANT NEOPLASM OF THE TRACHEA, BRONCHUS & LUNG, AGE-SEX ADJUSTED DEATH RATES BY SERVICE AREA,
1969-1972

Service Area

Age-Sex Adjusted Death Rate Per 100,000

Rate as a Proportion
of State Average (State Average = 100)

9

23

6

8

13

3

Above

21

State

22

Average

16

1

7

20

5

17

State Average

15

14

19

Below

12

State

10

Average

2

18

11

4

37.46 31.35 30.50 30.25 29.93 29.88 29.70 29.44 29.36 29.35 28.50 28.33 27.63 27. 13
26.53
26.34 24.89 24.22 23.59 23.55 23.46 21.56 18.20 17.88

141. 20 118.17 114.96 114.02 112.82 112.63 111. 95 110.97 110.67 110.63 107.43 106.78 104.15 102.26
100.00
99.28 93.82 91. 29 88.92 88.77 88.43 81.27 68.60 67.40

Source: Author

44

cancer is clustered in the major metropolitan areas. Valdosta, Atlanta, Macon, Savannah and Augusta rank number 2, 3, 4, 5 and 8 respectively. Increased concentrations of air pollution may be directly related to the urbanized pattern of lung cancer. The rates, highest of all the types of cancer investigated in this study, range from 17.88 to 37.46 per 100,000 population (Table 15).
There is no definitive pattern reflected in the distribution of cancer of the breast. However, there is a slight tendency for the majority of low risk areas to be located in the southern portions of the state. The map showing the distribution of cancer of the cervix is almost an opposite image of cancer of the breast. Service areas 15, 16, 21 and 22 are high-risk for cancer of the cervix while they are low-risk for cancer of the breast. Race is probably the most significant reason for this reversal in rates. Generally non-white females have a higher rate of cancer of the cervix than do white females and alternatively white females have a higher rate of cancer of the breast than do non-white females. Are the differences, however, due to racial characteristics or due to variations in the delivery of medical service?
Again, this section selectively illustrates that geographical variations of specific cancer types are of primary importance to the health planner. The category of "cancer" places undue decisional stress upon administrators, health planners, and directors when budgets are being reviewed. Specific cancer categories when mapped indicate vividly the high and low risk areas that must be utilized as a distributional characteristic in the allocation process of new resources.

CANCER OF THE BREAST, 1969-72

AGE-SEX ADJUSTED DEATH RATES PER 100,000
o 0.0-4.8
ETIJ 4.9-10.3
10.4-15.8
::::
STATE AVERAGE - 10.3

.................

.

"

00000 ooonOOOO"OOOOQO"O

:::::::::::::::::::::::::.. :::::::::::. ::::::::::::::::::::::.. ;. ggggg~~gggggg~gggoo :::::::::'.:::::.

oooog~gg~ggo~~::::::,,:::::::
::::::::::::::::::;::: :;:;:

.

-ISD 0 +ISD

Healthier

Unhealthier

.................
:.,':::::::::::::::
~ ~ ~ ~~~iiiiiiiiiiiiiiii~~iii
:::::::::::::::::::::::::::
:::::..:.:.:::::::::::::::::::::::::::::::::::::

TABLE 16.--MALIGNANT NEOPLASM OF THE BREAST, AGE-SEX ADJUSTED DEATH RATES BY SERVICE AREA, 1969-1972

Service Area

Age-Sex Adjusted Death
Rate Per 100,000

Rate as a Proportion
of State Average (State Average = 100)

19

6

5

18

2

Above

14

State

11

Average

8

23

10

4

9

12

State Average

1

20

22

7

Below

21

State

13

Average

3

17

15

16

16.00 13.75 12.50 12.44 12.25 12.21 11.60 11.50 11.35 11.00 10.62 10.46 10.41
10.30
9.83 9.75 9.53 9.38 9.36 8.75 8.50 6.96 6.50 5.68

155.34 133.50 121 .36 120.78 118.93 118.54 112.62 111 .65 110.19 106.80 103.11 101. 55 101.07
100.00
95.44 94.66 92.52 91.07 90.87 84.95 82.52 67.57 63.11 55.15

Source: Author.

47

CANCER OF THE CERVIX, 1969-72

AGE ADJUSTED DEATH RATES
PER 100,000

D NONE
I82TI 1.0-4.5

4.6-8.5

iii::::. 8 6 30 0

IIIIHI..

-



-15D 0 +15D

Healthier

Unhealthier

TABLE 17.--MALIGNANT NEOPLASM OF THE CERVIX, AGE-SEX ADJUSTED DEATH RATES BY SERVICE AREA, 1969-1972

Service Area

Age-Sex Adjusted Death
Rate Per 100,000

Rate as a Proportion of State Average
(State Average = 100)

16

8.57

22

7.19

Above

11

6.25

State

19

5.94

Average

21

5.18

12

5.09

15

4.84

State Average

4.55

17

4.38

9

4.21

13

4.21

23

4.10

14

4.07

10

4.00

7

3.88

Below

20

3.83

State

1

3.80

Average

18

3.56

6

3.50

4

3.25

3

3.00

5

3.00

8

2.50

2

2.21

188.35 158.02 137.36 130.55 113.85 111. 87 106.37
100.00
96.26 92.53 92.53 90.11 89.45 87.91 85.27 84.18 83.52 78.24 76.92 71.43 65.93 65.93 54.95 48.57

Source: Author.

49

ACCIDENTAL DEATH
The type of accident that continues to claim the greatest number of lives is the motor vehicle traffic accident. Consequently, deaths due to accidents rank fourth in the state of Georgia with automobile accidents accounting for this high ranking, while death rates related to non-motor vehicle accidents are somewhat lower. The rates for automobile accidents range from 24.35 in Fulton county to 84.04 per 100,000 population in coastal service area 9 (Table 18). On the other hand, rates for non-motor vehicle accidents range from 20.88 in Dekalb service area to 75.50 per 100,000 in service area 9 (Table 19).
Typically, urban centers have high automobile accident rates but deaths in these areas usually are rare. High-risk service areas are not clustered but tend to follow the major north-south and east-west arterials in the state. For example, linear patterns of high-risk are apparent from Atlanta to Macon to Valdosta ---- U.S. 75, and also from Atlanta to Augusta ---- U.S. 20. Further, the coastal counties also experience high motor vehicle accident death rates.
Accidental deaths, excluding motor vehicles, include such categories as railway, poisoning, and accidents related to falls. Principally, urban areas reflect low-risk areas which may be indicative of efficient emergency medical systems. The high-risk areas all fall into the southern section of the state. The only three southern service areas which are below the state average are 3, 13 and 20.
51

The strategy in identifying high-risk accident rates is to determine areas of need for implementing emergency medical services and accident prevention programs. In Georgia, 1974, accidents have been reduced by approximately 40 percent. However this reduction, primarily attributed to lower speed limits because of the energy crisis, is misleading. Of equal importance is the fact that tourist traffic also has been reduced approximately 40 percent in the first quarter of 1974. No matter the reason for reduced accidental death rates, the results are beneficial. Of course, this recent trend does not preclude the planning and initiating of a responsive state-wide emergency medical system.
52

MOTOR VEHICLE ACCIDENTS, 1969-72
AGE-SEX ADJUSTED DEATH RATES PER 100,000
D 7.2-33.0 illIIIJ 33.1-60.5
60.6-87.7
11
iii:::::: 87.8-166.7
STA TE AVERAGE 609

~lSD

0

+lSD

Healthier

Unhealthier

TABLE 18.--MOTOR VEHICLE ACCIDENTS, AGE-SEX ADJUSTED DEATH RATES BY SERVICE AREA, 1969-1972

Servi ce Area

Age-Sex Adjusted Death
Rate Per 100,000

Rate as a Proportion of State Average
(State Average = 100)

9

19

13

Above

4

State

14

Average

23

20

16

22

State Average

17

21

11

15

10

18

Below

1

State

12

Average

2

7

5

3

8

6

84.04 79.75 72.61 69.06 62.18 61.73 61. 61 61.25 61.25
60.96
60.92 60.88 60.50 58.47 58.43 55.94 53.67 52.75 50.92 48.50 41.38 38.25 27.38 24.35

137.86 130.82 119.11 113.29 102.00 101.26 101.07 100.48 100.48
100.00
99.93 99.87 99.25 95.92 95.85 91.77 88.04 86.53 83.53 79.56 67.88 62.75 44.91 39.78

Source: Author.

54

ACCIDENTAL DEATHS, 1969-72
EXCLUDING MOTOR VEHICLE ACCIDENTS
AGE-SEX ADJUSTED DEATH RATES PER 100,000
D 2.2-24.0
L8Iill 24.1-43.0
43.1-61.3
........
iii:::::: 61.4-125.0
STATE AVERAGE - 431

-ISD 0 tlSD

Healthier

Unhealthier

.:::;;:::: . :iHiHiHi:;iii' :.m....m...m....:.:...:.'........... ummi::::::::::::::.:..... "::m::::m:::i::::::::::::::;:;:;:;:;:;:;:;:::::::
"U:::::::::::

TABLE 19.--ACCIDENTAL DEATHS (EXCLUDING MOTOR VEHICLE ACCIDENTS), AGE-SEX ADJUSTED DEATH RATES BY SERVICE AREA, 1969-1972

Servi ce Area

Age-Sex Adjusted Death Rate Per 100,000

Rate as a Proportion of State Average
(State Average = 100)

9

14

17

18

Above

21

State

15

Average

19

23

16

22

75.50
61.18 55.00
50.38
49.27 48.13 46.91
44.98 43.64 43.44

175. 13
141.92 127.58
116.86 114.29 111 .64 108.81
104.34 101.23 100.77

------------------------------------------------------------------------

State Average

43.11

100.00

------------------------------------------------------------------------

3

20

13

4

12

Below

11

State

10

Average

1

2

6

7

5

8

40.13 38.61 38.00 37.96
36.03 35.85
35.30
32.38 30.00 29.50 28.38
24.00 20.88

93.09 89.56 88.15 88.05
83.58 83.16
81.88
75.11 69.59 68.43
65.83 55.67 48.43

Source: Author.

56

VENEREAL DISEASE
The present increase in venereal disease is worldwide in scope, being highest in the United States in those areas experiencing rapid social change and high population mobility. In Georgia, rates for primary and secondary syphilis and gonorrhea are among the highest in the nation. A closer examination of the rates by county and service area reflect considerable geographical differences.
The morbidity rates for primary and secondary syphilis range from 8.60 to 180.40 per 100,000 (Table 20). The area of highest risk is Atlanta ---- a demographic profile of young population groups with high internal mobility. Low-risk areas are concentrated in North Georgia with the exception of three southern service areas ---- 3, 9 and 20.
The second venereal disease, gonorrhea, is at a level of major epidemic proportions. The rates for this disease range from 32.14 per 100,000 to 2,932.7 per 100,000 in Fulton County - Atlanta. This disease is primarily concentrated in the major urban centers of Georgia. In addition to Atlanta other urban areas included are Savannah, Augusta and Macon. Rates of low incidence are principally located in the nonurban areas. It must be remembered that some of the differences in reported infectious syphilis and gonorrhea rates may reflect differences in casefinding, surveillance or available public clinics.
The incidence of gonorrhea and syphilis may be a strong indicator of social problems (i.e. social disorganization) and further that the disease distribution may be associated with a noticeable lack of health
58

care services. Planning for venereal disease control is most vital at the city and local community level. Like most diseases it should be included in the community health profile. Responsible leadership by health officers and appropriate staff can mobilize community resources towards a program of eventual eradication. Again, resource allocation must be equitable with respect to the problem areas.
59

SYPHILIS, 1967-72
INCLUDES PRIMARY AND SECONDARY CASES
MORBIDITY RATES PER 100,000
D 0.0-10.1
[ill2J 10.2-47.5
47.6-85.9
.......................... 86.0-180.4
STATE AVERAGE - 48.3

Healthier

Unhealthier

::::::iiiililllllllllililili:' o ...................

TABLE 20.--PRIMARY AND SECONDARY SYPHILIS, MORBIDITY RATES BY SERVICE AREA, 1967-1972

Servi ce Area Morbi dity Rate Per 100,000

6

23

21

18

11

16

Above

14

State

19

Average

17

10

13

15

12

22

State Average

3

20

9

Below

7

State

8

Average

5

4

1

2

Source: Author

180.40 69.82 67.24 66.90 63.56 62.19 60.30 59.56 56.70 54.36 54.34 53.68 52.58 49.59
48.35
46.75 36.72 36.58 31.05 27.30 18.25 16.82 16.27 8.60

Rate as a Proportion of State Average
(State Average = 100)
373. 11 144.41 139.07 138.87 131. 46 128.62 124.72 123.19 117.27 112.43 112.39 111. 02 108.75 102.56
100.00
96.69 75.95 75.66 64.22 56.46 37.75 34.79 33.65 17.79

61

GONORRHEA, 1967-72

MORBIDITY RATES PER 100,000

D

0.0-17.0 (ls,QUARTllEj

[::::::::1 17.1-39.0 (2nd QUARTIlE)

39.1-107.0 (3,d QUARTilE)
5i: 107.1-2390.0 (4th QUARTILE)

STATE AVERAGE - 116.6

TABLE 21.--GONORRHEA, MORBIDITY RATES BY SERVICE AREA, 1967-1972

Service Area

6

3

7

Above

16

State

13

Average

8

21

12

State Average

10

17

5

19

20

23

Below

9

State

15

Average

1

11

22

2

18

14

4

Source: Author.

Morbidi ty Rate Per 100,000
2,392.70 550.95 223.75 214.40 207.53 200.50 140.84 127.73
116.57
114.65 114.00 112.85 107.41 77.38 76.70 76.48 72.88 71.73 67.08 59.36 47.27 46.13 32.22 32. 14

Rate as a Proportion of State Average
(State Average = 100)
2,052.59 472.63 192.12 183.92 178.03 172 .00 120.82 109.57
100.00
98.35 97.80 96.81 92.14 66.38 65.80 65.61 62.52 61.53 57.54 50.92 40.55 39.57 27.64 27.57

63

GENERAL INDEX OF HEALTH STATUS
This final section attempts to synthesize the previous findings and to provide-an insight'into the total disease pattern in the state of Geo~gia. It must be emphasized that the old ways of measuring health appear to be strongly in need of reexamination largely because of changing social conditions. A refined proposal would be one that extends this present monograph to include a more comprehensive approach utilizing psychological, cultural, and social components. The intent in the above type of analysis would be to determine the "quality of life ll through the appropriate use of valid IIsocial indicators. 1I There are advantages to aggregate such indicators into a few factors representing various aspects of health status. A major advantage is simplification, by use of factor analysis, which would facilitate policy making and planning for health care.
Table 22 reflects the ranking of service areas in relation to health well-being in the state. The index was simply computed by summing all the standardized scores for each service area. The resulting 23 values (one for each service area) were then transformed to z-scores for comparative purposes. The facts are interesting.
The map delineates a pattern that has been typical of many of the previous diseases. The northern portion of the state represents a relatively healthy population. Thus, northern service areas 1,2,4, 5,7,8,10, and 12 all fall within the defined healthy region of the state.
65

GENERAL INDEX OF HEALTH STATUS
Dm-1 Standard Deviation
..... 0 (Mean)
.................................. + 1 Standard Deviation

TABLE 22.--GENERAL INDEX OF HEALTH STATUS, RANKED BY SERVICE AREA, 1972

Rank Order

Service Area

Index Va1ue*

~

9

2

3

3

6

Above 4

.23

State 5

i17

Index 6

19

Value 7

21

8

13

9

14

10

11

11

16

12

22

13

18

1.578 .810 .657 .592 .590 .549 .521 .328 .243 .138 .128 .057 .011

------------------------------------------------------------------------

State Index

.000

--------------------------------------------------------------------.---

14 15 16 BelrM 17 State 18 Index 19 Value 20 21 22 23

15

-.025

20

-. 133

12

-.186

10

-.354

1

-.485

8

-.750

7

-.990

2

-1.093

5

-1.228

4

-1. 301

Source: Author.
*Index value is a standardized z-score computed for each service area. See introduction for explanation of standardized scores.

67

The most unhealthy areas in the state are primarily rural. However, there are exceptions. For instance, the Savannah and Atlanta urban areas rank second and third respectively. These exceptions reflect a major need for more research and education at the intra-urban level. I have suggested many times in this monograph that urban areas must be analyzed at a different scale so target areas within the city may be recognized and investigated.
Table 23 shows a series of correlations among the seventeen disease patterns and the general index of health status. The primary purpose of this table is to allow basic interpretations among the disease patterns. One may determine the relationship or association of a specific disease with another disease or with the health index.
Among other things, Table 24 supplies the names for all the variables listed in Table 23. An example of how to interpret this table of correlation coefficients follows. Let us suppose that we are interested in knowing the relationship between the general index of health status and cancer of the lung. As can be seen from Table 24 we wish to look at variable numbers 1 and 12. Now, by referring to Table 23 we find at the left margin a column of numbers ranging from 1 to 18. Along the top row of the table we likewise find numbers ranging from 1 to 18. Next, we find the number 1 on the left and read across to the number 12 at the top and find a value of .400. By taking the square of this value we get approximately. 16. This value is called a coefficient of determination. Thus, we may conclude that the amount of variation accounted for by this correlation coefficient (.400) is approximately 16 percent. This low level of stastical explanation is probable in view of the problems inherent in disease distribution. It
68

TABLE 23.--CORRELATION MATRIX

Varible Number

2

3

4

5

6

7

8

9

10

11

12

1'3

14

15

16

17

18

1 1.000

.538 .504

.440

.088

.265

.254

.381

.271

.380

.181

.400

.189

.322

.166

.409

.498

.318

2

1.000

.811

.187

.122 - .033 - .014

.368

.170

.116 - .052

.052 - .081

.097 - .064

.153

.220

.014

3

1.000 .089 .099 .000 - .030 .227 .105 .131

.029

.146 - .015

.054 - .151

.128

.105

.114

4

1.000 - .211

.060 .236 .142 .136 .169 - .101

.171

.013 .026

.068 .224

.240 .059

5

1.000 - .082 - .256

.039 - .060 - .106 - .064

.~5

.004

.209 - .015 - .034 - .059 - .119

6

1.000 - .056 - .242

.054

.072

.132

.124

.005

.149 - .097 - .076

.223

.277

7

1.000 .056 .050 - .031 - .103 .115 .098 - .018 .066 .117 .109 .023

8

.'.",

9 10

1,00!! - .054 1.000

.190 - .088 - .022 .036 .131

.040

.027 .168 .061 - .025 - .093 - .070

1.000 .139 .132 .036 - .033 .122

.106 .244 - .011 .124 - .042 - .002 .049 .078 .082

11

1.000 - .027 .087 .028 - .028 - .109 .070 .139

12

1.000 .0lD - .062 .043 .163 .113 .187

13

1.000- - .113 .016 .125 .006 .062

14

1.000 .042 .160 .179 .014

15

1.000 .313 - .111 - .270

16

1.000 .039 - .199

17

1.000 .388

18

1.000

Source: Author.

would be extremely interesting to see representative values when using areas of high or low risk to relate to the index. Although not reported in this study the author has values calculated from a step-wise correlation indicating that variables 2$ 12 and 17 account for more than 55 percent of the explanation of the health status of Georgians. For this reason$ infant morta1itY$ syphilis and cancer of the lung explain 55 percent of the variation in the health status index.
Turning to Table 24$ a summary of the relationships among the variables is presented. As would be expected$ the summation of all the correlation coefficients from Table 23 for the general index of health
,
status is the highest equalling 5.604 (Table 24). This indicates a strong interdependence of the health index to all other variables. Infant mortality also exerts a strong linkage to the other disease patterns including the health index. Other variables which show moderate linkage are neonatal morta1itY$ syphi1is$ hypertensive disease and other forms of accidents. The variable showing an extremely weak linkage with the other disease patterns is cancer of the breast. The primary purpose of this table of aggregated coefficients is to indicate the general pattern of interdependence among variables.
In summary, we must broaden the dimension of health beyond that to which we have been accustomed. Health is much more than a biomedical or physiological phenomenon. It must integrate the social human being who functions in a social environment with social roles into the spectrum of a reevaluated definition of new system dimensions of health. Additionally, emotional and moral concepts must be incorporated into the multidimensional system of health. Within this context, the problems and the solutions related to the delivery of health care require 'new and sophisticated methods because we are seeing new and everchanging
70

TABLE 24.--SUM OF CORRELATION COEFFICIENTS

Variable Number

Variable Name

Summation of Correlation
Coefficients

1

General Index of Health Status

2

Infant Mortality

3

Neonatal Mortality

4

Hypertensive Disease

5

Myocardial Infarction

6

Ischemic Heart Disease

7

Other Forms of Heart Disease

8

Cerebrovascular Disease

9

Cancer of the Stomach

10

Cancer of the Large Intestine

11

Cancer of the Rectum

12

Cancer of the Trachea, Bronchus, Lung

13

Cancer of the Breast

14

Cancer of the Cervix

15

Traffic Accidents

16

Other Forms of Accidents

17

Syphilis

18

Gonorrhea

5.604 3.092
2.738
2.572 1.592
1. 947 1.632 2.377
1. 512
1.893 1.545
1.853
0.921 1.730 1.652 2.528
2.724 2.248

Source: Author.

71

patterns of "health well-being". 72

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HEALTH SERVICES RESEARCH AND STATISTICS SECTION, DIVISION Of PHYSICAL HEALTH