, Pan American Health Organization World Health Organization XVI PanAmericanSanitaryConference XIV RegionaCommitteel Meeting Ninneapolis_ litinnesotat U.S.A. August-September 1962 ,,. ,, , | ,,, , ,,,,. , , ,, , ,, ,, , Draft Agenda Item 2.8 CSP16/36 (Eng.) 13 August 1962 ORIGINAL: ENGLISH _REPORT ON THE RESEARCH PROGRAM ON MORTALITY STATISTICS IN THE AMERICAS In accordance with the plans pr:e_ented by the Director to the XIII Meeting of the Directing Council(l) in October 1961, the Organization has initiated a research program in mortality statistics. The purpose of this project is to obtain basic data as comparable as possible to serve as background for epidemiological research in the Americas. Because of differences in extent of certification by medical personnel, terminology in use, nosological viewpoints, lack of diagnostic standards, and methods of certifying the underlying cause of death, mortality statistics for countries at present are not comparable. As a first step in obtaining satisfactory data it was considered advisable to collect information from large cities where some of these problems are not so great, since medical facilities are readily available and most deaths are certified by physi- cians. The method of procedure is to have each death in the study investigated through interviews in the home, hospital, and clinic, and with the physician to obtain as complete a record as possible of the fatal illness, including results of laboratory and other diagnostic procedures and autopsy findings. A study sample of approximately 2,000 deaths per year among persons between the ages of 15 and 75 years is planned from each of ten cities for 1962 and 1963, giving in all 40,000 questionnaires for analysis. The Directing Council(2) in 1961 supported this research program by the following Resolution: "l. To recommend to Member Governments to give full support to the furtherance of this research program on mortality statistics, so that the benefits of this intensive investigation of mortality (1) Proceedings of the XIII Meeting of the Directing Counnil, Pan American Health Organization, Washington, D. C., October 196!_ (2) Regional Advisory Committee on Health Statistics, Second Report, So. Pub. 65 Pan American Sanitary BureSu, Augds_ _962. A csP16/36(Eng.) Page 2 on a regional basis may be fully utilized not only to provide clues for epidemiological studies but also to improve the quality of mortality statistics which are essential for health planning. 2. To recommend to the Director of the Pan American Sanitary Bureau that the Organization assist the investigators in the cities selected so as to ensure that these coordinated investigations provide comparable basic data and that the results of this research program are fully utilized in health services, in epidemiological studies, and in teaching in medical schools." During 1961, the planning phases for the research program were carried out, starting with a Planning Conference in May to consider the soundness of the proposal. Authorities on the subject of classification of diseases and causes of death --Dr. Percy Stocks, formerly Director of the WHO Center on Classification in Englan_ Dr. Darlo Curiel, Director of the Latin American Center on Classification in Venezuels_ and Dr. Iwao Moriyama of the United States National Center of Health Statistics-- participated in the development of plans and the design of the question- naire for the study of fatal illnesses and injuries in cities of the Americas. The Conference agreed that it was highly important to establish an accurate and comprehensive picture of mortality by age among the adult population in selected cities of the Americas, and that the effort and expense of such an investigation would be fully justified. In order to select cities and collaborators with the necessary qualifications as outlined in the proposal, potential collaborators in medical schools, schools of public health, and National Health Services were visited. Pilot testing of the questionnaire was initiated in August 1961 and more than 500 questionnaires were completed in eight cities. The analysis of the pilot testing demonstrated that the structure and actual content of the questionnaire were in general suitable for the purposes of the study. In November 1961, the United States Public Health Service through the National Institutes of Health awarded a grant for the field work of the project, Inter-American Investigation of Mortality, for a two-year period beginning in 1962 and ending in 1964. The protocol planning conference of the principal collaborators for development of the final standard questionnaire and procedures to be used in all cities in the Investigation was held from January 22-30, 1962. A Manual of Procedures was issued in order to maintain uniformity throughout the investigation. Field work was started utilizing deaths of adults 15-74 years of age occurring in January 1962 in five cities; namely, Bogota, Colombia; Caracas, Venezuel_ La Plata, Argentina; Lima, Peru_ and Sac Paulo, Brazil. Work started with the investigation of deaths occurring in March in Guatemala City, Guatemala and Mexico City, Mexico, and with those in May P J csPl6/3(E6 ng.) Page 3 in Cali, Colombia_ Local circumstances del_ved the beginning of the project in Santiago, Chile. Delay was encountered in the development of plans for the inclusion of one or more cities in English-speaking countries. However, it is expected that two such cities will be included shortly. The principal collaborators (given in Appendix A) are epidemiologists_ statisticians, and other members of _aculties of schools of public health, medical schools and National Health Services. i By the end of June 1962 completed questionnaires in seven cities were available for analysis for this first preliminary report. These questionnaires were reviewed by the medical referees (Dr. Stocks and Dr. Curiel) and the underlying cause of death was assigned independently by the two referees according to the international standards. If in the judgment of the referee the evidence was not sufficient to justify the designation of a single cause, he designated two causes with certain weights. Because work in the cities started a different times, the numbers of completed questionnaires available for processing from these cities varied considerably, as shown below: Bogota 287 Lima 339 Caracas 335 MexicoCity 30 Guatemala City 130 Sac Paulo 56 La Plata 384 Since the numbers of deaths for Sac Paulo and Mexico were less than I00, they have been excluded from this analysis. Although the numbers of deaths in the other five cities were not large enough for detailed study, this preliminary analysis has been made principally to evaluate the procedures and to consider the suitability of the data for the purposes for which the project was designed. Cities were selected for the study in which it was felt that hospital facilities and medical care would be readily available for residents and thus the medical histories and diagnostic evidence would be satisfactory. At this time a summary of such evidence is useful as a measure of the quality of the data from the cities. The first method of evaluating the material in this respect is through consideration of the deaths according to place of death (Table I). In three of the five cities over b_If of the deaths occurred in a hospital. Deaths occurring in emergency services are included as hospital deaths, since these services usually have the necessary equipment and diagnostic facilities of a hospital. csP16/36(Eng.) Page 4 Table I Deaths by Place of Occurrence for Five Cities in Inter-American Investigation of Mortality, Preliminary Data of June 1962 Bogota Caracas Guatemala La Plata Lima J,, , ,=,_ Place of Death Num- Per Num- Per Num- Per Num- Per Num- Per ber Cent ber Centl ber" Cent ber Cent ber Cent Total 287 i00 335 lOO 130 lOO 384 1OO 339 1OO Hospital(a) 161 56.1 195 58.2 49 37.7 186 48.4 177 52.2 Home 107 37.3 112 33.h 78 60.0 175 45.6_ 113 33.3 Publicplace(b) 15 5.2 24 7.2 2 1.51 19 5.0 13 3.9 Not stated and other 4 1.41 _ 1.2 i _ 0.8 4 I.O 36 10.6 (a) Including other institution and emergency service. (b) Including cases in transit to hospital, physician's office, etc. Over 60 per cent of these deaths were of persons who had been in the hospital in the last year of life or died in the hospital (Table 2). The proportion without medical care in the last year is small. Many of those without care or for whom informat_6n could not be obtained, the group "not stated", died from an accident or other violence. Thus the medical care rendered in hospitals or by physicians in clinics, offices or homes appears to be sufficient to give relatively complete information. To be sure some difficulties have been encountered in obtaining data in the field. On the whole, however, the situation is favorable and the principal collaborators are doing very well in overcoming many difficulties in locating families, physicians, hospital records, etc. Table 2 '_ Recorded Medical Care in Five Cities in Inter-American Investigatio_ of Mortality, Preliminary Data of June 1962 Type of care in Bogota Caracas Guatemala La Plata Lima last year of Num- Per Num- Per N_ Per Num- Per Num- Per life ber Cent her Cent her Cent ber Cent ber Cent Total 287 iO0 335 IOO 130 i00 384 I00 339 iOO • Hospital 182 63.4 233 69.6 88 67.7 245 63.8 207 61.1 Physician(a) 77 26.8 51 15.2 30 23.1 127 33.1 79 23.3 Other and none 13 4.6 16 _.8 IO 7.7 9 •_2.3 I O.3 Not stated 15 5.2 35 10.4 2 1.5 3 0.8 52 15.3 , , ,,, .