C. Selected Health Conditions
The leading causes of death in Indiana reflect national patterns both with regard to the diseases and other causes on the list and generally with regard to the relative importance of each cause of death. One hundred years ago, the leading causes of death were infectious diseases, such as pneumonia, tuberculosis, diarrhea, and enteritis, with heart disease, liver disease, injuries, cancer, senility, and diphtheria rounding out the top 10. In contrast, the leading causes of death in the United States in 1997 were heart disease, cancer, stroke, chronic obstructive pulmonary disease, unintentional injuries, pneumonia/influenza, diabetes, suicide, kidney disease, and chronic liver disease and cirrhosis (Healthy People 2010, figure 8). Leading causes of death differ by age group and by racial or ethnic group, as well as between men and women (see Women’s Health Statistical Information for the Media, “Leading Causes of Death for American Women by Racial/Ethnic Group (2000),” at www.4women.gov/media/chart.htm).
Five counties in Indiana exceeded state averages for deaths from all causes during 1995-1999: Clark, Lake, Marion, Scott, and Vigo. Thirteen counties were under the state average during the same period: Adams, Allen, Dubois, Elkhart, Franklin, Greene, Hamilton, LaGrange, Marshall, Monroe, Putnam, St. Joseph, and Tippecanoe.
Cardiovascular disease (CVD), including heart disease and stroke, is the number one cause of death for American women other than Asian/Pacific Islanders, for whom only cancer exceeds CVD in importance. Blacks have a nearly double the risk of heart disease and stroke than whites, and cardiovascular mortality among Hispanics is lower than the state average (see Casper et al. 2000). Men are more likely to have a heart attack at a younger age and survive than women, and about half of all women who have heart attacks die from heart disease each year.
Risk factors for cardiovascular disease in women include: smoking, high blood cholesterol (low-density lipoprotein or LDL) levels, high blood pressure, physical inactivity, being overweight, having diabetes, aging, heredity and genetic history, history of previous heart attack, birth control use by women who smoke or have high blood pressure, menopause, and excessive drinking.
In Indiana, diseases of the heart are the primary cause of death for all recorded racial and ethnic groups. Incidence rates are not reportable, and estimates of incidence are based on the number of deaths reported. For 1999, women died from heart disease at a rate of 235.7 deaths per 100,000 age-adjusted. Black females (305.3 deaths per 100,000 age-adjusted) exceeded white females (231.6 deaths per 100,000 age-adjusted). In 1998, Indiana’s age-adjusted death rate from diseases of the heart exceeded the national average, as it has for the last decade, in part due to high rates of obesity, smoking, and lack of exercise in the state.
Six counties exceeded the state age-adjusted death rate from cardiovascular disease for 1995-1999: Clark, Jefferson, Knox, Lake, Vermillion, and Vigo. Six counties fell under the age-adjusted death rate for cardiovascular disease for the same period: Allen, Franklin, Hamilton, Hendricks, Monroe, and St. Joseph. Death rates for women by racial and ethnic groups are available for individual counties at the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) interactive Website for Women and Heart Disease: An Atlas of Racial and Ethnic Disparities in Mortality (www.cdc.gov/nccdphp/cvd/womenatlas/statemaps.htm).
According to the American Heart Association, Indiana is in the so-called Stroke Belt of the southeastern United States, a region that includes Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Virginia. In 1998, more women in Indiana died of stroke (2,456 deaths) than did men (1,430 deaths) (Hamilton-Byrd 2001). Several sites in Indiana are currently active in Operation Stroke, a community awareness and mobilization initiative to improve acute stroke care piloted by the American Stroke Association.
According to a Gallup survey in 2001, women are not well informed about the risk of heart disease because, although about 36% of American women will die from it, only 4 % fear it as the leading cause of death. A disproportionate number of women fear dying from breast cancer, even though it poses a much less serious risk.
No nationwide cancer registry exists, so the number of new cancer cases diagnosed annually is an estimate based on the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program and Census Bureau data. SEER tabulates data from five states (Connecticut, Hawaii, Iowa, New Mexico, and Utah) and four metropolitan areas (San Francisco-Oakland, Detroit, Seattle, and Atlanta), which registries cover about 10% of the U.S. population. Indiana has a state cancer registry (see Cancer Incidence in Indiana: State and County Data 1996, published in 2001).
According to the National Cancer Institute’s analysis of data from 1992 to 1998, the rates for new cancer cases and deaths for all cancers combined has been declining. The incidence for all cancers combined declined on average 1.1% per year between 1992 and 1998. However, cancer is still the second leading cause of death in the United States and in Indiana, and there has been a long-term increase in female lung cancer mortality rates. The American Cancer Society estimated that 12,900 Indiana residents would die of cancer in 1999.
Women tend to underestimate the dangers of lung cancer, which is the second leading cause of death nationally and in Indiana. Lung cancer exceeds breast cancer as a cause of death, despite women’s greater fear of breast cancer. Nationally, lung cancer accounts for 29% of cancer deaths in the United States and 13.2% of cases. In 1996, Indiana ranked tenth highest of all states for rate of death due to lung cancer; in 1997, Indiana ranked thirteenth highest for lung cancer deaths in the United States. Lung cancer incidence for females in Indiana in 1993-1997 was 43.5 cases per 100,00 age-adjusted to the 1970 U.S. standard population, compared to the national rate of 43.0. In 1997, females had a rate of 38.2 age-adjusted per 100,000 population, and there has been an increase in the rate for females in Indiana since 1993. Four thousand new cases of lung and bronchial cancer were estimated for 2000. For the period 1995-1999, only Marion County had an age-adjusted death rate above the state average of 45.37. Three counties—Dubois, Greene, and Jackson—had age-adjusted death rates from lung cancer below the state average.
Breast cancer accounts for 16.3% of all cancer cases and 14.6% of all female deaths due to cancer. Improvements in treatment and detection have assisted the decline in death rates. However, as more early-stage disease is being diagnosed, breast cancer incidence rates appear to be increasing. Breast cancer incidence increased nationally between 1940 and 1988, and incidence rates have been level since 1988. Incidence rates for women aged 40 and over increased between 1973 and 1996; rates grew even more rapidly for women aged 50 and over. The good news is that mortality rates have been either stable (between 1950 and the late 1980s) or decreasing (since 1989), due to improvements in treatments and better mammography screening.
In Indiana, the invasive breast cancer incidence rate for 1991-1995 was 100.5 per 100,000, age-adjusted to the 1970 U.S. standard population, compared to the national rate of 110.6. For 1993-1997, the rate for Indiana was 101.0 per 100,000, age-adjusted to the 1970 U.S. standard population, compared to the U.S. rate of 111.9. The Indiana Cancer Registry recorded 3,768 cases of invasive breast cancer in 1996, for a rate of 102.6 per 100,000 women. “By race, 3,496 cases of invasive breast cancer were diagnosed in white women and 235 in black women, resulting in race-specific incidence rates of 102.9 and 96.5, respectively (see “Breast Cancer Incidence by Race”). These rates are not statistically different” (Friesen 2001). Incidence increases with age, and this fact is verified in incidence patterns in Indiana in 1996: 226 (5.2%) in women 30-39 years of age; 737 (16.9%) in women 49-49 years old; 898 (20.6%) in women 50-59 years of age; 981 (22.6% in women 60-69 years old; and 961 (22.1%) in women 70-79 years old (Friesen 2001). Four thousand two hundred new cases of invasive female breast cancer were estimated for 2000.
The Indiana breast cancer mortality rate for 1992-1996 was 25.9 per 100,000, age adjusted to the 1970 U.S. standard population, compared to the national rate of 25.4. In 1999, 895 Indiana women died from breast cancer. “The Indiana five-year breast cancer mortality rate for women of all ages and races is 30.2 deaths for every 100,000 women, [which is] statistically equivalent to the national rate of 29.6 per 100,000 (1994-1998)” (Friesen 2001). “Significantly more black women die from breast cancer,” and in Indiana, “race specific mortality rates are 29.7 and 40.9 for white and black women, respectively (see “Breast Cancer Mortality by Race”)” (Friesen 2001). These rates compare to national rates of 29.1 for white women and 36.4 for black women. Breast cancer in Indiana strikes older women in greater numbers than younger women (see “Breast Cancer Deaths in Indiana by Age Group, 1994-1998”). Only Lake County has a breast cancer mortality rate above the state average of 29.16 age-adjusted for 1995-1999.
Ovarian cancer is the most deadly of all cancers of the female reproductive system, with symptoms often appearing only in advanced stages of the disease. In 1999, about 25,200 cases of ovarian cancer were reported in the United States. In Indiana, ovarian cancer claimed the lives of 322 women in 1999. Based on the state ovarian cancer mortality rate of 9.48 age-adjusted, most counties in Indiana show unstable rates (fewer than 20 cases reported for 1995-1999).
Cervical cancer used to kill more American women, but Pap tests and annual pelvic exams have led to declining mortality rates since the 1970s. Cervical cancer is currently the seventh leading cause of cancer deaths among American women. The National Breast and Cervical Cancer Early Detection Program of the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, has provided a decade of valuable education, screening, and post-screening diagnostic services to underserved women. In 2000, President Clinton signed into law the Breast and Cervical Cancer Prevention and Treatment Act (Public Law 106-354), which gives states the option to provide medical assistance through Medicaid to eligible women who are screened for and found to have breast or cervical cancer. In 2001, Indiana passed House Enrolled Act 1938, which extends this coverage to Indiana women eligible through Medicaid. Indiana’s law provides for medical treatment, as well as diagnostic services.
In 1993-1997, the incidence rate in black women (11.4 per 100,000) was higher than the rate for white women (7.1 per 100,000). An estimate of 12,800 new cases of uterine cervical cancer was made for 2000 (12,900 for 2001), and in Indiana 300 new cases were estimated for 2000. The 1996 Indiana incidence rate for cervical cancer (8.0 per 100,000) was identical with the national incidence rate. An estimated 4,600 American females were expected to die from cervical cancer in 2000. In Indiana, all counties except Allen, Lake, and Marion had unstable cervical cancer mortality rates (fewer than 20 deaths from cervical cancer) for 1995-1999.
Colorectal cancer in the United States accounts for 11.6% of all cancer cases, ranging from 10.2 per 100,000 among Hispanics to 22.8 per 100,000 among blacks. The incidence rate for colorectal cancers has been declining since 1985, probably due to improved detection of early-stage disease and more aggressive polyp removal. In Indiana, the incidence rate of colorectal cancers among women is 36.6 per 100,000 age-adjusted to the 1970 U.S. standard population, compared to 37.2 nationally. The colorectal incidence rate for 1991-1995 in Indiana was 35.8 per 100,000, age-adjusted to the 1970 U.S. standard population, compared to 37.6 nationally. In 2000, 3,100 new cases of colorectal cancer in Indiana were estimated.
Colorectal cancer is the third leading cause of cancer deaths among American women. In 2001, colorectal cancers are expected to account for 10% of cancer deaths. Mortality rates for both men and women have also been declining in the last two decades. Improved treatments have led to improved survival rates nationally. The probability of developing colorectal cancers in females is 1 in 1,855 women from birth to 39 years, 1 in 146 women from 40 to 59 years, 1 in 33 women from 60 to 79 years, and 1 in 18 women throughout the life-span. Colorectal cancers were expected to kill 28,800 women in the United States in 1999. In Indiana in 1992-1996, the mortality rate from colorectal cancers was 15.9 per 100,000, age-adjusted to the U.S. 1970 standard population, compared to 14.6 nationally. In 1996, Indiana had the eighth highest rate of death due to colorectal cancers of all states. Rates of death due to colorectal cancer are significantly higher among blacks than among whites in Indiana
Osteoporosis incidence is difficult to measure, but it is estimated that osteoporosis afflicts more than 28 million Americans, most of whom are women. More than half of all women over age 65 suffer from osteoporosis, causing hip, wrist, vertebral, and other fractures. Seventy percent of all fractures in people over age 45 are due to osteoporosis. Osteoporosis is said to result in 1.5 million fractures annually. An average of 24% of hip fracture patients aged 50 years and older will die in the year following fracture, and half of all hip fractures result in impaired mobility. White women suffer from osteoporosis more than black women, and they have twice the incidence of fractures due to osteoporosis. Menopause poses the single greatest risk for osteoporosis for women, who can lose up to 20% of their bone mass in the 5-7 years following menopause, which makes them more susceptible to osteoporosis. There is no cure, but prevention measures are effective in preventing and reducing fractures and in reducing the cost of this disease nationally.
In the United States in 1994, there were 281,000 hospital discharges for hip fracture among people aged 45 years and older, only 26% of which were among men. One out of 6 white women will experience a hip fracture by age 90. In Indiana, hospital discharge data by any diagnosis of osteoporosis in females age 45 and over shows 3,667 cases of osteoporosis for 1994.
High blood pressure is a major risk factor for heart disease and stroke. It is called the “silent killer” because it often has no symptoms. About 90% of all Americans have their blood pressure measured at least once every two years. One-fourth of American adults have high blood pressure, although about one-third of them are not aware of it. It is especially a problem among blacks, who have a higher death rate from high blood pressure than do whites. Women are at risk of developing high blood pressure during pregnancy, especially in the last trimester. Women who smoke, are overweight, and/or take birth control pills are at increased risk of developing high blood pressure. About 60% of American women aged 65 to 74 have high blood pressure. In Indiana 34.5% of black, non-Hispanic females have been told by a doctor that they have high blood pressure, compared to 25.8% of white non-Hispanic women.
Diabetes was the seventh leading cause of death in 1996, although it is believed to be under-reported as to incidence and as a cause of death. Diabetes appears to affect men and women in about equal measure “Although males suffer greater mortality [from diabetes], females with diabetes have been found to use more health care resources and to report more activity limitation” (Summerson et al. 1999, p. 176). On average, non-Hispanic blacks are 1.7 times as likely to have diabetes as non-Hispanic whites of similar age. Among black, Native American, and Hispanic women, it is the fourth leading cause of death. Diabetes can affect the prognosis for other medical problems, such as heart disease, stroke, high blood pressure (hypertension), complications of pregnancy, and periodontal disease. In 1998, 8.1 million American women were said to have diabetes, or 8.2% of all women. In 2000 in Indiana, an estimated 6.0% of adults age 18 and over had diabetes. There were 878 female deaths from diabetes in Indiana in 1999. The incidence of diabetes in Indiana during 1990-2000 generally exceeded the national rate.
Arthritis is a major factor in limiting women’s daily activities, especially after age 65. It ranks as the number one cause of disability in the United States, and it trails only heart disease as a cause of work disability. Other quality-of-life measures, such as the number of healthy days in the past 30 days, are consistently worse for people with arthritis. People with arthritis in the working-age population have a low rate of participation in the labor force. The incidence of arthritis in women is significantly higher than it is in men. By age 65, about 80% of American women report some problem with arthritis. In Indiana, as elsewhere, the incidence of arthritis increases with age. In Indiana in 2000, nearly 50% of women aged 55-64 reported that they had been told by a doctor that they had arthritis, as did 58.6% of women age 65 and over. In all age groups, men reported less incidence of arthritis. It is predicted that by 2020 over 18% of the population of Indiana will be affected by arthritis (Helmick et al. 1995).
HIV is a growing problem among women, and women are now the fastest growing group of AIDS patients. In 1998 nationally, HIV/AIDS was the fifth leading cause of death among women aged 25-44 and the third leading cause of death among black women in the same age group. Although black women make up only 13% of the U.S. female population, they account for 63% of newly reported AIDS cases in 1999. In 1999, the national AIDS case rate for black women was 49 per 100,000 population compared to 2.3 per 100,000 population for white women. The disease is more prevalent among women of childbearing age. In 1999, 68% of new AIDS cases was reported in women aged 30-49. Women with HIV/AIDS who are receiving care are almost twice as likely as men to be covered by Medicaid and half as likely as men to be privately insured. A new treatment guide for women with HIV/AIDS released in 2001 by the HIV/AIDS Bureau of the Health Resources and Service Administration, U.S. Department of Health and Human Services, addresses the unique problems of HIV-positive women. In Indiana, 675 cases of HIV in women and 658 cases of AIDS in women were reported through 2000 (cumulative). Sixty deaths were attributed to HIV disease in the same period. The incidence rate of AIDS in Indiana during July 1999-June 2000 was 6.1 per 100,000 population for both men and women; the annual AIDS rate for Indiana during July 1999-June 2000 was 1.9 per 100,000 population, compared to the U.S. rate of 9.0 for the same period. Marion county is the only Indiana county with an HIV/AIDS mortality rate above the state average of 0.72 age-adjusted for 1995 - 1999.
Chlamydia, gonorrhea, and primary and secondary syphilis are sexually transmitted diseases (STDs). Chlamydia is caused by the bacteria Chlamydia trachomatis, and it can damage a woman’s reproductive organs. It is the most frequently reported infectious disease in the United States. In 1999, there were 607,602 reported cases in the United States, of which 75% were in people under age 25. Without treatment, 20%-40% of women with chlamydia may develop pelvic inflammatory disease (PID), which can lead to infertility in 20% of cases. The U.S. Preventive Services Task Force (USPSTF) recommends screening for chlamydia for all sexually active women aged 25 and younger. In Indiana in 2000, 13,986 women were diagnosed with chlamydia.
Gonorrhea is caused by Neisseria gonorrhea. There were 355,642 cases reported in the United States in 1999, or a rate of 132.2 per 100,000 persons. The incidence of gonorrhea is highest in high density urban areas among persons under age 24 with multiple sexual partners. In Indiana in 2000, 6,500 cases of gonorrhea in females were reported. The rate of gonorrhea infection among black women exceeded the rate among white women by 43% (19.62% of white women compared to 62.67% of black women).
Syphilis is caused by the bacteria Treponema pallidum, and its signs and symptoms are often indistinguishable from other diseases, making diagnosis difficult. Efforts to eliminate syphilis have been successful, resulting in a 22% decline in both cases and rates since 1997. It has become increasingly concentrated in a few geographic areas, such as the South; and 50% of all cases of primary and secondary syphilis occurred in less than 1% of counties nationally. In 1999, syphilis occurred primarily in persons aged 20-39, and the rate in men was 1.5 times higher than in women. The incidence of syphilis in Indiana in 2000 was 352 female cases, of which 304 cases were reported among black women. The geographic pattern of primary and secondary syphilis incidence in Indiana mirrors the national pattern. Although the state as a whole has a low rate of incidence, Indianapolis/Marion County was ranked as number one in the nation as the city with the most cases of syphilis in 1999, with a rate of 50.0 cases per 100,000 population (407 cases) compared to the national rate of 2.5 cases per 100,000 population. “The percent of Indiana counties reporting more than one case of [primary and secondary syphilis] remained at 5% for the first six months of 1999 and 2000. During the first half of 2000, five counties reported more than one case of infectious syphilis” (Beall 2000). Racial disparities in syphilis incidence primarily reflect differences regarding income levels and access to and use of health care services.