When assessing the health of children, it is important to examine the prevalence of chronic health conditions. Children with persistent health problems are more likely to miss school and require medical assistance and follow-up. Such chronic problems also pose difficulties for the parents, who may experience emotional stress, often lose days from work, and incur additional medical expenses associated with recurrent medical visits and follow-up care. The circumstances of both children and their parents in this kind of persistent difficult environment contribute to the predisease pathways described in Chapter 2.

Asthma is the most common chronic disease of childhood, affecting an estimated 4.8 million children. It is one of the leading causes of school absenteeism, accounting for over 10 million missed school days each year (U.S. DHHS, 1996). In addition, managing asthma is expensive and imposes financial burdens on the families of people who have it. In 1990 the cost of asthma to the U.S. economy was estimated to be $6.2 billion, with the majority of the expense attributed to medical care. A 1996 analysis found the annual cost of asthma to be $14 billion (CECS, 1998).

Table 4 shows the number of children per 1,000 children aged 0-17 in 1993 with a diversity of chronic conditions (NCHS, 1993). Over the past 20 years, respiratory conditions have been the most prevalent type of chronic health problem experienced by children aged 0-17. Rates for most of the chronic health problems identified in Table 4 were fairly constant during that time period, with the exception of chronic respiratory conditions, which showed sizable increases from 1982 to 1993. For example, rates of chronic bronchitis rose from 34 per 1,000 children in 1982 to 59 per 1,000 in 1993 (a 76 percent increase). Similarly, rates of asthma rose 79 percent, going from 40 cases per 1,000 in 1982 to 72 cases per 1,000 in 1993 (NCHS, 1982-1993).

Risk Factors

In a widely cited paper McGinnis and Foege (1993) showed that unhealthy behaviors and environmental exposures were the “actual causes of death” that accounted for 50 percent of all U.S. mortality. Heading the list of causes were tobacco (19 percent), diet/activity patterns (14 percent), and alcohol (5 percent). Smoking has transformed lung cancer from a virtually unknown disease in 1900 to the leading cause of cancer deaths in 1999, accounting with environmental tobacco smoke and interactions with other exposures (e.g., radon) for more than 90 percent of lung cancer deaths each year. Smoking is also the leading cause of chronic obstructive pulmonary disease and chronic bronchitis and emphysema (Warner, 2000). The prevalence of smoking has dropped from 45 percent in 1963, the year prior to publication of the Surgeon General's report on smoking and health (U.S.



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