SPECIAL ARTICLE
The High Cost of Heart Disease
By JEAN SPENCER FELTON, M.D.,
AND
ROBERT COLE, M.D.
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with some heat, that of the consumers. Surprisingly little thought, however, has been
given to the cost of sickness or disability in
terms of our national economy. Often, figures
are given for a particular disability by the
millions of work days lost or the man-loss
years, which, although valuable, give little
insight into the actual costs involved. Frequently, totals are cited, without supporting
documentation, of the economic inroads of
disease. Cancer has been alleged to cost $15.44
billion annually,' alcoholism has been estimated to cost industry more than $1 billion each
year,2 and an effort has been made to apply
a similar yardstick to heart disease. Weisbrod3
has explored methods for measuring the economic impact of disease, and has quantified
the losses from premature death resulting
from cancer, tuberculosis, and poliomyelitis.
In 1959, in a presentation of some of the
factual material on the "major killing and
crippling diseases in the United States,' 4 it
was stated that "at least 653,000 man-years
are lost each year in industry due to heart
disease disabilities," and that this was " equivalent to $3,246,030,000 lost in 1957 alone in
earnings by those suffering heart disease disabilities, and $448,693,000 in f ederal income
tax revenute on these earnings in the same
year. " Yet, the man-years loss figure was
cited from a 1949 publication,3 in which the
figures quoted stemmed from the 1937 health
survey made by the U. S. Public Health Service with the data adjusted to 1946-1947. The
classic work of Dublin, Lotka, and Spiegelman6 similarly is based upon data from the
National Health Survey, collected in the mid1930 's, and the depressed salary levels of that
period. It is believed that an effort should be
made to bring these data up to date in light
of contemporary wage and tax levels. As cost
analysis is part of any business operation, a
dollars-and-cents approach to the problem of
heart disease in the working population is
indicated to stimulate interest and initiate
action in the areas of prevention, control, rehabilitation, and eradication of this particular
group of diseases.
The purpose of this writing is to present
the determined impact of heart disease upon
the labor force and its ramifications within
the nation 's economy. To this end, the authors
have chosen from a variety of sources what
they consider to be the best available estimates
in terms of morbidity, mortality, and costs.
Every effort has been made to utilize statistics
based upon reliable studies, with similarly
defined population groups and identical periods of time.
Estimates of Contemporary Costs
Disability. The National Health Survey,
conducted by the U. S. Public Health Service
for the period July 1957 to June 1958,7 listed
the poputlation usually working* as 59,569,000
From the Division of Occupational Health, School
of Public Health, University of California, Los
Angeles, California.
*These are persons 17 years of age and older who
reported "w orking" as their major activity during
the 12-month period preceding the interview.
RISING COSTS in medical care in the
United States have drawn the interested
attention of economists, organized medicine
through its physician members, hospital administrators,
insurance
underwriters,
Circulation, Volume XXVII, May 1963
and,
957
FE5TON, COLIE
958
Table 1
DJata from the National Health Sufrrey, July 195e7 to Ju-ne 1958
Population usually working
Time lost per year due to all illness causes
Time lost per year by all persons aged 17 years and over, due to all causes
Portion of total work days lost per year, for all persons 17 years and over,
provided by the usually working population
Time lost per year, by all persons aged 17 years and over, due to cardiovascular conditions
Time lost per year, by usually w orking population, due to cardiovascular conditions
Portion of total work days lost per year, for usually working population, due
to cardiovascular conditions
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persons (table 1). This group experienced,
during the same period of time, 432.7 million
work-loss days per year due to illness.8 All
persons aged 17 years and over, in the same
year, lost 599.1 million days from work, for
all causes. Therefore, 72.2 per cent of the
total work-loss days per year for all persons
17 years and over were provided by the usually working population.
The total group-all persons-lost 71.9 million work days per year from cardiovascular
conditions,* (69.2 million work-loss days from
chronic conditions and 2.7 million work-loss
days from acute disorders).9 The figure for
the usually working population, then, would
be 72.2 per cent of this total, or 51.9 million
work-loss days per year due to cardiovascular
conditions. Cardiovascular disease accounted
for 12 per cent of all the time lost by the
usually working population.
There are no figures available in the National Health Survey findings indicating the
predicted or actual number of persons in the
usually working population losing time due
to cardiovascular conditions. Therefore, it is
not possible to determine the amount of time
lost per person from cardiovascular disease.
During the year July 1958 to June 1959, 7.3
million chronic eirculatory conditionis were
*These conditions are those assigned to codes
330-334 and 400-468 of the International Statistical
Classification of Diseases, Injuries, and Causes of
Death, and include, in general, vascular lesions affecting the central nervous system, heart conditions,
hypertension, hemorrhoids, varicose veiiis, and all
other chroniie circulatory conditions.
59,569,000 persons
432,700,000 work days
599,100,000 work days
72.2%
71,900,000 work days
51,900,000 work days
12.0%
estimated among the usually working popatlation by the National Health Survey.10 This
estimate included conditions that were responsible for work-loss days as well as those
for which no work loss was reported. In
addition, it was possible to have reported
more than one circulatory condition per
person; therefore, the 7.3 million figure is
defined as conditions and not persons.
Suppose, however, that a figure were available that would indicate the number of persons involved. To determine work-loss days,
and, from this, financial loss in terms of personal inconme lost to the worker and loss in tax
return to the government, would be fraught
with error, for this reason: many workers in
today 's industrial culture are covered by
health and accident insurance, and, in addition to these benefits, receive vacation pay as
well, so that a large percentage, if not all, of
the time lost would be returned to the employee in terms of income, nullifying a great
portion of the economic loss. Until such time
as exact figures are available for the actual
population involved, and the number of fully
conmpensable days known, an attempt at determiininog personal income loss and the taxes
lost on this income is not possible.
Deaths Exclusive of Disability
WVork Years Lost. In 1957, there were 876,793 deaths in the total population resulting
from cardiovascular conditions"' (table 2). Of
these deaths, 249,467 occurred in the age
group of 20 to 64 years.'2 If these deaths are
assumed to be within the working population,
Circulation, Volume XXVII, May 1963
959
I[IGH COST OF DISEASE
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each death represents an average loss of approximately 10 years from the earning force.'
Earnings Lost. The average annual earnings per employee for all industries in 1957
was $4,211.13 The 249,467 who died would
have earned $1,050,505,537. Therefore, approximately $1.05 billion was lost per year in
personal income because of deaths from cardiovascular disease, if one considers only the
loss of one of the 10 from the earning force.
Federal Income Tax Lost. It was found
that taxable income is 57 per cent of the gross
income, and that the effective tax rate is 23.1
per cent of the taxable income (if one takes
into account all earning groups). 4
Therefore, 57 per cent of a gross income of
$1.05 billion is $598.5 million taxable income.
In turn, 23.1 per cent of this amount is $137.3
*See Addendum.
million. This figure of $137.3 million represents the amount lost in federal income tax
revenue because of the deaths resulting from
cardiovascular disease.
Cardiovascular Disability Costs to Industry
As noted previously, 51.9 million work-loss
days were sustained by the usually working
pop.ulation because of cardiovascular conditions (table 3). If one assumes the average
number of working days per month to be 22,
there are 264 working days per year, including vacation days which, in most instances,
are paid, and thus equivalent to the usual
work days. If the average annual income is
$4,211 as cited previously, the average income
per day is $16. Multiplying this $16 by 51.9
million work-loss days, one finds a total of
$830.4 million in unearned wages each year
because of cardiovascular disability.
Table 2
Losses from Cardiovascular Deaths in 1957
Deaths in total population, due to cardiovascular conditions
Deaths in working population, aged 20 to 64 years
Average annual earnings per employee for all industries
Anticipated total annual income for those in wvorking population dying from
cardiovascular conditions, or personal income lost, rounded off
Taxable income (federal)
Effective tax rate (federal)
Total federal income tax reveinue lost, based upon total income of 1.05 billion
876,793
249,467
$4,211
&1,050,500,000
57%s of gross inconme
23.1% of taxable income
$137,300,000
Table 3
Cardiovascular Disability Costs to Industry in 1957
Time lost per year by usually working population, due to cardiovascular coniditions
Number of working days per year
Average annual earnings per employee for all industries
Average income per day
Total wages lost per year because of cardiovascular conditions ($16 X 51.9 million)
Cost to industry of lowered productivity ($830.4 million X 2) caused by
cardiovascular conditions
Benefit payments for illness-absenteeism in American inidustry per year
Portion of total work days lost per year for usually vorking populationi, due
to cardiovascular conditions
Benefit payments for cardiovascular illness-absenteeism in American industry
per year ($10 billion X 12.0%)
Cost to industry of one employee death or replacemenit
Deaths in working population, aged 20 to 64 years
Total cost to industry of workers lost through cardiovascular deaths
(249,467 X $500)
Circulation, Volume XXVII, May 1963
51,900,000 work days
264 working days
$4,211
$16
$830,400,000
$1,660,800,000
$10,000,000,000
12.0%o
$1,200,000,000
$500
249,467
$124,700,000
960
9FELTON, COLE
Table 4
Total Cost of Heart Disease
Disability Resulting from Heart Conditions
Industry 's production loss from absenteeism
Industry 's loss in benefit payments for abseniteeismii
.$;1,660,800,000
31,2O00,000,0O
$2,86O,800,000
Deaths Resulting from Heart Co9nditions
Labor 's loss in income
Federal government 's loss in inicome tax reveniue
Industry 's loss in turniover costs
$1,050,5000O,
$ 137,300,000
$ 124,700,000
$1,312,500,000
Total Loss
Loss from disability
Loss from death
$2,860,800,000
T-otal cost
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Newmnan,15 in considering absentee costs)
has stated, . . . for every dollar our employees fail to take hone, it costs us one or two
dollars extra." Usinig the single dollar value,
or doubling the amount not earned in wages$830.4 million X 2 one finds that $1.66 billion is the cost to industry for lowered productivity caused by absenteeism due to
cardiovascular disease.
The benefit payments for illness-absenteeism, excluding production costs, amount to
considerably over $10 billion per vear for
American industrv as a whole."' As previously
indicated (table 1) cardiovascular conditions
account for 12 per cent of all time lost.
Twelve per cent of $10 billion amounts to $1.2
billion, the amount paid by industry in the
form of cash benefits for cardiovascular conditions.
Recent studies on the cost of an employeedeath or turnover indicate an average figure
*Absentee cost is based upon:
1. The need for extra people on the payroll to take
the place of those absent.
2. Idle niaehinery and unused investment, when
w orkers ullexpecte(lly fail to come to work.
3. Disrupted productioni schedules with inconvenienced customers.
4. High iiiventory caused by delay in shipment.
5. Spoilage resulting from substitute workers having to do jobs for which they were not trained.
6. Overtime premiums paid to mnake up for lost
time.
$1,312,500,000
$4,173,300,000
of $500* per person loss or separatee.17' 18
Using the total of 249,467 deaths, multiplied
by $500, one gets $124.7 million as the cost
to industry of replacements for those lost
through cardiovascular deaths.
Recapitulation
Heart disease in the working population of
the United States for the year July 1957 to
June 1958 resulted in an estimated national
cost of $4.173 billion (equivalent to 5.8 per
cent of the national budget for the sanie
year19), excluding the cost of medical care.
This total cost is itemized in table 4.
Discussion
Other factors, of course, exist which, if included, would increase the national cost. These
are state income taxes, local taxes, medicalcare expenses, and such difficult-to-measure
entities as lowered buying power, with its resultant diminished retail and wholesale business.
No presentation of this nature is made
without the authors' being aware of some of
the balancing factors. Reference is made to
the financial gain of pharmaceutical companies, pharmacists, physicians, hospital equipment suppliers, and all otbers in a position to
*Actually, for certain jobs, the cost is much higher.
Einds' has pointed out that the cost of replacing an
engineer is $5,590.
Circulation, Volume XXVII, May 1963
HIGH COST OF DISEASE
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offer services for remuneration to cardiovascular patients. In addition, there is the gain
to the economy through the employment of
persons replacing the disabled and those who
have died.
A philosophic point can be raised, also, of
the worth of using an " average " wage. There
are great differences in lifetime incomes between the college graduate and postgraduate group, and the inadequately educated
segment of the population. Do all get heart
disease at the same age, with the same prognosis, and with the same degree of disability?
How much more cardiovascular illness is
eaused by the stress of low income? Or does
the stress of corporate life balance this? There
are many elements that could enter into a
discussion of the weighting of factors, but it
was not the intent to place all minutiae on the
pans of the balances.
There are specific statistical studies indicated by this kind of data asseinbly. First,
there should be a determination of the impact
of disease on the working population in terms
of the actual (or estimated) number of persons in the work force, with time lost from
cardiovascular conditions, i.e., in whom the
heart disease is the primary cause of the time
loss, and not one of several disabling
disorders.
Secondly, there should be a determination
of the national average of sick benefits paid
under various insurance coverage plans in
terms of the number of days for which benefits
were paid, and the amount of money involved.
Lastly, there should be data available of
the average anmount of paid and nonpaid vacation time taken by the usually working population, in numbers of days. With these
additional figures, it might be possible to determine the impact of disability on personal
incone, if any.
Summary and Conclusions
An effort has been made to demonstrate the
impact of the disability of a specific group
of disease states on the national economy. It
is believed that the presentation of this information can stimulate increased interest in the
Circulation, Volume XXVII, May 1963
961
prevention, control, and eradication of heart
disease, and the rehabilitation of its victims.
The cost of heart disease to the nation 's
economy, as adjudged by a review of the 19571958 data, totals $4,173,300,000. The annual
cost of heart disease in the United Statesone-seventeenth of the national budgetshould motivate greater research, epidemiologic, preventive, control, and rehabilitation
activities in this vast area of human wastage.
A plea is made for comparable cost mensuration of this country 's other leading chronic
diseases.
References
1. Editorial: The cost of cancer. The New Physician
10: 160: 1961.
2. PERLIs, L.: Alcoholism in Industry. New York,
The National Council on Alcoholism, Inc., 1958.
3. WEISBROD, B. A.: Economics of Public Health.
Philadelphia, University of Pennsylvania Press.
1961.
4. Facts on the Major Killing and Crippling Diseases in the United States Today; Section:
What Are the Facts about Diseases of the
Heart and Circulation in the United States.
New York, National Health Education Committee, Ine., 1959, p. 2 of section.
5. America's Health-A Report to the Nation by
the National Health Assembly. New York,
Harper & Brothers, 1949, p. 185.
6. DUBLIN, L. I., LOTKA, A. J., AND SPIEGELMAN,
M.: The Money Value of a Man. New York,
The Ronald Press Company, 1946.
7. Health Statistics from the U. S. National Health
Survey, July 1957-June 1958, Series B-10.
Washington, U. S. Department of Health,
Education, and Welfare, Public Health Service,
1960, p. 47.
8. Health Statistics from the U. S. National Health
Survey, July 1957-June 1958, Series B-10.
Washington, U. S. Department of Health,
Education, and Welfare, Publie Health Service,
1960, p. 19.
9. Health Statistics from the U. S. National Health
Survey, July 1957-June 1958, Series B-10.
Washington, U. S. Department of Health,
Education, and Welfare, Public Health Service,
1960, p. 44.
10. GLEESON, G. A.: Personal communication to the
authors, July 25, 1961.
11. Statistical Abstract of the United States: 1959.
Washington, U. S. Bureau of the Census, 1959,
p. 66.
12. Mortality from Selected Causes: 1957. Vital
Statistics- Special Reports. National Summar-
FELTON, COLE
962
13.
14.
15.
16.
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18.
19.
20.
ies, Vol. 50, No. 5. Washinigton, U. S. Department of Health, Education, and Welfare, Public
Health Service National Office of Vital Statisties, April 3, 1959, p. 128.
Statistical Abstract of the United States: 1959.
Washington, U. S. Bureau of the Census, 1939,
p. 323.
Statistical Abstract of the United States: 1960.
Washington, U. S. Bureau of the Census, 1960,
p. 380.
NEWMAN, L. E.: Reducing absenteeism: A three
step program. Management Review 44: 433,
1955.
Controlling Absenteeism. Survey No. 57. BNA's
Personnel Policy Forum. Washington, The
Bureau of Nationial Affairs, Inc. (June) 1960.
Abstracted as, Cutting the Cost of Chronic
Abseiuteeism. In Management Review 49: 61,
1960.
Suggestions for Coiitrol of Turnover and Absenteeisin, rev. BES No.; E-61. Washington, U. S.
Departnient of Labor, Bureau of Employment
Security, United States Employment Service
(July) 1957, p. 10.
Labor Turnover: Causes, Costs and Methods of
Control. Los Angeles, Merchants and Manufacturers Association (February) 1939, p. 39.
The "total budget expenditures'" for the fiscal
year 1958 amounted to $71,896,545,201. Hansen H., ed: The World Almanac-1959-and
Book of Facts. New York, New York WorldTelegram and The Sun, 1959, p. 748.
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Addendum
Determination of Average Time Loss from Earning
Force for Cardiovascular Death
Deaths in 1957
(1)
Age
20 - 24
23- 99
30 -34
35-39
40 44
45 -49
50 -.54
a3-) 9
60 -64
(2)
(3)
Average age
Number
27
2,174
32
37
42
47
52
57
62
4,353
1.366
8,603
16,082
27,253
42,448
60,560
86,626
249.467
(4)
Years remaining
in work life
42*
37
32
27
22
17
12
7
2
The aggregate of multiplying items in columns 3
anid 4 (2,433,094) divided by 249,467, will give the
average loss for eaeh person from the work life of
9.75 years, or approxinmately 10 years.
*Average age of 22 selected from age group 20-24.
Age 64 represents terminal work age; hence, for each
person aged 22, 42 years would remain in his work
life, wvere he to have lived to that age. Weisbrod,2'
in his computation of the present values of net future
earniings, shows money earnings for persons up
to age 75, but in light of contemporary industrial
personnel practices of compulsory retirement, the
mor e realistic mid-60 figure is used here.
Circulation, Volume XXVII, May 1963
The High Cost of Heart Disease
JEAN SPENCER FELTON and ROBERT COLE
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Circulation. 1963;27:957-962
doi: 10.1161/01.CIR.27.5.957
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