COMMUNITY HEALTH GENERAL the world before and after Rome have turned to engineers to solve urban problems of drainage, flooding, and crowding while at the same time pyramids and temples, cathedrals and castles, universities and markets were being built, all designed to maintain good health and integrity of communities Today, efficient land, sea, and air rapid transport networks help deliver farm products promptly to processors, relying heavily on refrigeration to maintain freshness and nutritional quality Water supplies, a vital element in human health as well as a basic unit of industry, no longer depend on insanitary streams or cisterns but are collected behind large dams, delivered over great distances through well-engineered conduits to filtration plants and there purified, chlorinated and fluoridated for safe consumption Epidemic diseases like typhoid fever and cholera, amoebiasis, malaria and yellow fever no longer threaten communities in developed nations, thanks to engineering that provides potable water, free from harmful parasites and available for human waste disposal Evaluation of any community’s health is both quantitative and qualitative Planners need to know how many hospitals exist within the city limits, where they are in relation to centers of population, and whether transportation for patients, staffs, and visitors is adequate Numbers of primary and secondary schools, technical training centers and universities, each with details of the students being served are important data in judging community ambience Local governments want to know how many of the people who work in a city actually reside there, how many residents rent apartments or own their own homes and in what direction these numbers are changing, measures of migration in and out of the jurisdiction Businesses and factories that are seeking new locations look closely at pertinent employment rates and skills of available workers that can support general manufacturing, or contribute to growth or modification of an enterprise Other statistics reflect the fire safety of a community, like the numbers of residential or business fires, annual dollar losses due to conflagrations, or the average response times of fire apparatus to alarms Law enforcement is rated by numbers and categories of crimes, numbers of crimes solved and the convictions that result Social health indices would include the numbers of persons on public welfare or assistance, and the numbers and rates of out-of-wedlock school-age pregnancies When a community’s ability to provide effective sickness care is weighed, the ratios of total population to physicians and other health professions, the number, size, accessibility, Health is the ability to cope with activities of daily living, ever a norm yet always relative.1 Most people enjoy and expect good health, boast of their abilities to perform but resent being unhealthy Health is valued most highly after it has been impaired Health and sickness are two contrasting aspects of our world’s life Sickness is a deviation from normal healthy functioning, much like any other system breakdown Each attracts a legion of helpers ready to aid ailing persons return to their diverse pre-illness states So it is with a community’s health.2 Evaluations of community health must consider many factors In addition to specialized and general medical care, variables include housing availability and ownership, transportation adequacy for work or pleasure, entertainment and recreation, severity of usual weather conditions, educational opportunities, and social and religious factors, among others Whereas a plethora of medical and surgical options contribute to what are sometimes claimed as miraculous recoveries from a personal illness, environmental engineering quietly strives to create basic healthy living conditions and protect communities from potential physical dangers, widely ranging in severity and in size from small to large Environmental health of a community is rated by the degrees of satisfaction that result from engineering works and organized community efforts that improve the physical freedom, comfort, and efficiency of residents Cities and towns are judged on the numbers and quality of existing recreation opportunities, schools and colleges, and transportation routes, and fiscal services Yet, while the processes that caused those amenities to be developed are important, the systems and organizations that currently maintain growth or stability must also be carefully noted and weighed A community’s health is not static and must be cared for continually, much like the health of any resident For millennia, communities have depended on engineering skills to install, maintain and improve necessities and amenities of life that contribute to the well being of citizens, animals, and plant life Ancient Crete used conical terra cotta pipes to keep sewage flowing, an early example of the venturi principle, and for centuries massive aqueducts provided ample supplies of fresh water to Roman communities Excellent roads and transport brought foodstuffs from farms to imperial cities and helped speed commerce and communications between businesses and governments Cities around 171 © 2006 by Taylor & Francis Group, LLC 172 COMMUNITY HEALTH and types of hospitals, with attention to emergency services and rehabilitation care are important Slightly different studies for evaluation of care must be given to rural areas where hospital accessibility, highway networks, and estimated transit times for ambulance services, become critical elements in area’s health study Residents and visitors, businesses and news media, continually assess the health of a community by studying reports that describe adherence to or departures from desired norms of community living Governmental publications provide estimates and statistical analyses of regularly collected data about commerce, industry, and banking Visitors fairly accurately sense or rate a community’s ambience by noting the frequency and types of cultural activities for residents or visitors, the numbers and quality of public and private schools, and available recreational facilities Competent urban planning encourages and supports neighborhoods that have identity and local pride, perhaps with islands of green park land, all served by excellent roads and public mass transit that make for easy access to cultural and recreational areas Community health depends upon diverse activities, many that result from excellent engineering and some directly related to personal health or sickness care of citizens The central official health authority for a community is its public health department, a major health agency under direct control of the mayor or county executive The health department is established by statute, and its chief health officer is a legal guardian of community health with an authority that includes subpoena power to enforce applicable health codes and regulations Sizes and complexity of official health agencies range from two or three persons in a town or village to major departments of states and territories, or the national U.S Department of Health and Human Services (DHHS) and the international World Health Organization (WHO) Health agencies or departments have a tradition of professional knowledge and compassionate service, two characteristics that usually provide a modest freedom from administrative interventions This varies somewhat in proportion with budget allocations but it allows health departments a certain flexibility to design their services as needed to carry out community health tasks Child health care in an affluent suburb will be patterned differently from clinics for expectant mothers and infants and family planning in low income or poverty areas Centers for treatment of drug abuse and addictions or patients recently discharged from state mental health hospitals need to be close to where those conditions are frequently encountered Basic services of most health departments include the epidemiology of infectious diseases; treatment clinics with emphases on sexually transmitted diseases and tuberculosis; family planning services, often a euphemism for contraception but they may also include advice on abortions in the first trimester of a pregnancy; child health care in well-baby clinics where newborn infants and preschoolers are followed closely with childhood immunizations and school health services; pediatric dentistry; services for drug and alcohol abusers who want relief from these personal burdens; and special clinics or services when needed by special communities, such © 2006 by Taylor & Francis Group, LLC as victims of AIDS or chronic psychiatric ailments Health education, once a major activity in a local health department, now is carried out by schools and numerous single-focus volunteer organizations, like those for heart disease or cancer Health promotion, too, has received much attention in the public press and from an increase in general awareness of the advantages of stopping smoking tobacco, weight control, cholesterol levels, and balanced diets Environmental control services, a major division of any health department, include restaurant inspection and food services control, with added concerns for area-wide sanitation, housing, industrial hygiene, and animal control Control and abatement of environmental hazards vary as an emphasis shifts from human health effects to a general community salubriousness, pushed by legislative actions that reflect the relative effectiveness of lobbyists for human health adherents or environmental activists Concentrations of population and their needs vary among cities, towns, or counties whose geographies, ethnic compositions, and industrial bases differ sufficiently so that each health unit needs flexibility in designing services Many health departments have citizen or legislative oversight through various boards of health, and functional tasks vary with the problems that confront the individual jurisdictions Malaria control, for example, is a prime concern for tropical and some developing countries while the energies of urban health agencies may be heavily invested in tuberculosis detection and treatment Each is governed by regulations or distinct health codes that have been written to implement laws enacted by respective legislatures Although occasional conflicts can arise between neighboring communities when confusion or contradiction exist in regulations or information flows, relatively consistent scientific and engineering standards developed by professional societies or governmental experts are available to make health codes more uniform, despite restrictions of jurisdictional boundaries Public health responsibilities were once synonymous with local and urban health departments and a few public health schools that were based in major universities Since about 1960, however, many other community agencies have assumed much of traditional public health’s former activities and have blurred the previously clear image of official health departments Federal funds to carry out public health programs once were limited to health departments but have been made available as grants to groups such as voluntary associations, hospitals, medical schools, neighborhood associations, and Indian tribes or ethnic groups Interested community health care provider groups now provide needed auxiliary services such as health education and promotion, medical services to disadvantaged groups, and family planning They also carry out limited data collection and disease specific epidemiology that support their ongoing research activities Coordination of numerous separate and isolated studies and consolidation of focused findings can be difficult for local health departments who may not have had a role in the investigations William Foege, a former director of the Centers for Disease Control, has described the environment COMMUNITY HEALTH for public health practice as changing beyond any predictions and urged support of government for health monitoring systems and interventions.3 Private health care has gradually become part of the greater public health system, largely due to change in funding and demands from the public and its elected officers for better quality control of health services These interests have led to closer supervision of medical services delivery Licensing boards and related quality assurance organizations have increased their efforts to assure that the professionals who provide health care are fully qualified to practice the disciplines for which they were trained Terminology like licenses, certificates, or permits tend to be specific for each profession even though a general public may use the names interchangeably Commonly, physicians and dentists are licensed, nurses are registered, midwives are certified, and physician assistants receive permits from specific state boards Each board evaluates the training that its applicants have received and administers a licensing examination that must be passed before permission to practice is awarded Licenses or certificates can be withdrawn when the specific board has, always by careful legal action, determined that the holder of that license has breached its standards for quality performance Sanctions of licensees or permit holders vary and may include a written admonition or reprimand, suspension for brief periods, requirement that the professional undergo special training or medical treatment, or even complete withdrawal of the permit to practice Failure to perform in accordance with accepted standards may result in disciplinary action by hospitals as well, and the results of such decisions are shared with all agencies that have official public responsibility for quality care, consistent with existing standards of confidentiality Categories of other health care practitioners who must possess licenses vary slightly from state to state but often include dental hygienists, psychologists, social workers, physician assistants, chiropractic, physical therapists, and acupuncturists Personal health care services, once known as the “private practice” of physicians and nurses, are gradually shifting from solo practitioners to corporate or group practices Remuneration has also shifted from personal payments by the patient or a guardian to public payments from sources like Medicare, Medicaid, and insurance programs Some of the new groups of health providers are independent practice organizations (IPAs) in which physicians are separate providers but relate to a central management group; preferred provider organizations (PPOs) where physicians retain independence but engage in contractual services; and health maintenance organizations (HMOs) in which physicians and other professionals may be contractual employees of a public or private entrepreneurial organization, rather than independent professionals Free-standing medical centers provide initial care for relatively minor illnesses or prompt referral of more serious conditions, sometimes known as “urgicenters,” have arisen to care for persons who have no regular medical attendant or whose physicians are not immediately available © 2006 by Taylor & Francis Group, LLC 173 Free-standing non-governmental medical clinics are often located at vacation resorts or in busy shopping malls and are part of a community’s medical resources These are also known as walk-in clinics or colloquially as “doc in a box” services of various complexity and usually meant to suffice only for short-term care Mergers of smaller health care groups create progressively larger corporations which control wide-ranging delivery sites with well-equipped outpatient clinics for initial care and specialty consultations of medical and surgical illnesses, ambulatory surgical centers for one-day surgery, as well as more complex invasive and diagnostic procedures, similar to those provided in hospitals Pharmacies and laboratories and rehabilitation centers may be part of major health care groups Special medical units have been created to provide general care services for entire families at university medical centers with their own professional schools, or by major hospital groups or industries whose employees might otherwise lack quality medical care Urban and rural US communities have always had cadres of health care providers or “healers” who were considered by traditional licensed physician groups as being less well trained and to whom medical licensure was denied Some of these care givers in remote or isolated communities were folk medicine healers who had received instruction from older practitioners or even been self-taught These indigenous healers and a large number of other allied health care providers have been roughly designated as complementary or alternative health care Complementary and alternative are general terms applied loosely to more than a hundred or so unrelated healing methods whose adherents believe each is effective Complementary health care refers to those skills or systems that will support customary medical or surgical care directed by a licensed physician Acupuncture is a complementary system, an insertion of needles in parts of the body in accord with a complex system to relieve pain or cure ailments.4 The practice of chiropractic, also, is increasingly accepted as complementary to physician directed care In contrast, alternative health care is a term to denote a therapy or system that is meant to supplant regular medical care of a physician Iridology, the diagnosis of human disorders by examining the ocular iris, and naturopathy are two of many alternative care systems Homeopathy and chiropractic practitioners, for example, are recognized as healers to be licensed by their own boards in many states, thus subjecting them to a degree of oversight and legal responsibility Several popular journals now exist in which the various supportive health care modalities are featured Meanwhile, any of the other alternative care practitioners may be found in local jurisdictions with little or no official supervision or control, unless medical licensure laws are violated or use of a specific method causes harm to a subject under care.5 Quiet controversy or open disagreement exists about the value of any one system in these two fields, but a federal office has been created in the Department of Health and Human Services (DHHS) to study and evaluate efficacy and safety in complementary or alternative health care practice 174 COMMUNITY HEALTH One school of fully qualified healers, the osteopathic physicians, were once considered as having a discipline that was distinctly different from allopathic physicians Today, osteopathic physicians graduate from osteopathic medical schools that have full governmental certification and provide training of equivalent quality to other U.S medical schools Osteopathic physicians are licensed in all states and osteopathic specialty certifications are acceptable for full practice privileges and positions on hospital medical staffs Modern socialized health care that began in Germany in 1876 has spread in one form or another to almost all of the world’s developed nations, notably excepting the United States of America Socialized health systems have varied from care that is nearly totally government controlled to that which is delivered by independent practitioners whose patients have freedom to select their caregivers Payment systems also differ, with mixtures of public pay from government directed services to private pay for personal services to individuals In the U.S., mixtures of private or public insured care and public entitled care exists Health care insurance is available to many workers as part of their employment obtained through union efforts or purchased by employers Federal Medicare is available to persons over 65 years of age and those who receive Social Service disability payments Public entitlements include military personnel, certain categories of persons in need, such as pregnant mothers, children, prisoners, and Medicaid for persons receiving governmental subsistence aid Federal grants were given to medical schools during WW I to speed the training of medical students and produce the physicians needed by an expanding military establishment Funding for medical education and research increased regularly during World War II and continued to escalate after hostilities ceased Medical school enrollments grew and new schools were opened to accommodate the soldiers who were returning to seek new careers Premedical courses were expanded to provide basic instruction to prepare medical school candidates, and hospital residency programs expanded rapidly to provide training after medical school in the burgeoning medical specialties Concurrently, efforts were under way to make sure that patients and entire communities that once suffered tragically from diseases like acute poliomyelitis and chronic tuberculosis would no longer be threatened by these scourges Protective oral and injectable vaccines have nearly eliminated polio, and effective antituberculosis drugs have rendered sanitoria for very long-term care no longer necessary The severe late effects of sexually transmitted diseases [STDs], like cardiac complications of syphilis and its severe central nervous system damage, or late complications of gonorrhea that resulted in sterility, pelvic abscesses, or purulent arthritis, are now forestalled by early treatment with antibiotics Scarlet fever, child-bed fever or puerperal sepsis, rheumatic fever, and erysipelas, streptococcal infections are nearly medical rarities However, drug-resistant forms of all common bacteria are viewed as major therapeutic dangers, and new diseases like those of the Ebola and Hanta viruses © 2006 by Taylor & Francis Group, LLC begin to challenge infectious disease specialists, leading to a surging interest in global infectious diseases Major advances occurred in basic health care technology and pharmaceutical products manufacturing but also in the engineering skills and sciences that produced computed tomography, magnetic resonance imaging, molecular biology, laparoscopic surgery, and rapid, convenient laboratory methods A current view of these fields has been described by N.P Alazraki.6 Medical divisions of all major universities and large private hospitals compete vigorously for federal funding for basic and advanced research in health sciences, and insurance reimbursements and private bequests or donations of money to enable the expansion of existing facilities and structures needed for new health technologies and the related technical staffs Much controversy exists over rising costs of medical care, specialized equipment, laboratory procedures, and growing numbers of professional personnel Efforts to remedy the large U.S medical care system and reduce expenditures met much opposition from organized caregivers and thwarted the efforts of the Clinton administration to carry out sweeping changes in the way that health care would be delivered Perhaps paradoxically, much attention is now being given to curbing excessive or elaborate care through better organization, shorter hospital stays, living wills and durable powers of attorney that help patients to terminate useless care under predetermined conditions, and even a medical concept of “futility care” that attempts to deal with hopeless cases Despite many condemnations of modern medical practice that has grown rich, the balance of curative efforts has been positive Abel Wolman, the famed water and sanitation engineer, once summed up the progress that federal and other monies have supported by saying, “Money is the root of all … good!” HEALTH AGENCIES The health department of any political subdivision is the governmental unit that enforces the health code and the sanitary ordinances and regulations that follow Its director is a governmental officer for health sworn to uphold the laws that relate to health and sanitation and to recommend new measures to counter any recognized dangers to the public’s health No other licensed physician group or hospital or voluntary health agency has this key legal authority to maintain health in a political jurisdiction Each health department is responsible for guarding the health of its entire assigned geographic and political subdivision, a legal commitment to abate any health hazard that is as broad as the political units to which they belong Contrasted to the border-to-border obligations of a health officer, the wall-to-wall scope of hospitals is limited to medical events within its buildings or in contractual obligations of outreach programs Physicians and other healthcare providers are more or less limited in their concerns to person-to-person duties in the care of individual patients COMMUNITY HEALTH Official public health services provide some sickness care but are legally charged to assure that all citizens have safe and healthy environments in which to live and work Health departments must respond to complaints from anyone within their jurisdiction, and their officers are expected to act promptly to abate health dangers These agencies have a duty to intervene and a right to enter whenever a hazard exists that threatens the community’s health Although actual physical entry can legally be obtained only by permission or by warrant, health departments have long been considered to have a right to enter any dispute that involves community health In this respect, official health departments are truly safety agencies equal to fire or police departments In addition to this unique legal status, the health officer is a member of the central staff or cabinet of the chief elected official and provides advice on health matters The mayor, county executive, or governor can direct that health officer to begin appropriate corrective actions whenever the public health is endangered To help in fulfilling statutory and directed functions, health departments have four essential community functions: Epidemiology, disease prevention, needed services, rescue and protection EPIDEMIOLOGY The importance of epidemiology, or the knowledge of a disease that exists in a community, was clearly stated as early as 1879 in a Baltimore City health ordinance that began with this statement: “It shall be the duty of the Commissioner of Health, from time to time to make a circuit of observation to the several parts of the city and its environs” to detect dangers to health and promptly order their correction This legal charge codified the duty of the health officer personally or through delegated agents to gather information about the healthiness of the community or its inhabitants Often known as “shoe leather epidemiology,” this direction is similar to a military axiom that tells commanders to “go to the sound of the guns,” to go where troubles exists Further, the Baltimore ordinance directed the health commissioner to take immediate steps to correct noxious conditions and to report to the mayor with advice on further actions needed to maintain a healthy city All of these steps are a part of epidemiology, or wisdom “among a people.” Health departments collect information about communicable diseases, analyze reports of births and deaths, follow trends in accidental injuries and childhood development, and provide annual summaries of the health of a community Possibly the earliest example of modern measurement of health statistics occurred in 1882 when vital records of Baltimore, MD, and Washington, DC, were analyzed by sensing punch cards John Shaw Billings, who would later design the Johns Hopkins Hospital and the New York Public Library, asked an electrical engineer, Herman, Hollerith, to devise a means of electrically sensing and counting the holes in a series of punch cards that contained census information about the respective populations This venture was successful and the information obtained is listed in the annual reports of the 1880 U.S census for the two cities © 2006 by Taylor & Francis Group, LLC 175 Gathering health facts and analyzing them is such a distinctive health department function that a well-known national health officer once urged that they be named “Departments of Epidemiology” to emphasize this importance.7 The discipline of epidemiology determines and analyzes the distribution and dynamics, or changing characteristics, of diseases in human populations Physical health in a community is measured inversely by the incidence of a disease or injury over time or its prevalence at any given moment or time period.8 The lower the incidence or prevalence, the better the community’s epidemiologic health Health officers utilize epidemiology to determine where, how and why disease exists in their communities Other measures of the impact of diseases on community health are found in statistics of morbidity and mortality, as well as a disease intensity in a neighborhood, where a disease is spreading, and any deaths as noted by gender, age, and race Epidemiology is a basic tool for allocation of departmental protective and preventive resources and services Health departments gather and analyze data supplied in reports to central agencies received from physicians and health care workers who are required by law to so report on official forms each occurrence of certain human diseases, at least 52 of which must be reported to the U.S Centers for Disease control Reporting enables health officials to deploy public health workers and resources who can act to limit the spread of infection to susceptible inhabitants A health officer can require that patients with certain communicable diseases can be isolated in a single household, or order a communitywide investigation of food poisoning or a measles outbreak in local schools that is preliminary to focused prevention When spread of a disease can be minimized by vaccination, localized or mass specific inoculation programs are offered to all persons at risk, some of whom may also require specific antibiotic therapy as prophylactic against infection DISEASE PREVENTION The first case of an infectious disease, the “index case,” is the well-spring of epidemiology (Sartwell) Certain diseases spread rapidly in a community and cause severe economic loss if workers are incapacitated or children are disabled by severe complications Infections like measles and rubella (German measles), are no longer accepted as unavoidable risks to children but have been markedly reduced by protective vaccines Poliomyelitis has nearly been eliminated in the Americas and small pox has in fact been eliminated from the world by mass immunizations.9 Epidemic cholera appeared in Peru in the last decade and spread through neighboring countries, and Lyme disease was identified several decades ago in New England; recent findings show that it also has a world-wide distribution Diseases are spread easily by tourists and business people who return to homes by air, unwittingly carrying early infections of exotic diseases These may include malaria, typhus, hemorrhagic dengue fever, and others, many of which require prompt public health attention to minimize or eliminate transmission to U.S residents 176 COMMUNITY HEALTH An initial report of a case of tuberculosis, for example, will require that all persons who have contacted the patient be skin tested (tuberculin test) several times for evidence of existing tuberculosis; those persons who test positive must be further examined to determine if active or progressive disease is present Prophylactic treatment with isoniazid can be safely offered to persons with positive skin tests if they are under the age of 35 or 40 years, but full therapeutic courses of antibiotic drugs are recommended for those with clearly evident pulmonary or extra-pulmonary infection Some strains of tuberculosis germs (mycobacteria) have arisen that are resistant to several of the four customary therapeutic drugs The specific type of mycobacterium responsible for a patient’s disease must be determined so that the initial drug regime will be effective from the beginning, not after months of partially effective therapy have elapsed and the infection has not been controlled To prevent the spread of drug resistant mycobacteria, initial courses of multiple antituberculosis drugs are individually administered by nurses who see to it at each scheduled dosing that an infected patient ingests the total amount of drugs that have been prescribed This mode of anti-tuberculosis therapy is “Directly Observed Treatment” (DOT) and, while costly in staff time, it has resulted in effective control of a dangerous disease In many political jurisdictions, when a patient with tuberculosis is judged to be a public danger because of failure to cooperate in treatment and control of the spread of infection, public health officers can request courts to incarcerate that patient so that treatment can be carried out under close supervision to protect the public Reported tuberculosis has increased as a complication of the human immunodeficiency virus (HIV), the causative agent of the AIDS epidemic Because of this, the Centers for Disease Control (CDC) in Atlanta have advised state and local health departments to tuberculin skin test all persons with HIV infection.10 Conversely, persons with tuberculosis are urged to be tested for HIV, and the registries of patients with these two diseases should be matched at least annually.11 When many cases of enteric diseases are reported, either localized as endemics or widespread as epidemics, health departments mount intensive searches to determine the nature and source of infections Control measures to prevent further spread can include mass vaccination, provision of safe food supplies and potable water, official quarantine or isolation of sick persons and their excreta, evacuation of critically ill persons for definitive therapy, and vigorous public information programs to help uninfected persons at risk take appropriate steps to avoid the disease.12 Infectious disease outbreaks can result in heavy loads of sick or injured persons that may overwhelm community resources and require help from allied governmental or voluntary health providers for the short term as in disasters or damage to water supplies, or over the long term to remedy the ill effects of continued poverty or devastation Rats and mice, the animals chiefly regarded as signs of environmental deterioration, easily find homes and food in the debris customarily associated with poverty housing Rat urine spreads leptospirosis, an infection that results in © 2006 by Taylor & Francis Group, LLC jaundice and occasionally renal impairment or aseptic meningitis, but small children who must live in rat infested neighborhoods are also at risk of rat bites Major control projects strive to teach communities to deny rats an access to food in accumulated garbage, and eliminate easy harborage in piles of casually discarded trash or poorly maintained, dilapidated residential structures Rats have proved to be courageous adversaries and survive despite major attempts to eliminate them with poisons, traps, gases, high frequency sound, and education of human residents Yet, the dangers from rat bites are intolerable and health departments continue to war on rat populations ENVIRONMENTAL HAZARDS Huge plumes of dark smoke billowing from industrial stacks was once a sign of a community’s prosperity, but no longer Oil and electricity heat have replaced coal as fuels for residences, industry, locomotives, and ships Municipalities have banned or severely curbed the operations of home and apartment incinerators, and those that remain must have stack scrubbers and other equipment to drastically reduce emissions of particulates into the atmosphere Half a century ago, the dark, gray lungs of city dwellers that resulted from inhalation of coal dusts and other particulates were easily distinguished at autopsies from the pinkish gray ones of rural citizens Funded by federal grants, states are now well equipped to measure gaseous atmospheric pollutants and gather the data needed to support limiting toxic gaseous emissions by motor vehicles and major industries, and human pulmonary health has markedly improved Control of hazardous materials (HAZMATs) may be divided between health and other agencies yet emphasize safe storage and transport to protect neighborhoods and safe usages for workers Local fire departments and state fire marshals or departments of environment are charged with the responsibility for containing spills and subsequent decontamination Fire officials, for example, at all times carry handbooks and catalogs of toxic substances in their vehicles, and have been trained in the appropriate responses to hazardous spills Frequent reconnaissance inspections of known locations where hazardous materials are stored helps to insure safe management of toxic materials Departments of public works, health, and police may also be called upon to assist in management of spills Official health agencies now participate as consultants for community health in air pollution management, or advisors on the health aspects of building construction when toxic substances are used incorrectly When lines of authority are not clear, duplication of municipal or county services and conflicting regulations may result in failure to respond promptly to early warning signs of environmental hazards Health officials may be called after a chemical spill has been abated to counsel communities about possible delayed hazardous effects on humans Health sanitarians and technical inspectors of other agencies investigate complaints made by workers, nearby COMMUNITY HEALTH residents, or the general public about unsafe workplace environments Officials inspect sites where alleged infractions of regulations have occurred, interview complainants and workers, and take samples or measurements of gases, dusts, or other possible toxic agents Corrections may be made on the scene, or the respective departments will initiate official regulatory actions or seek legal sanctions Airborne particles of asbestos, silica, metallic dusts, chemical gases or fumes, and organic fibers can pose dangers to workers or the general public and must be promptly abated Once widely used in fireproofing, building construction, and insulation, asbestos, if inhaled, results in fibrosis or chronic scarring of lungs with moderate to severe respiratory disability Late effects include cancer (mesothelioma) of the lining membranes of the pleura (chest) or the peritoneum (abdominal wall) and is uniformly fatal Abatement of existing asbestos-containing material from limited building areas that not involve major razing must be sealed off to prevent dusts from spreading to unaffected areas; workers engaged in asbestos removal must be carefully garbed in protective clothing and equipped with approved protective respiratory equipment All asbestos demolition activities, and the debris containing asbestos must be handled with strict attention to federal and local laws and regulations Inhaled coal dusts result in coal miner pneumoconiosis or black lung disease, a disabling condition more often seen in mines producing anthracite or hard coal Unprotected inhalations of dusts from the floors of factories that produce pottery or electrical insulators has resulted in silicosis, a severe pulmonary fibrosis that may be associated with recurrences of old pulmonary tuberculosis Control of known toxic volatile inhalants is also spread among several agencies at all governmental levels, occasionally with no clear delineation of regulatory boundaries or with control and enforcement distributed among several departments Urged by insurance companies and pressured by legal actions to improve worker and community safety, industries strive to provide healthy workplace environments and still achieve satisfactory manufacturing profits Federal funding remains for lead paint poisoning prevention, rodent control in cities, water fluoridation, air pollution control, protection against hazardous materials, and staff education or training The blood lead level that is considered to be toxic in children and adults continues to decrease, but the problems of plumbism (lead poisoning) associated with chipped and worn lead paint in homes persist Although paints containing lead were banned in Baltimore city by an ordinance more than half a century ago, walls and woodwork of old homes retain lead paints under successive covers of new lead-free paint Nevertheless, children continue to suffer from plumbism, albeit lower levels, because they inhale lead dusts in homes or eat lead paint chips that fall from old painted surfaces Adults who are unaware of the toxic effects of lead paint dust may suffer from a more acute form of plumbism when they fail to wear protective masks of industrial-quality in de-leading homes To correct environmental hazards, officials benefit from epidemiologic data to locate where toxic wastes have been © 2006 by Taylor & Francis Group, LLC 177 dumped and to measure the effects of toxic substances on community health After chemically damaged land has been identified, reclamation or redevelopment as prime commercial and residential sites is often difficult without costly decontamination States have established official registries of toxic substances that include listings of associated cancer cases Toxic substance registries are valuable in the long run but high initial costs, operational difficulties, and challenges from local industries have hampered their development Air pollutants may merely annoy residents in a neighborhood because of unpleasant odors but, when residents suspect that pollution can be hazardous, high levels of general community anxiety can result Persons who work or dwell in a polluted area cannot avoid breathing the air that may cause acute or chronic respiratory difficulties When pollutants are known to have serious short-term or long-term effects, citizens or workers demand that regulatory action be taken to reduce or eliminate the offending pollutants However, if threats of job losses occur should the cost of controls cause major industries to move away, low level pollution may be tolerated Detection, accurate measurement and clearly defined pathologic effects of fumes and dusts on human and animal health have been recorded, as well as toxic damage to fabrics or delicate machinery and other personal or industrial equipment Air pollution from industrial processes or solvents used in manufacturing is closely monitored by most industries but small, non-union or inexperienced producers may be unaware that hazards exist in a workplace In some cases, managers will ignore or defy governmental regulatory control Health department inspection staffs may be too small to carry out regular inspections of the thousands of small industries in their jurisdictions and complaints from citizens or workers may be needed to give the earliest warnings of serious smallfactory air pollutions Health inspectors may be called upon to test and measure for toxicity of fumes in workplaces from chemical processes, spills or misuse of dangerous mixtures, or emanations from treated fabrics, compressed wood products, and other finished products Local health departments, however, are no longer responsible for water supply, sewage treatment, and trash and garbage disposal The emphases of governmental air pollution control efforts range from entire geographic areas, such as area-wide ambient levels of industrial stack pollutants and motor vehicle emissions, to residences that may be contaminated with radon emissions from soils or rocks Although state or federal governments are responsible for monitoring large area contaminations, toxic emissions control in local industries is often a community task Water pollution results when surface contaminants from industry spills or runoffs from soil fertilizers and pest control agents enter streams and reservoirs or filter into an area’s aquifer and wells Water filtration plants carefully monitor bacterial and chemical contaminants of inflows and outflows to assure that pleasantly tasting potable water and low mineral content is delivered to a community This is a major task when a downstream community depends on river water to supply its needs while upstream another community dumps 178 COMMUNITY HEALTH its sewerage and industrial wastes Water potability and safety must meet national standards but water qualities for drinking, food preparation, and industrial uses may vary widely Adequate water supplies are vital to community health, recreation and cleanliness, but also to industry and related employment Carefully controlled use of low mineral content non-potable water can be used carefully for garden plots and residential lawns and general use in irrigation technologies for agriculture National dental societies have urged that minimum levels of fluoride be added to residential water supplies because of the protective action of this chemical against tooth decay However, opposition has arisen in some communities because high fluoride levels may cause annoying dental discoloration Effects of chlorination, also, has been reported to be remotely associated with malignant conditions in humans but the net value of better control of intestinal diseases is believed to far outweigh any possible small toxic effect of chlorinated water Water with high mineral content, known as “hard water,” even though potable, may require water softening equipment in homes to make it satisfactory for laundry and food preparation or manufacturing Anti-smoking campaigns have emphasized documented tragic ill effects from tobacco smoke produced by burning tobacco products, both for the smoker and for persons who are breathing “second hand smoke,” a mixture of exhaled smokes and that which rises from the tips of lit cigarettes Increased mortality from lung cancer, emphysema, and cardiovascular disease has been thoroughly documented and other cancers of the gastrointestinal and genitourinary tracts are believed to result in part from the swallowing of saliva that contains nicotine and other constituents of tobacco smoke, and the urinary excretion of tobacco-associated chemicals through those channels Bans on indoor use of smoking tobacco have been promulgated by many local and state governments to protect non-smokers from immediate or long-term effects of noxious chemicals in tobacco smoke Existing efforts to restrict the purchase of tobacco products to adults and prevent sales to adolescents have been increased So-called smokeless tobacco (snuff) has been shown to cause precancerous lesions of oral structures and ultimately to lead to localized cancer, even in young adults Carbon monoxide (CO) emissions are highly toxic because the CO radical bonds tightly to hemoglobin in circulating blood cells, markedly reducing their oxygen-carrying capacity and resulting in serious impairment of cerebral or cardiovascular function and death Poisonings have occurred from CO in motor vehicle exhausts in home garages or poorly maintained underground parking garages with deficient ventilation, in homes that use fossil fuels for heating when flues have been obstructed, and when unvented space heaters are used in small, closed spaces and room oxygen has been markedly diminished or exhausted Poorly maintained mufflers or exhaust systems may leak CO into automobile or passenger compartments at any time, even when driving through traffic Slow and quiet development of this highly toxic gas can result in unrecognized but fatal levels of CO in vacation cabins, recreational boating, and private airplanes © 2006 by Taylor & Francis Group, LLC Radon is a radioactive gaseous chemical element formed as a first product in the atomic disintegration of radium Rather frequently encountered in homes of what is known as the “Reading Prong,” a geographic area around the city in Pennsylvania, radon levels vary from home to home This radioactive gas may be an environmental hazard when high levels exist in confined human habitations that are surrounded by radioactive soils or rocks Ambient atmospheric levels can usually be reduced to safe levels by adequate ventilation Additional disease prevention activities of community health departments include sanitary control of food production and distribution, large-scale childhood vaccination programs, strict quarantine or relative isolation of persons with infectious diseases, and animal control to minimize animal bites or rabies and other zoönoses (diseases spread by animals to humans) In Baltimore, for example, when animal control was transferred to the health department and the collection of all stray dogs was emphasized, reported animal bites of humans decreased from over 8000 to under 1500 in a period of four years Feral animals are dangers to all humans, to each other, as well as their excreta being a major source of area insanitation Increasingly, local laws provide improved community protection by requiring that animals be leashed and that owners collect and dispose of animal feces in a sanitary fashion NEEDED SERVICES Governments, large and small, provide health care services in many bureaus other than the official health department, and often with little or no coordination For example, a county may operate jail medical care, a personnel system for employees, fire fighters and police, school health programs, health units in a department of social service, care for indigent elderly, ambulance services, a public general hospital, and more The totality of community health services operated by a government is generally poorly comprehended, frequently underestimated and understated Rescue and protection require health departments to work with police, fire and other rescue agencies where human health is endangered When local sickness care units refuse to care for ill or injured persons, for whatever reasons, health departments are expected to supply medical care Because treatment of homeless or abandoned indigent persons can be costly for diseases such as tuberculosis or complex conditions such as AIDS (acquired immunodeficiency syndrome), these tasks may fall to health departments when other health providers fail to meet their obligations or are overwhelmed by patient loads of epidemics Official health departments in cities and counties operate personal health clinics for special populations Although these services vary with local needs, they have been categorized by one local health officer as traditionally treating “unwashed patients with dirty diseases, who live in hard to reach places and can’t pay.”13 These groups of patients constitute indigent or needy citizens with ailments like tuberculosis, leprosy, sexually transmitted diseases, or AIDS COMMUNITY HEALTH Major health problems that confront community health departments include teen-age pregnancies and inadequate child health care, homicides that are highest among young males, substance abuse (drugs and alcohol) that lead to severe personal and community deterioration and high crime rates in any community, and AIDS with its costly and complex terminal care The total number of cases since first reporting in 1981 of AIDS worldwide in 1995 was 436,000, with 295,493 deaths In one state alone, namely Maryland, the total number of cases was 13,082 since 1981, with 7,507 deaths This epidemic of a terrible new disease has been devastating The disease is transmitted via body fluids, in heterosexual as well as homosexual contacts, by inadequately screened blood transfusions, and by the use of inadequately sterilized parenteral equipment such as shared needles in illicit drug use An office of the state medical examiner, often incorrectly identified as the coroner, is a public health agency that is closely allied with the judiciary Directed by a physician who is a specialist in forensic pathology, this department operates a morgue to which is taken a person who has been found dead under suspicious circumstances or who died without medical attention A medical examiner performs an autopsy to determine the cause of death, and may be called upon to testify to this fact in criminal cases A medical examiner should have immediately available a complete forensic or criminal laboratory to examine human tissues, clothing stains, and body fluids that might relate to or explain a crime The skills of these pathologists are often called upon to identify bodies from comparison of oral structures to dental records, or even by sending specimens or entire parts of a body to federal crime laboratories for analysis Although often a grisly business, a prime function of medical examiners is to assure that justice is served and diverse community concerns are assuaged Public general hospitals (PGHs) are owned by the political subdivision and have major fiscal support from any of several governments The PGH reports directly to the chief executive officer (CEO) of the respective jurisdiction or the hospital is supervised by an appointed or elected board The future of this once important resource of a city or county medical system is in jeopardy, threatened by growth of voluntary, not-for-profit, and profit-making hospitals Funding equivalent to that of private hospitals has not readily reached public city and county hospitals perhaps for many reasons It may have been that inexperienced or inattentive elected officials, medically unskilled appointed governing boards, serious budgetary limitations or other critical but unmet needs have all been responsible for the decrease in public hospital care efforts Whatever the reasons for poor support of these public hospitals that were often the major care centers for immediate and long-term care of needy citizens, many of them have closed and some have been sold to voluntary groups or medical schools Some have simply been closed, leaving communities with inadequate sickness care Others remained in central city locations, inadequately funded, surrounded by blighted areas and required to serve large populations with major health problems These hospitals © 2006 by Taylor & Francis Group, LLC 179 are still unable to accomplish easily their missions of helping critically and chronically ill needy residents Often located in population centers where per capita income and insurance payments are low, public general hospitals serve patients who, for whatever reasons can find no other medical resource Their populations also present with severe illnesses, chronic conditions, and with multiple complications of various addictions, poverty lifestyles, and AIDS Obsolescent or convoluted governmental policies set by local, state and federal statutes can hamper smooth operations of these municipal or county hospitals Employment practices, budgeting, purchasing and plant maintenance may be insensitive to the needs of hospitals Medical care demands rapid response by all persons involved if services must adapt to changing professional practices For better patient care, larger PGHs may be linked with nearby professional schools to help train graduate physicians, medical students and other health care workers In this exchange, the teaching and research staffs of medical schools bring with them a bevy of talented professionals who supervise patient care and prepare physicians for a life of learning and service It remains to be seen whether the fresher and better funded investor-owned and corporately managed HMOs and hospitals will find it possible before the end of the century to assume a sizable portion of the heavy load of poverty patients with complex problems, and still make the profits demanded by their stockholders Hospitals in the U.S struggle to maintain fiscal stability in a health care system that is undergoing rapid change Some may not easily or willingly accept indigent patients suffering from complex medical and social problems Maryland and several other states in the USA, however, have enacted legal requirements to ease fiscal burdens of hospitals by mandating that private and public patient care costs be shared by all hospitals and all payers in an equitable fashion Fiscal support for any general hospital is derived in part from local taxes, federal grants for disease management, and private philanthropy for specified tasks Considerable income is also generated by fees for service charged to and paid by Medicare (elderly persons), Medicaid (indigent patients), payments from Blue Cross and other insurance companies, and from direct self-payments Any community that operates a jail or prison faces a growing need to provide quality medical care to its prisoners Penal systems, once condemned for their inattention to the medical needs of inmates, have instituted policies to expand services while shortening sick-call lines, improve staff and prisoner morale, and reduce risky transport of prisoners to hospitals for medical or surgical consultations Large jail populations, also regarded as a class of “regulated communities,” include inmates who suffer from drug abuse, alcoholism, mental illness and behavioral disorders Some jails have created obstetrical and infant care facilities to serve female populations, or special care units for geriatric prisoners Designers of new jails must also consider special handling of two major illnesses among prisoners when health units are being planned—pulmonary tuberculosis and AIDS (acquired immunodeficiency syndrome) Patients with tuberculosis infections may ascribe a chronic cough to smoking, 180 COMMUNITY HEALTH or be nearly free of symptoms yet spread the infection to other inmates via sputum droplets that contain live tuberculosis bacteria The customary elements (volume, rate of change, direction, etc.) in ventilation and air flow in prison cells, hospital suites, recreation and dining areas, need careful attention to minimize the spread of tuberculosis and other respiratory infections from patients with unrecognized disease to other inmates Health suites should provide for temporary isolation of tuberculosis patients in the early phase of therapy Longer term isolation may be required rarely but can be needed if the disease is advanced Moreover, some tuberculosis infections are being increasingly recognized as due to “multiple drug resistant” (MDR) bacilli and the usual anti-tuberculosis drug regimes are not effective New and expensive drugs, carefully administered, are needed to achieve successful treatment of stubborn MDR infections Although AIDS is believed transmissible only through body fluids like blood or semen, isolation may be needed to provide special care for persons who are critically ill with AIDS These patients are at high risk of severe illnesses from “opportunistic” infections due to organisms that opportunistically take advantage of AIDS patients whose resistance to infections is compromised These organisms may be bacteria, viruses, or even fungi and other parasites that are normally part of a prison environment Management of patients with advanced HIV disease can be difficult and requires that the health staff be aware of the continuing advances in therapy that may be available Medical or administrative protective isolation may be needed to remove AIDS patients from cell blocks where they might be exposed to physical danger from other inmates Health services for governmental employees are similar to those of industry and vary in size and complexity with the jurisdiction served Pre-employment examinations and on-the-job injury care follow customary standards, and worker’s compensation claims are processed in accord with state or federal regulations Medical advisory programs (MAPs) for employees whose on-the-job performances are thought to be due to emotional disorder or substance abuse helps guide affected workers to appropriate care and permit continued employment If existing buildings are to be altered for use as employee health clinics to include a wide range of health services, special attention must be given to shielding staff workers from x-radiation A surgical suite should be available for initial care and follow-up of injured workers, and adequate soundproofing provided for rooms where psychiatric counseling is to be delivered RESCUE AND PROTECTION Ambulance services have become an important part of any medical care system, with marked expansion after the mid 1970s Although turn-of-the century horse-drawn ambulances had long been replaced by hospital-based motor vehicles, only major cities provided this vital emergency transport The city of Baltimore, for example, had provided a crude transport that used canvas litters in police patrol © 2006 by Taylor & Francis Group, LLC wagons (paddy wagons) until 1928 At that time several limousine-type ambulances were purchased to be based in and operated by the Fire Department Fire fighters who volunteered for this duty received basic first aid training and were assigned permanently to this service for better patient care of citizens who could not afford a private ambulance Commercial ambulance services, many being operated by funeral directors who used converted hearses and personnel with little or no training in patient care, were not supervised or licensed until federal funding was assured with the passage of Medicare in 1965 Local governments developed regulations to assure that patients being transported would have emergency care immediately available and that they would be secure Regulations specified the training that should prepare ambulance attendants, as well as the medications and patient care equipment to be carried in ambulance vehicles Today, municipal or county ambulance services are usually based in fire departments, to take advantage of a communication network that is already in place Fire houses provide ambulance bases that are open around the clock, staffed by fire fighters who are a uniformed and disciplined corps, and who have a tradition of rapid response to emergencies Air ambulance services using helicopters are operated by state police departments, in the absence of functioning fire departments Some local governments may contract with private ambulance companies to provide both emergency and routine medical transport, and hospitals may also be used both as bases and to provide quick and ready access to medical critical care specialists for urgent consultations An ambulance is a sick-room on wheels for urgent care Whereas once these emergency vehicles and staff operated simply in a “scoop and run” format, providing rapid transit for critically ill or injured persons, today’s ambulances have state-of-the-art design and equipment, and their crews have expert training in the provision of immediate and effective responses to life-threatening conditions Communities have quickly recognized the value of highly trained attendants who can stabilize critically ill or injured persons prior to careful transport to hospital centers for definitive care Radio two-way communications for voice and electronic equipment, like electrocardiographs, enable attendants to administer initial medical care beyond usual first aid, and provide hospitals with information that helps them have ready any special equipment or staff for prompt attention on arrival of the ambulance Ambulance attendants, or emergency medical technicians, ambulance (EMT-As), are the first-responders in any emergency transport system To be designated an EMT-A, each applicant must undergo special training, pass a stringent examination, and be certified by an official body of the local or state jurisdiction before being permitted to care for patients with medically emergent conditions Ambulances dedicated to critical emergency care are stocked with approved medications for use by EMT-As in the field Technical equipment is readily available to reestablish damaged airways or stop dangerously irregular heart action by electrical defibrillation,14 immobilize fractured bones, or provide intravenous COMMUNITY HEALTH fluids All ambulance equipment and EMT-A training is approved by official boards of physicians and other health care professionals; it is used in accord with tested protocols and the support of hospital physicians via radio communication when needed Helicopter emergency transport of patients, first used by several municipal ambulance systems in the early 1960s, was proven of value in military use Helicopters and emergency technicians provide rapid patient evacuation over difficult terrain or locations that wheeled vehicles can reach only with difficulty Helicopters are dispatched from a central location and radio communication provides directions to the helicopter pilot and continuous medical consultation for the medical attendants As in any other ambulance, expert patient care is provided both initially on the ground and then in the air en route to a designated hospital center, thus avoiding rough highway carries Vital data for on-going patient care is supplied by electrocardiograms (ECGs) and other clinical information is transmitted directly to a base hospital trauma center where a skilled physician is in direct voice radio contact and guides the prompt resuscitation of patients Additional electronic support for advanced mobile sick care, including image transmission and limited or special laboratory services can be expected to be developed in this decade Regional hospital-based trauma centers receive casualties according to protocols that have been developed by regional emergency medical service committees Each is staffed and equipped to provide complete skilled care for critically injured or severely ill patients Trauma centers are regulated by a state agency and based at hospitals after a careful selection process that considers need, existing transport networks, and available staffing Each must agree to maintain superior medical and surgical staff capability, and be ready to receive patients with urgent medical problems or extensive injuries around the clock Critical care support must be extended in hospitals allied with the trauma center to provide patients needed long-term care through expected periods of recovery and initial rehabilitation A trauma center concept best fits hospitals that are closely allied with medical schools, and it relieves small community hospitals of legal and economic burdens of severe trauma Trauma centers may also accept urgent transfers from efficient community hospitals when severe injuries have been stabilized sufficiently for transport A community hospital need not operate an emergency care department but, if it does, all persons seeking medical, surgical, or psychiatric help must be accepted Each patient must receive prompt and appropriate treatment and disposition, even if continued care is accomplished elsewhere Although residents of a community may view a nearby emergency department as a walk-in clinic for the management of minor ailments, each of these special departments must be fully equipped and adequately staffed for critical care conditions Physicians should be qualified for advanced life support care (ALS) and the nurses for basic life support (BLS), as a minimum Emergency physicians preferably are certified by an appropriate emergency specialty board The high costs of hospital emergency care is offset by assured © 2006 by Taylor & Francis Group, LLC 181 payments for a wide range of costly services to patients with full insurance coverage who are admitted COMPUTERS AND TELEMEDICINE Computer storage and transmission of information in clinical practice has lagged behind industrial usage, largely due to the confidential nature of patient data A relative inadequate computer literacy of older, experienced physicians who must learn to enter data according to prescribed formats may account for some continued reluctance in the acceptance of electronic clinical data systems Despite more general availability of more compact personal computers and electronic bookkeeping systems now installed in the offices of most physicians and clinics, maintaining patient records in computerized systems has advanced slowly In 1991, the Institute of Medicine (IOM) released a report that urged adoption of a computer-based patient record as standard medical practice in the United States.15 In 1995, Beverly Woodward discussed many aspects of computer use in medical care.16 Attempts to design algorithms that replicate complex thought processes a trained physician uses to probe the history of a patient’s illness or solve a clinical problem have not been uniformly commercially successful Generation, storage, and easy retrieval of clinical records expose the data to improper use by persons who are not entitled to confidential information Data that include treatment for AIDS or psychiatric illnesses, for example, are particularly sensitive because of their possible misuse by employers, insurance companies, or legal systems Computers have proven useful in hospitals to store and have readily available cumulative information that records hourly and daily patient care data and provides easy review of a patient’s progress But start-up costs are high and training of hospital staffs includes nursing personnel, administrators, and other care givers, such as visiting personal physicians and consultants Lindberg and Humphreys of the National Library of Medicine (NLM) have discussed other uses for computers in medicine that are now being explored.17 Boards in each state that license physicians and national professional specialty societies regularly use computers to store data and track careers of individual physicians and other regulated health care professionals State licensing boards that need to research a physician’s application for medical licensure can access information in the National Practitioner Data Bank that briefly describes pertinent disciplinary experiences in any of the 50 states.18 National specialty societies have computerized the credits earned in cumulative continuing medical education (CME), critical information that each member can access when applying for license or specialty certification renewals Telemedicine and related modem technology provide access through e-mail or the World Wide Web to specialists and the National Library of Medicine in Bethesda, MD for instant consultations, making it possible for distant and isolated communities quickly to obtain needed expert medical and surgical advice and guidance 182 COMMUNITY HEALTH Telemedicine is the transmission of laboratory information, radiologic interpretations, and clinical information, including actual examination of patients, by audio-visual communication via fiber optic telephone line or satellite transmission between isolated areas and medical specialists in urban teaching hospitals Begun in Scotland in the 1960s to provide medical consultations to explorer units in Antarctica, telemedicine is now established as a medical subspecialty with its own journals.19 Telecare refers to the delivery of health care by means of telecommunications technology, and is relevant to community care An early example of telemedicine in the United States was a cable linkage that provided one-way transmission of blackand-white video and two-way audio between a medical facility at Logan Field, the major airport of Boston, MA, and physicians several miles away at the Massachusetts General Hospital Patients could be interviewed and even their urines and simple blood stains examined microscopically through this electronic hook up More complex equipment and communication alternatives helped to increase use of telemedicine in the U.S., and $85 million in federal funds was made available in 1995 for this field Several states established telemedicine networks to link hospitals and clinics with correctional facilities for more readily available medical consultations, and to join universities for mutual support of medical student education Quick and accurate transfer of information between primary care physicians, the “gatekeepers” in health care nets, with tertiary care centers hundreds of miles away has resulted in telemedicine expansion especially in states with large rural populations or great distances between medical centers.20 Telemedicine also enables the Cancer Treatment Center at the University of Kansas to follow-up patients undergoing medicinal treatment but who have returned home When U.S troops were deployed to Bosnia in 1996, telemedicine interchange between medical commands in field hospitals and their home bases in Landstuhl, Germany, and various military medical facilities in the U.S was arranged through facilities at Fort Detrick, Maryland J.H Sanders has described telemedicine services established in 1991 at the Medical College of Georgia to provide continuing medical education and consultations for rural practitioners, using a system described as “totally distanceinsensitive.” A digital communication link integrates modalities from twisted pair 56 k copper wire to cable, fiber, microwave, or to satellite in series or in parallel, Sanders notes.21,22 The efficacy of telemedicine in supervising continued care and patient education has been proven Efforts are now underway to extend its value to medicine and personal health, including improved sensors that substitute for palpation of a tumor mass or body parts, electronic stethoscopes, cardiac ultrasound, and radiographs Distant physicians can visualize the ocular retina and the tympanic membrane of the ear by scopes that have been adapted for telemedicine use Ethical and legal concerns also have arisen, given that telemedicine transmits patient data over publicly accessible lines to physicians in another state or country Privacy and confidentiality are not yet fully protected, even though several varieties of patient consent forms have been used © 2006 by Taylor & Francis Group, LLC Current requirements that physicians be licensed by the state or nation in which they practice must be modified to permit effective telemedicine examinations of patients in another state, as well as consultations between physicians similarly located in different jurisdiction, must be resolved DISASTER CARE All health units are important when disasters such as floods, tornadoes, hurricanes, earthquakes, train derailments, major air crashes, or major acts of terrorism strike a community Disasters of any size are accompanied by varying degrees of incoordination in rescue operations, and complicated by stress and fatigue of both trained and volunteer personnel who have responded to the emergency Roads that are usually available for patient transport may be obstructed by fallen buildings, large trees, and other debris Water supply, sewerage, communication, and power lines may have been damaged so that hospitals that respond to unusual casualty loads find that equipment may be inoperable, lighting inadequate, telephones out of order, and water supplies for cleansing or sterilization impaired Although many calamities are relatively small and localized, each community must prepare plans for rapid responses and quick resolutions Relatively simple planning brings together the several agencies that will respond to disasters to discuss staffing and organization for recovery, define available resources, list locations of supplies and equipment, determine the availability of outside help in rescue work, clarify usable radio frequencies, and work out the multitude of other elements of a disaster plan Ideally, representatives of community physicians, hospital information officers, and many other health care workers, even morgue attendants, should be brought into disaster drills to share information with fire and police units As a plan develops, each department or agency should become familiar with the others’ capabilities because in the throes of an emergency it may not be possible to refer to a written plan, page by page “Planning is everything, the plan is nothing,” General Dwight Eisenhower is reported to have said In regional disaster planning, Eisenhower’s dictum applies First responder agencies strive to develop a radio communication network with compatible radio frequencies that will link rescue units whose usual work does not require regular exchange of on-the-scene communications Rescuers must learn to know where community supply depots and equipment pools are located, who owns or manages the materiel, plus knowledge of what is available in civilian depots Responsibilities for establishing refugee centers with food and shelter, and locations of emergency medical sites should be defined Repeated drills prepare a community’s disaster workers for their duties in response to a disaster, and are the key to rescue and rapid resolution of disorder Training of health and allied workers begins with standard courses prepared for firefighters and police officers who, along with public works personnel, are often known as “first responders.” Training is available from state agencies COMMUNITY HEALTH and the U.S Federal Emergency Management Administration (FEMA), based at Emmitsburg, Maryland, who provide control and coordination of disaster relief efforts Analysis of responses to previous disasters is also a major effort of governments in all of the Americas where an international networking exists to share information and prepare or a wide range of mutual support efforts by communities in emergencies Easily accessible first aid stations provide initial care for injured and ailing persons and transfer critically ill persons to hospitals via designated medical transport When catastrophes occur in limited areas, well-defined routes into and out of the disaster area must be defined for ambulances that are to be used to evacuate patients Dispatchers should maintain accurate lists of patients and their destinations to provide timely information to communities of relatives and friends Supplies of special protective clothing and personal equipment that support workers in the rescue operations must also be in the planning calculus Schultz, Koenig, and Noji have described a modified simple triage and rapid treatment system aimed at reducing immediate mortality after earthquake.23 Hospitals may not be able to use telephone lines in some areas, for example, and should become part of the radio net for disasters If hospitals are liable to be damaged by earthquakes, floods, or major neighborhood fires, all staff persons should be trained in rapid and safe patient evacuation techniques When even modest numbers of casualties are expected, hospitals must prepare to receive worried relatives and curious friends as well as patients Hospitals should be assured of effective highway traffic control for ambulances in addition to their own internal management of patient flow and necessary restriction of visitors Administrators plan to meet needs of hospital personnel who may have difficulty in reaching the hospital, and may have to be housed and fed until the emergency has subsided Continued supplies of medications and surgical material, food, and laundry are additional concerns of municipal departments that support the hospital community During early recovery and mop up periods, community health planners should anticipate that a disturbed environment may be a seed-bed for enteric diseases due to several bacteria, such as salmonella or staphylococci, and other pathogens that contaminate damaged water supplies and foodstuffs that lack refrigeration or safe storage Increased numbers of respiratory diseases can be expected among the very young and old survivors, as well as exacerbated severity of many existing chronic diseases that require a continuous supply of remedies, like diabetes, heart or kidney disease, and seizure disorders A natural disaster or major industrial calamity often calls out the best in a community and may reveal unsuspected leadership strengths Nonetheless, each jurisdiction should be prepared by careful community planning to meet the abrupt challenges of a flood, tornado, earthquake, building collapse, explosion, or fire CONCLUSIONS Community health care is more than what is provided by an official public health department It includes manifold © 2006 by Taylor & Francis Group, LLC 183 basic structures and services that give a community an identity and allow it to serve the needs of its citizens A catalog of core services would include both governmental and non-governmental agencies and range from police, fire, health and public works to housing, food supply and safety, sickness care, education, and entertainment—and more A healthy community is a vital organization, continually growing by systematic or irregular alterations and adjustments to meet continuing challenges Not all of its activities are planned by a central agency but each contributes to some degree to the general good Whether hamlet or major city, a community must form friendly liaisons with its neighbors and eschew bitter relations if they are to prosper as a region Councils of governments can bring together the elected officials of adjoining subdivisions conjointly to solve selected administrative problems such as fire and police protection along borders, trash disposal, recreation and entertainment, and public health To keep a community in good health, the chief executive officer directs that each of its elements be alert to changes and any resultant needs to adjust, as well as continuing to be secure financially A healthy community, like a healthy body, needs constant care even when it appears to be functioning almost automatically and with little direction REFERENCES Health n physical and mental well-being; freedom from disease, pain, or defect HALE, WHOLE, HEAL Webster’s New World Dictionary, 1980 health [A.S health] The state of the organism when it functions optimally without evidence of disease or abnormality Stedman’s Medical Dictionary, 25th Ed 1990 Public health., the art and science of community health, concerned with statistics, epidemiology, hygiene, and the prevention and eradication of epidemic diseases Stedman’s Medical Dictionary, 25th Ed 1990 Foegge, W., Preventive Medicine and Public Health, J Amer Med Assoc 1995; 273: 1712–1713 Mirom, B.A., Hill, S.B., Acupuncture, How It Works, How It Cures Keats Publishing Co New Canaan, CT Complementary Medicine: New Approaches to Good Practice British Medical Association Oxford University Press, Oxford, UK 1993 Reader’s Guide to Alternative Health Methods, American Medical Association, Chicago 1993 Burroughs, H, Kastner, M Alternative Healing Halcyon Publishing, La Mesa, CA 1993 Alzraki, N.P., Nuclear Medicine, J Amer Med Assoc., 1995; 273: 1697–1978 Personal communication (1981), Alexander Langmuir, M D., former Director of the Centers for Disease Control, Atlanta, Georgia Prevalence is the number of cases of a disease existing in a given population at a specific period of time or particular moment in time Incidence is the number of new cases of a disease in a defined population over a specific period of time Killed polio virus, given by injection, was the first effective vaccine (IPV), followed by a live polio virus vaccine given orally (OPV) The smallpox vaccine was made from cowpox, with which cross-immunity exists 10 Morbidity and Mortality Weekly Report CDC 19 Jan 96, pp 38–41 11 Ibid p 40 12 Brooks, S.M., et al eds Environmental Medicine, 780 pp ISBN 0–8016–6469–1 St Louis, MO, Mosby, 1995 13 Personal communication from Peale A Burbugh, M.D., MPH, 1995 14 This stops a rapid, totally irregular heart muscle twitching by use of a momentary electrical shock to the chest, enabling the heart to resume its normal rhythmic beating 15 Dick, R.S., Steen, E.B., eds The Computer-based Patient record: An Essential Technology for Health Care Washington, D.C.: National Academy Press, 1991 184 COMMUNITY HEALTH 16 Woodward, B., The Computer-based Patient Record and Confidentiality, N Engl J Med., 1995; 333: 1414–1422 17 Lindberg, D.A.B., Humphreys, B.L., Computers in Medicine J Amer Med Assoc., 1995; 273: 1667–1668 18 Johnson, I.D., Report to the National Practitioner Data Bank, Chicago IL J Amer Med Assoc., 1991; 265: 407–411 19 Journal of Telemedicine and Telecare, Royal Society of Medicine, Wimpole Street, London, WIM 8AE, UK 20 Borzo, G., States Leading the Way with Telemedicine Projects Chicago, IL Amer Med News., 21 Nov 1994 © 2006 by Taylor & Francis Group, LLC 21 Sanders, Jay H Future Trends: Telemedicine Bulletin of the Federation of State Medical Boards, Vol 82; Number 4, 1995 22 Sanders, J.H., Tedesco, F.J., Telemedicine: Bringing Medical Care to Isolated Communities J Med Assoc Ga., 1993: 82: 2370241 23 Schultz, C.A., Koenig, K.L., Noji, E.K., A Medical Disaster Response to Reduce Immediate Mortality After an Earthquake, N Engl J Med., 1996: 438–444 JOHN B DE HOFF Cockeysville, Maryland ... future of this once important resource of a city or county medical system is in jeopardy, threatened by growth of voluntary, not-for-profit, and profit-making hospitals Funding equivalent to that of. .. similar to those of industry and vary in size and complexity with the jurisdiction served Pre-employment examinations and on-the-job injury care follow customary standards, and worker’s compensation... today’s ambulances have state -of- the-art design and equipment, and their crews have expert training in the provision of immediate and effective responses to life-threatening conditions Communities