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.. Public health respons
Trang 1GENERAL
Health is the ability to cope with activities of daily living,
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
func-tioning, 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,
trans-portation 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
contrib-ute 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
rang-ing 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
physi-cal freedom, comfort, and efficiency of residents Cities and
towns are judged on the numbers and quality of existing
rec-reation opportunities, schools and colleges, and
transporta-tion 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
com-munity’s health is not static and must be cared for
continu-ally, much like the health of any resident
For millennia, communities have depended on
engineer-ing 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
pro-vided ample supplies of fresh water to Roman communities
Excellent roads and transport brought foodstuffs from farms
to imperial cities and helped speed commerce and
communi-cations between businesses and governments Cities around
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 net-works 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 quan-titative and qualitative Planners need to know how many hospitals exist within the city limits, where they are in rela-tion to centers of popularela-tion, and whether transportarela-tion for patients, staffs, and visitors is adequate Numbers of primary and secondary schools, technical training centers and uni-versities, each with details of the students being served are important data in judging community ambience Local gov-ernments want to know how many of the people who work
in a city actually reside there, how many residents rent apart-ments 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 avail-able 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 num-bers 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 catego-ries 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,
Trang 2and types of hospitals, with attention to emergency services
and rehabilitation care are important Slightly different
stud-ies for evaluation of care must be given to rural areas where
hospital accessibility, highway networks, and estimated
tran-sit times for ambulance services, become critical elements in
area’s health study
Residents and visitors, businesses and news media,
con-tinually 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
accu-rately sense or rate a community’s ambience by noting the
frequency and types of cultural activities for residents or
vis-itors, the numbers and quality of public and private schools,
and available recreational facilities Competent urban
plan-ning 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
offi-cer 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
pro-fessional knowledge and compassionate service, two
char-acteristics that usually provide a modest freedom from
administrative interventions This varies somewhat in
pro-portion with budget allocations but it allows health
depart-ments 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
contracep-tion but they may also include advice on aborcontracep-tions 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
ser-vices; pediatric dentistry; services for drug and alcohol
abus-ers who want relief from these pabus-ersonal burdens; and special
clinics or services when needed by special communities, such
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 vol-unteer 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 sanita-tion, housing, industrial hygiene, and animal control Control and abatement of environmental hazards vary as an empha-sis shifts from human health effects to a general community salubriousness, pushed by legislative actions that reflect the relative effectiveness of lobbyists for human health adher-ents 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 over-sight through various boards of health, and functional tasks vary with the problems that confront the individual jurisdic-tions 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 tuberculo-sis 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 stan-dards 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 epi-demiology 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
Trang 3for public health practice as changing beyond any predictions
and urged support of government for health monitoring
sys-tems and interventions. 3
Private health care has gradually become part of the
greater public health system, largely due to change in
fund-ing 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
profession-als 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
perfor-mance 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
with-drawal of the permit to practice Failure to perform in
accor-dance 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
respon-sibility 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
thera-pists, and acupuncturists
Personal health care services, once known as the
“pri-vate practice” of physicians and nurses, are gradually
shift-ing 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
pro-viders but relate to a central management group; preferred
provider organizations (PPOs) where physicians retain
inde-pendence 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
seri-ous conditions, sometimes known as “urgicenters,” have
arisen to care for persons who have no regular medical
atten-dant or whose physicians are not immediately available
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 progres-sively larger corporations which control wide-ranging deliv-ery 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 hos-pital 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 indig-enous 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, alter-native 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 fea-tured Meanwhile, any of the other alternative care practitio-ners may be found in local jurisdictions with little or no official supervision or control, unless medical licensure laws are vio-lated 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
Trang 4One 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
osteo-pathic 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
govern-ment 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
avail-able 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,
prison-ers, and Medicaid for persons receiving governmental
sub-sistence 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
establish-ment 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
medi-cal 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
tuber-culosis would no longer be threatened by these scourges
Protective oral and injectable vaccines have nearly
elimi-nated polio, and effective antituberculosis drugs have
ren-dered 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
puru-lent 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
begin to challenge infectious disease specialists, leading to a surging interest in global infectious diseases
Major advances occurred in basic health care technol-ogy and pharmaceutical products manufacturing but also in the engineering skills and sciences that produced computed tomography, magnetic resonance imaging, molecular biol-ogy, 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 pri-vate hospitals compete vigorously for federal funding for basic and advanced research in health sciences, and insur-ance 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 medi-cal 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 caregiv-ers 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 prog-ress 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 sani-tary 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 vol-untary health agency has this key legal authority to main-tain 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 hos-pitals 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
Trang 5Official 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
war-rant, 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
offi-cer 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
essen-tial community functions: Epidemiology, disease prevention,
needed services, rescue and protection
EPIDEMIOLOGY
The importance of epidemiology, or the knowledge of a
dis-ease 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
count-ing 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
Gathering health facts and analyzing them is such a distinc-tive health department function that a well-known national health officer once urged that they be named “Departments
The discipline of epidemiology determines and analyzes the distribution and dynamics, or changing characteristics,
of diseases in human populations Physical health in a com-munity is measured inversely by the incidence of a disease
or injury over time or its prevalence at any given moment
better the community’s epidemiologic health Health offi-cers 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 statis-tics 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 pre-ventive 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 community-wide 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 spe-cific 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 protec-tive vaccines Poliomyelitis has nearly been eliminated in the Americas and small pox has in fact been eliminated from the
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 tour-ists and business people who return to homes by air, unwit-tingly 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
Trang 6An 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
resis-tant mycobacteria, initial courses of multiple
antituberculo-sis 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
crit-ically 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
vol-untary 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
jaundice and occasionally renal impairment or aseptic men-ingitis, but small children who must live in rat infested neigh-borhoods 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 resi-dences, 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 cen-tury 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 gas-eous 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 advi-sors on the health aspects of building construction when toxic substances are used incorrectly When lines of author-ity 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 haz-ardous effects on humans
Health sanitarians and technical inspectors of other agencies investigate complaints made by workers, nearby
Trang 7residents, or the general public about unsafe workplace
envi-ronments 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
construc-tion, and insulaconstruc-tion, 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
exist-ing asbestos-containexist-ing material from limited buildexist-ing areas
that do 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
inhala-tions of dusts from the floors of factories that produce
pot-tery 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,
occa-sionally 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
preven-tion, rodent control in cities, water fluoridapreven-tion, air pollution
control, protection against hazardous materials, and staff
education or training The blood lead level that is
consid-ered 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
wood-work 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
dumped and to measure the effects of toxic substances on community health After chemically damaged land has been identified, reclamation or redevelopment as prime com-mercial 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 neighbor-hood because of unpleasant odors but, when residents sus-pect 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 small-factory 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 prod-ucts, 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 vehi-cle emissions, to residences that may be contaminated with radon emissions from soils or rocks Although state or fed-eral 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 min-eral 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
Trang 8its 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
tech-nologies 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
prepa-ration 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
uri-nary 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
nox-ious 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
circu-lating 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
defi-cient 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
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 produc-tion and distribuproduc-tion, large-scale childhood vaccinaproduc-tion pro-grams, 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 ani-mals to humans) In Baltimore, for example, when animal control was transferred to the health department and the col-lection 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, ambu-lance services, a public general hospital, and more The total-ity of communtotal-ity 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 condi-tions 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
Trang 9Major 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
com-plex 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
dev-astating The disease is transmitted via body fluids, in
het-erosexual 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
medi-cal attention A medimedi-cal examiner performs an autopsy to
determine the cause of death, and may be called upon to
tes-tify 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
busi-ness, 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
politi-cal subdivision and have major fispoliti-cal 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
vol-untary, 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
offi-cials, medically unskilled appointed governing boards,
seri-ous 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
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 condi-tions, and with multiple complications of various addiccondi-tions, 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 physi-cians, 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 super-vise patient care and prepare physicians for a life of learn-ing 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 mandat-ing 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 communi-ties,” include inmates who suffer from drug abuse, alcohol-ism, 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 han-dling of two major illnesses among prisoners when health units are being planned—pulmonary tuberculosis and AIDS (acquired immunodeficiency syndrome) Patients with tuber-culosis infections may ascribe a chronic cough to smoking,
Trang 10or be nearly free of symptoms yet spread the infection to
other inmates via sputum droplets that contain live
tuber-culosis 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
care-ful attention to minimize the spread of tuberculosis and other
respiratory infections from patients with unrecognized
dis-ease to other inmates Health suites should provide for
tem-porary 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
opportunis-tically 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
simi-lar 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
ambu-lances 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
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 vol-unteered 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 pas-sage 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 medica-tions and patient care equipment to be carried in ambulance vehicles
Today, municipal or county ambulance services are usu-ally based in fire departments, to take advantage of a commu-nication 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 depart-ments Some local governments may contract with private ambulance companies to provide both emergency and rou-tine 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 tran-sit 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 immedi-ate and effective responses to life-threimmedi-atening 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 techni-cians, 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 medi-cations 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