ENCYCLOPEDIA OF ENVIRONMENTAL SCIENCE AND ENGINEERING - COMMUNITY HEALTHGENERAL pot

171
COMMUNITY HEALTH
GENERAL
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 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 population, and whether transportation 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,
© 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 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 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 ser-
vices; pediatric dentistry; services for drug and alcohol abus-
ers who want relief from these personal 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
© 2006 by Taylor & Francis Group, LLC
COMMUNITY HEALTH 173
for 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.
© 2006 by Taylor & Francis Group, LLC
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 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.
© 2006 by Taylor & Francis Group, LLC
COMMUNITY HEALTH 175
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 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
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 com-
munity 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 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
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 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.
© 2006 by Taylor & Francis Group, LLC

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 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
© 2006 by Taylor & Francis Group, LLC
COMMUNITY HEALTH 177

residents, 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 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 exist-
ing asbestos-containing material from limited building 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 fluoridation, 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
© 2006 by Taylor & Francis Group, LLC
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 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 distribution, large-scale childhood vaccination 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 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 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.
© 2006 by Taylor & Francis Group, LLC
COMMUNITY HEALTH 179
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 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 medical 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 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 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 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 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,
© 2006 by Taylor & Francis Group, LLC
180 COMMUNITY HEALTH
or 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-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 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 defibrilla-
tion,
14
immobilize fractured bones, or provide intravenous
© 2006 by Taylor & Francis Group, LLC
COMMUNITY HEALTH 181
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 communica-
tion 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 emer-
gency technicians provide rapid patient evacuation over dif-
ficult terrain or locations that wheeled vehicles can reach

only with difficulty. Helicopters are dispatched from a cen-
tral location and radio communication provides directions
to the helicopter pilot and continuous medical consulta-
tion 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 spe-
cial 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 selec-
tion 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 dispo-
sition, 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 manage-
ment 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
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 clini-
cal practice has lagged behind industrial usage, largely due
to the confidential nature of patient data. A relative inad-
equate computer literacy of older, experienced physicians
who must learn to enter data according to prescribed formats
may account for some continued reluctance in the accep-
tance of electronic clinical data systems. Despite more gen-
eral 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 com-
puter use in medical care.
16
Attempts to design algorithms
that replicate complex thought processes a trained physi-
cian 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 clini-
cal 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 expe-
riences in any of the 50 states.
18
National specialty societies
have computerized the credits earned in cumulative continu-
ing 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 iso-
lated communities quickly to obtain needed expert medical
and surgical advice and guidance.
© 2006 by Taylor & Francis Group, LLC
182 COMMUNITY HEALTH
Telemedicine is the transmission of laboratory infor-
mation, 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 black-
and-white video and two-way audio between a medical facility
at Logan Field, the major airport of Boston, MA, and physi-
cians 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 alter-
natives 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 pri-
mary 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 inter-
change 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 estab-
lished in 1991 at the Medical College of Georgia to provide
continuing medical education and consultations for rural
practitioners, using a system described as “totally distance-
insensitive.” 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 acces-
sible 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.
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 usu-
ally 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 inade-
quate, telephones out of order, and water supplies for cleans-
ing or sterilization impaired.
Although many calamities are relatively small and local-
ized, 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 equip-
ment, 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, rep-
resentatives 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 commu-
nication 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 equip-
ment pools are located, who owns or manages the mate-
riel, 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 stan-
dard 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
© 2006 by Taylor & Francis Group, LLC
COMMUNITY HEALTH 183
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 emergen-
cies. 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 catas-
trophes 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 main-
tain accurate lists of patients and their destinations to provide
timely information to communities of relatives and friends.
Supplies of special protective clothing and personal equip-
ment 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 visi-
tors. 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 mate-
rial, food, and laundry are additional concerns of municipal
departments that support the hospital community. During
early recovery and mop up periods, community health plan-
ners 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 con-
taminate damaged water supplies and foodstuffs that lack
refrigeration or safe storage. Increased numbers of respira-
tory 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
basic structures and services that give a community an iden-
tity and allow it to serve the needs of its citizens. A cata-
log 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 adminis-
trative problems such as fire and police protection along bor-
ders, trash disposal, recreation and entertainment, and public
health. To keep a community in good health, the chief execu-
tive 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.
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JOHN B. DE HOFF
Cockeysville, Maryland
© 2006 by Taylor & Francis Group, LLC