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 hospitalsare 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,C003_002_r03.indd 179C003_002_r03.indd 179 11/18/2005 10:17:41 AM11/18/2005 10:17:41 AM