The Role of the Public General Hospital in Community Health 1974 Rosenhaus Lecture JAMES G. HAUGHTON, MD, MPH Twelve years ago, after 10 years of private clinical practice, I turned to the public sector. I did this in an attempt to address myself to some of the problems of health care delivery which I had encountered as a private practitioner. Those problems related to what we have chosen to call the dual system of health care-a system about which we talk interminably but do very little. My private practice had been a prime example of the operation of this system. Working in a predominantly black and Spanish-speaking community of mixed economic circumstances, my colleagues and I had been forced to treat the health problems of our community in two different ways. Those patients who were adequately insured or were otherwise able to pay for services received their care in our private offices and in the private nonprofit community and teaching hospitals on whose medical staffs we served. Those patients who were unable to pay sometimes received care in our offices, sometimes in the emergency rooms of private or public hospitals, and, almost always, when hospitalized, were forced to use the open wards of public hospitals or the charity wards of private hospitals, where they were called ''service cases." It appeared to me then that the private, fee-for-service model of health care delivery did not serve my community well, and that there was a large segment of our population which such a system would never serve well. It also seemed to me that, if the dual system was ever to be replaced by one which would guarantee the benefits of American health care technology to all of our people fairly and equitably, the initiative would have to come from the public sector. My 12 years of service in the public sector have reinforced those initial perceptions, and it is from that perspective that I propose a role for the public general hospital in community health. But first, what is community health? For the purposes of this monograph let us define community health as all those activities supported by a community either through private or public resources for the purpose of assuring to all its citizens a reasonable level of physical and mental health Dr. Haughton is Executive Director, Health and Hospitals Governing Commission of Cook County, Chicago, Illinois. This lecture was presented at the Awards General Session, 102nd Annual Meeting of the American Public Health Association New Orleans, October 21, 1974.
and an environment which contributes to a reasonable quality of life. Sir William Petty, an eminent British physician of the 17th century, having been invited in 1676 to give a lecture in Dublin, took the occasion to propose his idea of a teaching hospital based upon egalitarian principles, saying: "Another cause of defect in the art of medicine and, consequently, of its contempt, is that there have not been Hospitals for the accommodation of sick persons to resort unto them-Every sort of such Hospitals to differ only in splendor, but not at all in the Sufficiency for the means and remedy for the Patient's health."' This model of a teaching hospital was not actually established until 200 years later; but, by describing two kinds of hospitals-both equal in "the sufficiency for the means and remedy for the patient's health," but "differing in splendor," Dr. Petty, years before its time, actually described what has become known in 20th century U.S.A. as "the dual system of health care." The nature of the developmental history of hospitals in the United States has lent itself to the development of a dual system. Many of our great voluntary and public hospitals began as hostels for the poor. The New York Hospital of Cornell University began as the New York Society for the Poor. New York City's Bellevue Hospital is said to have begun as a poorhouse across the street from City Hall. When the politicians coming and going from City Hall became tired of being accosted by the beggars from the poorhouse, the City Council authorized the purchase of the present site of Bellevue and the poorhouse moved uptown. Both of these institutions have evolved into large, famous hospitals-one, as a private university hospital which, until not too long ago, had a charity teaching section "of less splendor"; the other as a public hospital generally "of less splendor" for the poor. Charity Hospital in New Orleans, Cook County Hospital in Chicago, and Los Angeles County Hospital in Los Angeles were all designed for the poor and were all constructed with large open wards or, to use Sir William Petty's words, "with less splendor." At the same time Columbia-Presbyterian Hospital in New York, Michael Reese Hospital in Chicago, Cedars of Lebanon in Los Angeles, and all the other private hospitals we could name were built with private and semi-private accommodations for the nonpoor and with open wards for the poor. ROSENHAUS LECTURE
21
As these separate and unequal facilities developed, the exhortation of Sir William Petty and others like him to egalitarian care was ignored, and the charity wards of both the private and public hospitals became the loci for the medical teaching process. It was assumed that private patients would not allow themselves to be objects in the teaching process but that the poor, since they were charity patients, had no choice other than to be grateful and to offer themselves as teaching subjects for the care they received. The poor, therefore, became "clinical material," and, as recently as 1966, because they were clinical material, large private teaching hospitals in New York City refused to allow their private voluntary physicians to admit their Medicaid patients as "private" patients. Even in this enlightened era the hospitals felt that by doing so they would lose clinical material and jeopardize their teaching programs. It has been within this context of separate and unequal services that public health professionals have assessed the role of public general hospitals in community health. Rightfully, they have assumed that, since private physicians generally address themselves to the episodic, acute needs of patients and hospitals concern themselves with problems requiring hospitalization, it was left to public health agencies to be concerned with health matters which had broad community implications. Venereal disease control, tuberculosis detection and treatment, immunization, environmental control, health education-all these were community health concerns and, therefore, rightfully within the purview of the only organization in the community which had legal responsibility for the health of all members of the communitythe public health departmnent. And so, for more than a century, general hospitals, both public and private, as well as most private physicians, have consistently pursued a course directed at the acute episodic and emergency needs of individuals, completely ignoring the broader health concerns of the community on the assumption that the local health department was quite capable of dealing with them. At the same time, out of fear of displeasing the local medical establishment, local health departments have ignored the medical care needs of their communities while zealously guarding their responsibility for preventive health services. The unnatural dichotomy has persisted to the present time in most political jurisdictions, nourished by govemment funding mechanisms. For example, as recently as the early 1960s the New York City Health Department, under the leadership of Dr. Leona Baumgartner, had determined that there was a deficit of acute pediatric medical care in one of the city's poverty-stricken districts. Braving the displeasure of the local medical society, the department established an acute pediatric medical care service on the assumption that community health embraced the entire spectrum of health needs. When the bill for this service was submitted to the state health department for reimbursement, it was rejected on the grounds that medical care was not "public health" 22
AJPH JANUARY, 1975, Vol. 65, No. 1
and was, therefore, not reimbursable by a "public health" agency. Years later, the State Public Health Code was amended to permit such reimbursement. That amendment immediately became known as the "Ghetto Medicine Law," a fact which stigmatized all those who received medical care under its provisions. The medical-technological breakthroughs of the last half-century also have diminished the role of those health departments which persisted in pursuing the goals of the past. As the care of tuberculosis patients has moved into the general hospital, health departments no longer operate TB sanatoria. Health departments no longer operate contagious disease hospitals because influenza, poliomyelitis, smallpox, diphtheria, and measles have ceased to be the "killers" they were in the past. And, as plumbing has replaced the latrine, the sewage treatment plant has replaced the septic tank, and atomic waste disposal has become a more serious problem than sewage disposal, health departments have lost their role as the sole guardians of environmental health and have been forced to share these responsibilities with other agencies. The social and technological changes of this period, therefore, suggest that, in addition to a change in the definition of community health, there must be a re-definition of the roles of the various participants in the health enterprise of our nation. If they are to continue as a viable part of the process, public health departments can no longer isolate themselves from the medical care deficits and needs of their communities. They must play some role-if not one of delivery of services, then a regulatory or review role. General hospitals, on the other hand, must recognize an equal mandate for change. The social and demographic revolutions of the past 25 years have surrounded urban hospitals with problems which can no longer be ignored. In many communities these hospitals have become the sole source of medical care for large populations. Many have responded by making their emergency rooms the resource for family care in these communities. This phenomenon has had an even more dramatic impact upon large public general hospitals which, because of their image as resources for the poor, have traditionally existed primarily in large urban centers where the poor have always tended to congregate. The parallel streams of the emigration of upper and middle income families from the cities to the suburbs and the immigration of the poor to the largest cities of the nation have resulted in population changes which are threatening the stability of many of our largest cities. These changes enverop the public general hospital with problems which create an imperative that must transcend any desire to maintain the artificial dichotomies of the past. The public general hospital is where the action is, and the time has come for us to deflne its role in realistic terns and to provide it with the resources to accomplish that role. At the same time, we must provide, within government, the mechanisms for sound business management, flexibility, and accountability.
What, then, is the role of the public general hospital in community health? Unless unforeseen demographic and economic changes occur in our nation within the next decade or two, public general hospitals must take their place as equal partners in the health care process. This means that public general hospitals must be attractive enough and responsive enough to serve the needs of an integrated community without regard to social, economic, and ethnic differences. Furthermore public general hospitals now serve the health needs of more people than any other resource in the community. In 1973, the outpatient departments of the public hospitals of New York City received almost 4,800,000 visits and their emergency rooms more than 1,700,000 visits.2 Los Angeles County hospitals received 837,000 visits in their ambulatory facilities.3 At Cook County Hospital, we will provide 240,000 emergency room visits and over 300,000 outpatient visits in 1974. In 1973, we admitted 75,000 new patients to our outpatient department. These staggering numbers represent access to a population size unmatched by any public health department or any private hospital system. Thus, public hospitals, because of the role they play in delivering acute medical care, are a potential instrument for the delivery of preventive services of unprecedented magnitude. Public health officials have often rejected acute hospitals as instruments for the delivery of preventive health care because of the fear that, when bones are broken and blood is flowing, there is a tendency to forget all but the most urgent demands of the moment. This concern is legitimate but can no longer be used as an excuse for not applying the. major resource already in place in the public general hospital to community health services. What is required is leadership with a commitment to the broad definition of community health and a community with sufficient vision to make the investment in transforming these medical care resources into community health resources. Can such leadership be found, and will any community make such an investment? I believe the answer to both questions is resounding "'yes." In 1969, the city of Chicago was faced with the possibility of the loss of its only public general hospital. Cook County Hospital had served the city's poor for over 100 years and had once been a very prestigious teaching hospital. It had recently come upon hard times and was now facing the loss of its accreditation by the Joint Commission on Accreditation of Hospitals. Prodded by pressures from many sources, the Illinois State legislature took action to preserve this major health resource. It created an independent nonpolitical commission to operate not only Cook County Hospital but all of the county's hospital and medical facilities. It also made this commission financially independent by granting it the authority to collect all third party sources of payment for the services it rendered, and, in addition, created a specially earmarked tax through which funds could be raised to cover any legitimate deficits which the commission might incur in its operation. During the past 4 years, the Health and Hospitals Governing Commission of Cook County has become the
largest single provider of health services in the state of Illinois. Early in its existence, the commission established policies and goals which have guided its activities through these years. Among these goals was the creation of an instrument for the delivery of the broadest possible range of community health services. This required the recruitment of physicians and other health professionals with a commitment to the principles of community health as we have defined here. It has not been easy to accomplish this recruitment because our health professions schools have not been the leaders in fostering the principles of preventive health services and community health. On the contrary, they have been major contributors to the maldistribution of health services in our nation because of the nature of the education they have provided. They have given us a generation of physicians who concentrate on learning more and more about less and less and nurses who need the dramatic stimulus of the trauma center, the coronary care unit, and the intensive care station for professional satisfaction. In spite of these difficulties, the commission has created a health care team of medical and allied health professionals and workers committed to providing to the people of the County of Cook all of the benefits of community health services. High on its list of priorities is the provision of preventive health services, and it has proven that, amid the gore, drama, and heartbreak of actue urban medicine, preventive services can be given high visibility and can capture the imagination of provider and consumer alike. Let me cite a few examples, commencing with an approach to the problems associated with TB: In March, 1973, the then newly appointed chairman of the Division of Pulmonary Medicine at Cook County Hospital recommended to the Program Committee of the Governing Commission, which sets policy for the hospital, that, because of the large numbers of people who use the services of Cook County Hospital, both as inpatients and as outpatients, Cook County Hospital should be a major source of case finding and treatment for cases of
tuberculosis. He pointed out to the commissioners that the new case rate for the city of Chicago was twice the national average of 16 per 100,0004 and that the community immediately surrounding Cook County Hospital had a new case rate in excess of 300 per 100,000. Agreeing that a public agency charged with the responsibility for delivering health services to this large population could not ignore the problem of TB in its immediate community and upon the recomm'endation of the Program Committee, a resolution was adopted by the commission authorizing the establishment of a tuberculosis control program at the hospital. The program was initiated on July 1, 1973. Since then, all hospital admissions are tested with intermediate strength PPD and are given a chest X-ray. All cases detected are thoroughly interviewed to determine close contacts, and these contacts are referred to the clinics of the Municipal Tuberculosis Sanatorium, the ROSENHAUS LECTURE
23
city's agency for TB control, for screening and preventive therapy. Those contacts who do not readily present themselves to the clinics are sought out at home by the public health nurses of the local health department. Patients discovered to have active infectious tuberculosis are admitted to the tuberculosis ward of Cook County Hospital where treatment that may include a hospital stay of from 2 to 3 weeks is initiated. After discharge, the TB patients are followed at the Cook County Hospital Chest Clinic or at clinics of the metropolitan Tuberculosis Sanatorium for 18 to 24 months of ambulatory therapy. During the first 12 months of this program 354 culture-positive patients were detected and treated at Cook County Hospital. Although many of these patients are alcoholics from the streets of the city of Chicago, 97 per cent of them have remained in treatment throughout this period.5 This has been accomplished by the use of trained field workers who actively seek out patients who are delinquent in keeping their clinic appointment. A nonpunitive, supportive approach has proved successful in enabling these field workers to maintain contact. Hypertension, which is rapidly becoming recognized as America's number one public health problem, is another example of an opportunity for adapting the resources of a public general care hospital to serving the community's public health needs. The National Health Survey has indicated the prevalence of hypertension to be 21.1 per cent in urban blacks and 13.5 per cent in urban whites. In a Chicago Heart Association detection project in industry, it was found that most persons with hypertension had no awareness of their condition. Of 2,725 individuals evaluated as hypertensive, 58.9 per cent denied prior knowledge of the diagnosis. In the urban ghetto, 75 per cent of black males screened had no prior knowledge of their condition. In 1973, the Chainnan of the Division of Nephrology of Cook County Hospital recommended to the Program Committee of the Governing Commission that Cook County Hospital could be a major resource for the screening and detection of persons with hypertension. The commission agreed and a program has been established in collaboration with the Chicago Board of Health. One result has been that the Westside Hypertension Clinic was established. All adults using the emergency room at Cook County Hospital are offered the opportunity to be tested for high blood pressure. Persons whose blood pressure is found to be elevated are referred to our Hypertension Clinic or to another source of medical treatment. The Board of Health also has mobile units which screen for hypertension on the streets of Chicago using protocols prepared by the staff of the hypertension program at Cook County Hospital. Patients found to be hypertensive are referred to the Hypertension Clinic at Cook County Hospital, to the cooperating clinics of the Board of Health, or to their physicians. During the first year of this program at Cook County Hospital, a total of 1,200 patients have been enrolled for treatment and are now under medical
supervision.6
Again, detection and treatment of diabetes mellitus offers public general acute care hospitals an additional opportunity for community service. Diabetes mellitus has 24 AJPH JANUARY, 1975, Vol. 65, No. 1
long been recognized as a primary health problem in the United States, and public health departments have for many years carried out diabetes detection programs. A report by the Metropolitan Life Insurance Company published in the Journal of the American Medical Association in 1973 revealed the following: "In the United States, diabetes mortality rates for the white population in 1967 to 1968 were 13.1 per 100,000 for men and 13.5 per 100 000 for women. The rates for non-whites were 19.9 and 31.6 respectively. Compared to the figure ten years previously, it was found that diabetes mortality rates for white men had risen by 17%, in contrast it rose 46% for non-white men. For white females, the diabetes mortality rate actually dropped by 4%; in contrast it rose by 24% for non-white females. "7
In view of the fact that 90 per cent of the patients using Cook County HIospital are nonwhite the Governing Commission approved the establishment of the Diabetes Detection and Treatment Program. The program began in May, 1973, and the Diabetes Detection Clinic operates daily in the outpatient department of the hospital. All patients coming to the outpatient department or admitted to the hospital are screened for diabetes. Those found to be positive or suspect are referred to the Diabetes Clinic for further follow-up and supervision. The Diabetes Clinic now sees an average of 30 patients per day and we will soon be expanding it to accommodate 50 to 60 patients per day. The program is staffed by a combination of physicians and specially trained nurse practitioners. In addition, on any given day, there may be an average of 30 patients hospitalized for the care of diabetes or its serious complications. Through the establishment of the detection and treatment clinic, we have been able to reduce the number of hospital admissions to some extent. A patient follow-up rate of 85 per cent is maintained through the use of follow-up letters, telephone calls, or home visits when patients become delinquent in keeping their clinic appointments. Another example: Four years ago, through a grant provided by the Family Planning Council of the city of Chicago, a Family Planning Clinic was established at Cook County Hospital. In 1973, the clinic was reorganized and expanded to provide a broader service to the childbearing population. It now meets five evenings each week, providing services to 60 to 70 patients at each session. Patient education is an important feature of this activity and other preventive services are stressed as a part of the
program. All new patients receive a Pap smear, are screened for breast tumors, and receive a gonorrhea culture, serology, complete urinalysis, hypertension screening, and diabetes screening. In 1973, there were 4,650 new admissions to the Family Planning Clinic and a total of 15,000 visits. In 1969, there were approximately 12,000 deliveries at Cook County Hospital, while in 1973 there were less than 8,000. We do not claim direct causal relationship, but we would like to believe that a successful family planning prograrnm has contributed to this decline.
Preinvasive cancer of the cervix or carcinoma in situ has long been recognized as the precursor of invasive cancer. The incidence of carcinoma in situ in the white population is 32.5 per 100,000 and is 62.6 in the black population. In 1973, faced with this information, we at Cook County began a conscious attempt to do Pap smears on all female patients seen in our clinics as well as on the inpatient gynecological service. During that year, 26,327 smears were evaluated and 709 were found to be Class III.8 Our gynecology department considers Class III smears to be indicative of carcinoma in situ and an indication of the need for corrective surgery. With this aggressive program of cancer detection, we hope to bring about a decrease in clinical invasive carcinoma of the cervix, which is a known major killer of women. I could go on to describe our broader cancer detection program, our prenatal program, our program of well-baby supervision, and our nutrition program, but I believe the ones I have described suffice to show that an acute medical care setting can simultaneously be an instrument for preventive health services. The Governing Commission has recently begun the development of neighborhood health programs so that delivery of services will be decentralized and more convenient to the population served. All of these neighborhood programs will include the services described. Another stated goal of the commission is to train health professionals committed to the principles of community health. Because of this commitment, all of the programs I have described both in the hospital and in the neighborhood health centers are included in the commission's residency training of physicians. They are also included as part of the training for student nurses in our nursing school. Through these educational efforts, we hope to create a cadre of health professionals both committed to the principles of community health and trained to carry out these programs. In pursuit of this goal we have developed an affiliation with the School of Public Health of the University of Illinois through which physicians pursuing specialty training at Cook County Hospital can simultaneously acquire training in public health administration and receive a master's degree in that discipline. We hope that these young professionals will leave our institution to take the leadership in the creation of the kinds of programs we have attempted to develop and, hopefully, to broaden the scope beyond that which we have been able to accomplish. During the past 4 years, we have seen a major urban
community make a commitment to save its public general hospital. We have participated in the creation of a mechanism for governance which has transformed a decaying, strife-ridden public general hospital into an instrument for the delivery of community health services and we have begun the process of training highly skilled medical specialists and nurses to include preventive health services among their professional concerns and career commitments. This experience has convinced me that there is no question but that the public general hospital is a major health resource and can, indeed, be where the action is. But before this can be a reality for all such hospitals, communities must be persuaded to invest in the renascence of their public hospitals, as cities such as Detroit, Cleveland, and New York are now doing. In addition, public health leaders must recognize the potential inherent in these hospitals and take the initiative in developing cooperative relationships with them. In this way, I am convinced preventive health services will be brought into the mainstream of health care delivery and the objectives of public health professionals can be accomplished. It is up to us to relinquish our parochialisms while joining hands with our clinical colleagues in this exciting adventure.
References 1. Ober, Wm. B. Sir Wm. Petty: Medical Education, Hospitals and Health Care. Bull N. Y. Acad. Med. 48:998-1002, 1972. 2. Health and Hospitals Corporation of New York City,
Office of Public Information. 3. County of Los Angeles Department of Health Services Administration, Office of Public Information. 4. U.S. Public Health Service, Communicable Disease Center, Atlanta. Annual Report, 1972. 5. Addington, W. W. Progress Report on Tuberculosis Control to the Program Committee of The Health and Hospitals Governing Commission of Cook County, July 22, 1974. 6. Dunea, G. Progress Report on Hypertension Screening to the Program Committee of The Health and Hospitals Governing Commission of Cook County, July 17, 1974. 7. Metropolitan Life Insurance Company. Statistical Bulletin, September, 1972. J. A. M. A. January 29, 1973, p. 566. 8. Stepto, R. C. Significance of the Abnormal Pap Smear. Presented at a meeting of the Medical Alumni of the University of Chicago, June 13, 1974.
ROSENHAUS LECTURE 25
and an environment which contributes to a reasonable quality of life. Sir William Petty, an eminent British physician of the 17th century, having been invited in 1676 to give a lecture in Dublin, took the occasion to propose his idea of a teaching hospital based upon egalitarian principles, saying: "Another cause of defect in the art of medicine and, consequently, of its contempt, is that there have not been Hospitals for the accommodation of sick persons to resort unto them-Every sort of such Hospitals to differ only in splendor, but not at all in the Sufficiency for the means and remedy for the Patient's health."' This model of a teaching hospital was not actually established until 200 years later; but, by describing two kinds of hospitals-both equal in "the sufficiency for the means and remedy for the patient's health," but "differing in splendor," Dr. Petty, years before its time, actually described what has become known in 20th century U.S.A. as "the dual system of health care." The nature of the developmental history of hospitals in the United States has lent itself to the development of a dual system. Many of our great voluntary and public hospitals began as hostels for the poor. The New York Hospital of Cornell University began as the New York Society for the Poor. New York City's Bellevue Hospital is said to have begun as a poorhouse across the street from City Hall. When the politicians coming and going from City Hall became tired of being accosted by the beggars from the poorhouse, the City Council authorized the purchase of the present site of Bellevue and the poorhouse moved uptown. Both of these institutions have evolved into large, famous hospitals-one, as a private university hospital which, until not too long ago, had a charity teaching section "of less splendor"; the other as a public hospital generally "of less splendor" for the poor. Charity Hospital in New Orleans, Cook County Hospital in Chicago, and Los Angeles County Hospital in Los Angeles were all designed for the poor and were all constructed with large open wards or, to use Sir William Petty's words, "with less splendor." At the same time Columbia-Presbyterian Hospital in New York, Michael Reese Hospital in Chicago, Cedars of Lebanon in Los Angeles, and all the other private hospitals we could name were built with private and semi-private accommodations for the nonpoor and with open wards for the poor. ROSENHAUS LECTURE
21
As these separate and unequal facilities developed, the exhortation of Sir William Petty and others like him to egalitarian care was ignored, and the charity wards of both the private and public hospitals became the loci for the medical teaching process. It was assumed that private patients would not allow themselves to be objects in the teaching process but that the poor, since they were charity patients, had no choice other than to be grateful and to offer themselves as teaching subjects for the care they received. The poor, therefore, became "clinical material," and, as recently as 1966, because they were clinical material, large private teaching hospitals in New York City refused to allow their private voluntary physicians to admit their Medicaid patients as "private" patients. Even in this enlightened era the hospitals felt that by doing so they would lose clinical material and jeopardize their teaching programs. It has been within this context of separate and unequal services that public health professionals have assessed the role of public general hospitals in community health. Rightfully, they have assumed that, since private physicians generally address themselves to the episodic, acute needs of patients and hospitals concern themselves with problems requiring hospitalization, it was left to public health agencies to be concerned with health matters which had broad community implications. Venereal disease control, tuberculosis detection and treatment, immunization, environmental control, health education-all these were community health concerns and, therefore, rightfully within the purview of the only organization in the community which had legal responsibility for the health of all members of the communitythe public health departmnent. And so, for more than a century, general hospitals, both public and private, as well as most private physicians, have consistently pursued a course directed at the acute episodic and emergency needs of individuals, completely ignoring the broader health concerns of the community on the assumption that the local health department was quite capable of dealing with them. At the same time, out of fear of displeasing the local medical establishment, local health departments have ignored the medical care needs of their communities while zealously guarding their responsibility for preventive health services. The unnatural dichotomy has persisted to the present time in most political jurisdictions, nourished by govemment funding mechanisms. For example, as recently as the early 1960s the New York City Health Department, under the leadership of Dr. Leona Baumgartner, had determined that there was a deficit of acute pediatric medical care in one of the city's poverty-stricken districts. Braving the displeasure of the local medical society, the department established an acute pediatric medical care service on the assumption that community health embraced the entire spectrum of health needs. When the bill for this service was submitted to the state health department for reimbursement, it was rejected on the grounds that medical care was not "public health" 22
AJPH JANUARY, 1975, Vol. 65, No. 1
and was, therefore, not reimbursable by a "public health" agency. Years later, the State Public Health Code was amended to permit such reimbursement. That amendment immediately became known as the "Ghetto Medicine Law," a fact which stigmatized all those who received medical care under its provisions. The medical-technological breakthroughs of the last half-century also have diminished the role of those health departments which persisted in pursuing the goals of the past. As the care of tuberculosis patients has moved into the general hospital, health departments no longer operate TB sanatoria. Health departments no longer operate contagious disease hospitals because influenza, poliomyelitis, smallpox, diphtheria, and measles have ceased to be the "killers" they were in the past. And, as plumbing has replaced the latrine, the sewage treatment plant has replaced the septic tank, and atomic waste disposal has become a more serious problem than sewage disposal, health departments have lost their role as the sole guardians of environmental health and have been forced to share these responsibilities with other agencies. The social and technological changes of this period, therefore, suggest that, in addition to a change in the definition of community health, there must be a re-definition of the roles of the various participants in the health enterprise of our nation. If they are to continue as a viable part of the process, public health departments can no longer isolate themselves from the medical care deficits and needs of their communities. They must play some role-if not one of delivery of services, then a regulatory or review role. General hospitals, on the other hand, must recognize an equal mandate for change. The social and demographic revolutions of the past 25 years have surrounded urban hospitals with problems which can no longer be ignored. In many communities these hospitals have become the sole source of medical care for large populations. Many have responded by making their emergency rooms the resource for family care in these communities. This phenomenon has had an even more dramatic impact upon large public general hospitals which, because of their image as resources for the poor, have traditionally existed primarily in large urban centers where the poor have always tended to congregate. The parallel streams of the emigration of upper and middle income families from the cities to the suburbs and the immigration of the poor to the largest cities of the nation have resulted in population changes which are threatening the stability of many of our largest cities. These changes enverop the public general hospital with problems which create an imperative that must transcend any desire to maintain the artificial dichotomies of the past. The public general hospital is where the action is, and the time has come for us to deflne its role in realistic terns and to provide it with the resources to accomplish that role. At the same time, we must provide, within government, the mechanisms for sound business management, flexibility, and accountability.
What, then, is the role of the public general hospital in community health? Unless unforeseen demographic and economic changes occur in our nation within the next decade or two, public general hospitals must take their place as equal partners in the health care process. This means that public general hospitals must be attractive enough and responsive enough to serve the needs of an integrated community without regard to social, economic, and ethnic differences. Furthermore public general hospitals now serve the health needs of more people than any other resource in the community. In 1973, the outpatient departments of the public hospitals of New York City received almost 4,800,000 visits and their emergency rooms more than 1,700,000 visits.2 Los Angeles County hospitals received 837,000 visits in their ambulatory facilities.3 At Cook County Hospital, we will provide 240,000 emergency room visits and over 300,000 outpatient visits in 1974. In 1973, we admitted 75,000 new patients to our outpatient department. These staggering numbers represent access to a population size unmatched by any public health department or any private hospital system. Thus, public hospitals, because of the role they play in delivering acute medical care, are a potential instrument for the delivery of preventive services of unprecedented magnitude. Public health officials have often rejected acute hospitals as instruments for the delivery of preventive health care because of the fear that, when bones are broken and blood is flowing, there is a tendency to forget all but the most urgent demands of the moment. This concern is legitimate but can no longer be used as an excuse for not applying the. major resource already in place in the public general hospital to community health services. What is required is leadership with a commitment to the broad definition of community health and a community with sufficient vision to make the investment in transforming these medical care resources into community health resources. Can such leadership be found, and will any community make such an investment? I believe the answer to both questions is resounding "'yes." In 1969, the city of Chicago was faced with the possibility of the loss of its only public general hospital. Cook County Hospital had served the city's poor for over 100 years and had once been a very prestigious teaching hospital. It had recently come upon hard times and was now facing the loss of its accreditation by the Joint Commission on Accreditation of Hospitals. Prodded by pressures from many sources, the Illinois State legislature took action to preserve this major health resource. It created an independent nonpolitical commission to operate not only Cook County Hospital but all of the county's hospital and medical facilities. It also made this commission financially independent by granting it the authority to collect all third party sources of payment for the services it rendered, and, in addition, created a specially earmarked tax through which funds could be raised to cover any legitimate deficits which the commission might incur in its operation. During the past 4 years, the Health and Hospitals Governing Commission of Cook County has become the
largest single provider of health services in the state of Illinois. Early in its existence, the commission established policies and goals which have guided its activities through these years. Among these goals was the creation of an instrument for the delivery of the broadest possible range of community health services. This required the recruitment of physicians and other health professionals with a commitment to the principles of community health as we have defined here. It has not been easy to accomplish this recruitment because our health professions schools have not been the leaders in fostering the principles of preventive health services and community health. On the contrary, they have been major contributors to the maldistribution of health services in our nation because of the nature of the education they have provided. They have given us a generation of physicians who concentrate on learning more and more about less and less and nurses who need the dramatic stimulus of the trauma center, the coronary care unit, and the intensive care station for professional satisfaction. In spite of these difficulties, the commission has created a health care team of medical and allied health professionals and workers committed to providing to the people of the County of Cook all of the benefits of community health services. High on its list of priorities is the provision of preventive health services, and it has proven that, amid the gore, drama, and heartbreak of actue urban medicine, preventive services can be given high visibility and can capture the imagination of provider and consumer alike. Let me cite a few examples, commencing with an approach to the problems associated with TB: In March, 1973, the then newly appointed chairman of the Division of Pulmonary Medicine at Cook County Hospital recommended to the Program Committee of the Governing Commission, which sets policy for the hospital, that, because of the large numbers of people who use the services of Cook County Hospital, both as inpatients and as outpatients, Cook County Hospital should be a major source of case finding and treatment for cases of
tuberculosis. He pointed out to the commissioners that the new case rate for the city of Chicago was twice the national average of 16 per 100,0004 and that the community immediately surrounding Cook County Hospital had a new case rate in excess of 300 per 100,000. Agreeing that a public agency charged with the responsibility for delivering health services to this large population could not ignore the problem of TB in its immediate community and upon the recomm'endation of the Program Committee, a resolution was adopted by the commission authorizing the establishment of a tuberculosis control program at the hospital. The program was initiated on July 1, 1973. Since then, all hospital admissions are tested with intermediate strength PPD and are given a chest X-ray. All cases detected are thoroughly interviewed to determine close contacts, and these contacts are referred to the clinics of the Municipal Tuberculosis Sanatorium, the ROSENHAUS LECTURE
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city's agency for TB control, for screening and preventive therapy. Those contacts who do not readily present themselves to the clinics are sought out at home by the public health nurses of the local health department. Patients discovered to have active infectious tuberculosis are admitted to the tuberculosis ward of Cook County Hospital where treatment that may include a hospital stay of from 2 to 3 weeks is initiated. After discharge, the TB patients are followed at the Cook County Hospital Chest Clinic or at clinics of the metropolitan Tuberculosis Sanatorium for 18 to 24 months of ambulatory therapy. During the first 12 months of this program 354 culture-positive patients were detected and treated at Cook County Hospital. Although many of these patients are alcoholics from the streets of the city of Chicago, 97 per cent of them have remained in treatment throughout this period.5 This has been accomplished by the use of trained field workers who actively seek out patients who are delinquent in keeping their clinic appointment. A nonpunitive, supportive approach has proved successful in enabling these field workers to maintain contact. Hypertension, which is rapidly becoming recognized as America's number one public health problem, is another example of an opportunity for adapting the resources of a public general care hospital to serving the community's public health needs. The National Health Survey has indicated the prevalence of hypertension to be 21.1 per cent in urban blacks and 13.5 per cent in urban whites. In a Chicago Heart Association detection project in industry, it was found that most persons with hypertension had no awareness of their condition. Of 2,725 individuals evaluated as hypertensive, 58.9 per cent denied prior knowledge of the diagnosis. In the urban ghetto, 75 per cent of black males screened had no prior knowledge of their condition. In 1973, the Chainnan of the Division of Nephrology of Cook County Hospital recommended to the Program Committee of the Governing Commission that Cook County Hospital could be a major resource for the screening and detection of persons with hypertension. The commission agreed and a program has been established in collaboration with the Chicago Board of Health. One result has been that the Westside Hypertension Clinic was established. All adults using the emergency room at Cook County Hospital are offered the opportunity to be tested for high blood pressure. Persons whose blood pressure is found to be elevated are referred to our Hypertension Clinic or to another source of medical treatment. The Board of Health also has mobile units which screen for hypertension on the streets of Chicago using protocols prepared by the staff of the hypertension program at Cook County Hospital. Patients found to be hypertensive are referred to the Hypertension Clinic at Cook County Hospital, to the cooperating clinics of the Board of Health, or to their physicians. During the first year of this program at Cook County Hospital, a total of 1,200 patients have been enrolled for treatment and are now under medical
supervision.6
Again, detection and treatment of diabetes mellitus offers public general acute care hospitals an additional opportunity for community service. Diabetes mellitus has 24 AJPH JANUARY, 1975, Vol. 65, No. 1
long been recognized as a primary health problem in the United States, and public health departments have for many years carried out diabetes detection programs. A report by the Metropolitan Life Insurance Company published in the Journal of the American Medical Association in 1973 revealed the following: "In the United States, diabetes mortality rates for the white population in 1967 to 1968 were 13.1 per 100,000 for men and 13.5 per 100 000 for women. The rates for non-whites were 19.9 and 31.6 respectively. Compared to the figure ten years previously, it was found that diabetes mortality rates for white men had risen by 17%, in contrast it rose 46% for non-white men. For white females, the diabetes mortality rate actually dropped by 4%; in contrast it rose by 24% for non-white females. "7
In view of the fact that 90 per cent of the patients using Cook County HIospital are nonwhite the Governing Commission approved the establishment of the Diabetes Detection and Treatment Program. The program began in May, 1973, and the Diabetes Detection Clinic operates daily in the outpatient department of the hospital. All patients coming to the outpatient department or admitted to the hospital are screened for diabetes. Those found to be positive or suspect are referred to the Diabetes Clinic for further follow-up and supervision. The Diabetes Clinic now sees an average of 30 patients per day and we will soon be expanding it to accommodate 50 to 60 patients per day. The program is staffed by a combination of physicians and specially trained nurse practitioners. In addition, on any given day, there may be an average of 30 patients hospitalized for the care of diabetes or its serious complications. Through the establishment of the detection and treatment clinic, we have been able to reduce the number of hospital admissions to some extent. A patient follow-up rate of 85 per cent is maintained through the use of follow-up letters, telephone calls, or home visits when patients become delinquent in keeping their clinic appointments. Another example: Four years ago, through a grant provided by the Family Planning Council of the city of Chicago, a Family Planning Clinic was established at Cook County Hospital. In 1973, the clinic was reorganized and expanded to provide a broader service to the childbearing population. It now meets five evenings each week, providing services to 60 to 70 patients at each session. Patient education is an important feature of this activity and other preventive services are stressed as a part of the
program. All new patients receive a Pap smear, are screened for breast tumors, and receive a gonorrhea culture, serology, complete urinalysis, hypertension screening, and diabetes screening. In 1973, there were 4,650 new admissions to the Family Planning Clinic and a total of 15,000 visits. In 1969, there were approximately 12,000 deliveries at Cook County Hospital, while in 1973 there were less than 8,000. We do not claim direct causal relationship, but we would like to believe that a successful family planning prograrnm has contributed to this decline.
Preinvasive cancer of the cervix or carcinoma in situ has long been recognized as the precursor of invasive cancer. The incidence of carcinoma in situ in the white population is 32.5 per 100,000 and is 62.6 in the black population. In 1973, faced with this information, we at Cook County began a conscious attempt to do Pap smears on all female patients seen in our clinics as well as on the inpatient gynecological service. During that year, 26,327 smears were evaluated and 709 were found to be Class III.8 Our gynecology department considers Class III smears to be indicative of carcinoma in situ and an indication of the need for corrective surgery. With this aggressive program of cancer detection, we hope to bring about a decrease in clinical invasive carcinoma of the cervix, which is a known major killer of women. I could go on to describe our broader cancer detection program, our prenatal program, our program of well-baby supervision, and our nutrition program, but I believe the ones I have described suffice to show that an acute medical care setting can simultaneously be an instrument for preventive health services. The Governing Commission has recently begun the development of neighborhood health programs so that delivery of services will be decentralized and more convenient to the population served. All of these neighborhood programs will include the services described. Another stated goal of the commission is to train health professionals committed to the principles of community health. Because of this commitment, all of the programs I have described both in the hospital and in the neighborhood health centers are included in the commission's residency training of physicians. They are also included as part of the training for student nurses in our nursing school. Through these educational efforts, we hope to create a cadre of health professionals both committed to the principles of community health and trained to carry out these programs. In pursuit of this goal we have developed an affiliation with the School of Public Health of the University of Illinois through which physicians pursuing specialty training at Cook County Hospital can simultaneously acquire training in public health administration and receive a master's degree in that discipline. We hope that these young professionals will leave our institution to take the leadership in the creation of the kinds of programs we have attempted to develop and, hopefully, to broaden the scope beyond that which we have been able to accomplish. During the past 4 years, we have seen a major urban
community make a commitment to save its public general hospital. We have participated in the creation of a mechanism for governance which has transformed a decaying, strife-ridden public general hospital into an instrument for the delivery of community health services and we have begun the process of training highly skilled medical specialists and nurses to include preventive health services among their professional concerns and career commitments. This experience has convinced me that there is no question but that the public general hospital is a major health resource and can, indeed, be where the action is. But before this can be a reality for all such hospitals, communities must be persuaded to invest in the renascence of their public hospitals, as cities such as Detroit, Cleveland, and New York are now doing. In addition, public health leaders must recognize the potential inherent in these hospitals and take the initiative in developing cooperative relationships with them. In this way, I am convinced preventive health services will be brought into the mainstream of health care delivery and the objectives of public health professionals can be accomplished. It is up to us to relinquish our parochialisms while joining hands with our clinical colleagues in this exciting adventure.
References 1. Ober, Wm. B. Sir Wm. Petty: Medical Education, Hospitals and Health Care. Bull N. Y. Acad. Med. 48:998-1002, 1972. 2. Health and Hospitals Corporation of New York City,
Office of Public Information. 3. County of Los Angeles Department of Health Services Administration, Office of Public Information. 4. U.S. Public Health Service, Communicable Disease Center, Atlanta. Annual Report, 1972. 5. Addington, W. W. Progress Report on Tuberculosis Control to the Program Committee of The Health and Hospitals Governing Commission of Cook County, July 22, 1974. 6. Dunea, G. Progress Report on Hypertension Screening to the Program Committee of The Health and Hospitals Governing Commission of Cook County, July 17, 1974. 7. Metropolitan Life Insurance Company. Statistical Bulletin, September, 1972. J. A. M. A. January 29, 1973, p. 566. 8. Stepto, R. C. Significance of the Abnormal Pap Smear. Presented at a meeting of the Medical Alumni of the University of Chicago, June 13, 1974.
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