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Community Oriented Primary Care: New Directions for Health Services Delivery (1983)

Chapter: The Meaning of Community Oriented Primary Care in the American Context

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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 65
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 66
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 67
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 68
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 69
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 70
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 71
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 72
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 73
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 79
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 80
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 81
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 89
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 90
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 91
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 92
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 93
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 94
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 96
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 97
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 98
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 99
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 100
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 101
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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Page 102
Suggested Citation:"The Meaning of Community Oriented Primary Care in the American Context." Institute of Medicine. 1983. Community Oriented Primary Care: New Directions for Health Services Delivery. Washington, DC: The National Academies Press. doi: 10.17226/1917.
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The Meaning of Community Oriented Primary Care in the American Context H. Jack Geiger Any attempt to examine the concept of community oriented primary care (COPC) and consider itS implications for health care in the United States is, for me, a retrospective as well as a prospective exercise, one that recalls powerfully imprinting past experiences and invokes strongly held hopes for the future. At the outset, therefore, I believe I should identify those ex- periences and, tO the extent that I can, the biases they produced. During my senior year in medical school, in what proved to be the central experience of my undergraduate medical education, I worked and studied for 6 months with Professors Kark, Abramson, and their colleagues in South Africa at the Polela Health Center, serving a rural Zulu tribal reserve, and the Lamontville Health Center, serving an extraordinarily diverse peri- urban, African and Asian population near Durban.i That experience led definitively, if circuitously, to my own attempts at an approximation of community oriented primary care in rural Mound Bayou, Mississippi, and urban Columbia Point, Boston efforts in which Dr. Kark, Dr. John Casel, and other veterans of the South African endeavors served as occasional consultants. More recently, Dr. Kark spent 18 months as a visiting professor at the School of Biomedical Education at City College, assisting in attempts tO initiate practices of community oriented primary care as he now defines them in Harlem, the North Bronx, and Chinatown. Although almost 25 years have passed, my memories of Polela and La- montville are vivid. The health center's task was the provision of community oriented primary care, though it did not yet have that name, and a student's work consisted of the elements of COPC, continuing a tradition that ex- tended back to the community orientation of the Peckham Health Center2 60

COPC in the American Context 61 and the descriptive epidemiology of William Pickles3 in England, and to the development of rural and urban health centers of the Peking Union Medical College by John Grant in China.4 The walls of the examining, consulting, and conference rooms at Polela and Lamontville were lined with charts and graphs of community demography, infant mortality rates, other mortality and morbidity rates, and their changes over time. It was almost impossible not to be aware of denominators when seeing an individual patient. The influence of culture, social structure, and environment on health status and health services was all the more apparent because all three were, to non-African eyes, exotic. Finally, and most fortunately, I did not learn about community organization and health education as didactic subjects. Instead, I had the opportunity tO acquire my sense of community structure and function by seeing patients in the community in their homes, in schools, in clusters of huts on rural hilltops, at the practices of traditional healers- and by working with indigenous community organizers and ed- ucators. Obviously, this experience made me an enthusiast, though I hope not an uncritical advocate. The later work at Mound Bayou and Columbia Point tempered that enthusiasm with an awareness of the difficulty of swimming upstream against the main current of medical care in the United States. And the recent experiences in New York working with health centers that have a constantly shifting constituency, in ill-defined communities, in a wildly irrational "marketplace" of personal health services have con- vinced me that community oriented primary care projects in the United States should be attempted, in the near term, primarily in rigorously defined settings that might permit rational growth and evaluation. As I will indicate, I believe there are more than enough such opportunities. DEFINITIONS: THE IDEOLOGY OF COMMUNITY MEDICINE In all this, I have not yet defined community oriented primary care or examined the definition offered by Drs. Kark and Abramson in their com- panion paper. To do that, I think we must first examine some of the problems in our definitions of community medicine itself. All of us in the field claim to be practicing community medicine, yet some of us assert it is a clinical discipline, while others tend to limit it to administrative and management sciences, policy studies, or epidemiology and behavioral sci- ence.5 Some see it as consultative to primary care; others insist it must be immersed in primary care and point to the community health center de- velopments of the last two decades as complete examples of community medicine and even of COPC. Still others, interested in COPC as an ex- pansion and clarification of the scope of community medicine, would argue that most of the community medicine efforts of the 1960s illuminated the

62 PART I: THEORETICAL ISSUES concept of COPC but did not truly become full-scale community oriented primary care practices. In this view, interest in COPC is not simply nostalgia for the community medicine efforts of the 1960s, and bringing such prac- tices fully into being with the 1980s and 1990s will require us to do a great deal more (and some things differently) than we did then. I believe this ongoing argument over definitions is important, because it reflects something deeper: a long-standing and profound gap between the theoretical discussions and the working practices of community medicine. At its most general level, it is a separation between ideology, methodology, and clinical practice. By "ideology" in this context I mean simply the coherent set of principles or beliefs with which we approach a field of work principles or beliefs that determine the questions we ask, the data we collect, the analyses we make, and the interventions we attempt. The "ideology" of community medicine includes beliefs that are widely acknowledged but then stu- diously ignored in traditional "scientific" medicine. We believe that the biological, social, and physical environments are among the most powerful determinants of health and illness for populations and their individual mem- bers. We insist that in practice every individual patient must be seen and understood also as a member of multiple groups and populations; families, age cohorts, occupational groups, social classes, racial and ethnic groups, geographic clusters, and the like. We know that different populations ex- perience different environments (or experience similar environments dif- ferently, or manifest different behaviors) and are therefore differently at risk of disease. We believe these distributions of risks (or, conversely, of health, or strengths, or resources) call for multiple strategies of intervention. We care about the management of the individual patient, but we also assess patients as numerators, drawn from that local universe of denominators, the community, which requires us to combine curative with preventive or anticipatory medicine and individual with environmental (or even social and political) change. Of course, these are the traditional beliefs of "public health"—that is, of concern for the health status of whole groups, communities, or populations, and not just the patients among them. It is the merger of these public health concerns with the clinical practice of medicine, and their application to the defined and socially coherent groupings we call communities, that creates the discipline of community medicine. By "methodology" I mean in particular the application to organized clin- ical practice of the methods of epidemiology and the behavioral sciences, particularly sociology, social psychology, and anthropology. By "clinical practice" I refer particularly to primary care, provided in organized health care delivery settings the kind of medicine least likely to be indifferent

COPC in the American Context 63 to the causes of disease, bored with prevention, excessively focused on pa/ho-physiologic processes, and preoccupied with the details and refine- ments of technological intervention. Community oriented primary care (COPC) is an attempt, not merely in the abstract but in the performance of a practice of medicine, to end that separation between the ideology of community medicine, the methods of epidemiology and social science, and the provision of primary care clinical . . . services to communities. But this is precisely the claim that has been made repeatedly during the last two decades by one practice or another of community medicine. More often that not, these practices approached, rather than fully realized, a definition of community medicine. Though they had one or more of its essential characteristics, calling them "community medicine practices" con- fused the part with the whole. SIX FALLACIES IN SEARCH OF A DEFINITION This confusion has been so widespread and persistent that it is possible, by now, to identify a whole series of fallacies or errors in the working defi- nitions of community medicine practice. Each one has interfered with the development of a shared understanding of the nature of the field. It is important to review them before examining the operational meaning of something even more specific: community oriented primary care. THE GEOGRAPHIC FALLACY This confuses the practice of medicine in a community with a practice of community medicine. It fails to distinguish between passive community facilities that serve an area simply by virtue of their location (a subway stop, for example, or an emergency room) and active community programs that are based on a partnership with a defined community, a mutual definition of needs and programs, and shared goals. One of itS variants might be called the "underserved area fallacy." This assumes that projects serving low- income or urban minority populations must, by virtue of that characteristic alone, be practicing community medicine, and it has resulted in such pe- culiarly meaningless terms as "ghetto medicine." THE DEMOGRAPHIC FALLACY This assumes that the collection or recitation of denominators and popu- lation descriptors—census data, vital statistics, morbidity and mortality f~g- ures, geographic mapping of patient origins means that this information

64 PART I: THEORETICAL ISSUES is actually being used in a practice and that the practice is therefore targeted effectively at the population or area so described. But in fact, compiling data of this sort is often simply a requirement of grant applications, certif- icate of need clearances, or local health planning agency approval, and neither the grantor nor the grantees ever look at them again. The same is often true of data on other medical care resources in a target area, of information on utilization, of economic and environmental descriptions, and of other elements of community diagnosis. A more explicit and troublesome variant of this fallacy, in my view, is the contention that "the community tO which COPC is oriented need not be a true community in the sociological sense; it may be the people who live in a defined neighborhood, the list of patients registered with a provider of care, the children in a school, or the workers in a factory," or "all members of a local union or a mere collectivity of the practice's clients." These are useful and important aggregates. They are denominators of a special kind, and looking at them immediately carries a practice beyond the one-by-one examination of patients to an epidemiologic framework and an approach to rates. They may be important for such areas as occupational medicine, maternal and child health, health program planning, or quality- of-care audits. They make more sense when a provider has access to a whole community and wants to look at a part, with that larger denominator always in mind. But, with the possible exception of"defined neighborhood," these ag- gregates are not communities, as either health workers or the members of communities themselves understand that term. A practice that carries out such analyses may increase its effectiveness and efficiency, identify unsus- pected problems, and review what it is doing about them, but that does not, per se, make it a practice of community medicine or community ori- ented primary care. It is this willingness tO use the word "community" as a catch-all that has made it the battered child of the literature in social and community medicine, more often abused than respected. THE ORGANIZATIONAL FALLACY This assumes that organized settings of primary care delivery especially the existence of multidisciplinary health teams, outreach workers, and com- munity health workers drawn from the local population- indicate that COPC is happening. The assumption is more likely to be made if the provider's resources also include a management information system for the analysis of utilization, diagnostic and reimbursement data, or a mechanism for bud-

COPC in the American Context 65 geting or health program planning. These are necessary but not sufficient elements in the achievement of COPC. They are present in many programs that do not, or cannot, assume responsibility for the health of a total com- munity or neighborhood. THE COMMUNITY ORIENTATION/AWARENESS FALLACY This is the most difficult to discuss, for I do not mean to suggest that orientation to the community as well as tO the individual, or awareness of a community's characteristics, are fallacious. They are among the most important elements in a practice of community medicine; everything else is built around them. They are the central attributes of the new kinds of physicians (and other health workers), defining their professionalism in new ways, that will be needed, together with profound changes in the structure of the health care delivery system, if community oriented primary care is tO be achieved as the dominant mode of health service delivery. Community orientation and awareness require systematic knowledge of the cultural, subcultural, and socioeconomic characteristics of communities and their members but almost everyone knows, in a general way, whether the community is urban or suburban or rural, middle-class or working-class, transitional or stable, ethnically distinct or polyglot. What is important is systematic use of that information in exploring the health status of popu- lations or delivering health services to individuals: information on family structures, community customs and mores, health belief systems, social networks, definitions of deviance, and systems of help. And also information on aspects of the micro- and macroenvironments: housing, water, sanitation, food, air quality, toxic hazards, and other risk factors. It is community orientation, the process of continually "looking at" or "keeping in mind" the community, that leads to the formulation of health status goals and plans of action for a community as well as for individuals. A community oriented practice almost by definition must know what's going on in its community, epidemiologically as well as socially and in terms of strengths and resources as well as pathology. The fallacy lies in the belief that community orientation and awareness are all or most of what is needed to achieve good community medicine. Community oriented primary care is not just an attitude one holds; it is something one does, a set of actions taken regularly and systematically as part of a strategy for changing the health status of a whole population. If for any reason these actions cannot be taken consistently, orientation and awareness themselves will not suffice to accomplish change.

66 PART I: THEORETICAL ISSUES Nowhere is this more evident than in the experience of many highly motivated physicians who worked in community health centers, Indian Health Service projects, migrant health centers, or the National Health Service Corps. They wanted to do more than respond to the complaints of individual patients suffering from disease; they sought to conserve health in populations as well as restore it in sick individuals. In Julian Tudor Hart's striking phrase, they wanted to move decisively away from the entrepre- neurial physician's role as a"medical shopkeeper," passively responding to customers, treating the sick and discarding the apparently healthy.6 They hoped, instead, to exploit the possibilities latent in everyday practice for the development of community health strategies not just patient care plans longer in time and broader in scope. They came to their work committed to community involvement, to "public health" interventions, and even to social and political activism in relation to health. Further, in choosing community-based care they had freed themselves of the medical establishment's pre-Copernican view of the health care sys- tem, which places the hospital at the center and regards the community (and its primary care providers) as the satellites. This is a view expressed powerfully in our professional language: When patients are in their com- munities, their jobs, and their families, we call them outpatients, and, when they are oat of all these settings, we call them inpatients. But what resulted, in all too many cases, was frustration and burn-out. Despite occasional forays beyond the confines of their offices, they were often overwhelmed by the continual burden of acute illness care, the re- volving door they had hoped to escape, and they could not get beyond the presenting symptom in the sick to the risk factor in the population at large. In recent years, furthermore, if teams existed they. were often cut back; if epidemiologic information was available at the outset, it was rarely main- tained, updated, or used in their work. They discovered, to quote Hart again, that: Anticipatory care is generally available in inverse proportion to the pressure of symptom-demand, and since prevention is most needed where contingencies are most frequent, no serious preventive service is ever able to develop. In the absence of planned care, salvage inevitably takes priority over maintenance. Health services evolving spontaneously in directions determined by the conflict- ing demands of clinicians, each claiming a share of shrinking or stagnant resources, inevitably favor hospital-based salvage, mainly concentrated on acute or what eventually proves terminal illness, rather than on simpler, cheaper care of less advanced disease outside hospitals This process, in many programs, was reflected in inexorable pressure to increase "productivity" that is, to see ever-higher volumes of patients for reimbursable acute curative care in shorter periods of time and by cutbacks

COPC in the American Context 67 in the nonreimbursed services that are essential to a community oriented program: outreach, epidemiologic study, risk factor surveillance, community organization, and health education. The basic problems faced by these physicians (and other health workers) in practicing community oriented primary care were not those described by Mullan,7 or reported earlier by Geiger,8 Gordon,9 and others in dis- cussion of community conflict. They were, rather, the absence or insuffi- ciency of the other elements of COPC, particularly the community-based epidemiology. THE COMMUNITY INVOLVEMENT FALLACY In the United States, the usual meaning of"community involvement" and "accountability" is a community board, either advisory or with real budgetary and programmatic control, and a staff drawn in part from local community residents. But these are very different than a full-fledged ongoing process of community organization and health education, and they do not in them- selves unleash the strengths latent in almost every community and create "the vigor possible when a community is mobilized for an agreed social objective."6 That vigor and intensity of effort were often expressed when new health facilities or programs were sought for a community, but it frequently proved difficult to maintain them once programs were in op- eration and access to acute care was established. In recent years, there has been growing recognition that the first locus of primary care decisions is not in health services at all, but in families, social networks, and basic community institutions such as the church. The task can be redefined: It is not simply to involve the community in the programs of a community oriented practice, but rather to involve the practice in basic processes and structures within a community. (Community medicine practices have been guilty of their own pre-Copernican views.) This is the real significance of the development of organized lay referral networks, the training of "health facilitators," and the systematic enlistment of churches and other commu- nity-based institutions in health education and case-f~nding.~° They have the potential to create "agreed social objectives" in relation to health in . i` . . specific commumtles. THE EPIDEMIOLOGIC FALLACY In a modest number of organized settings of primary care delivery, careful and solid epidemiologic studies have been conducted, usually with special research funding. The participant sites in the national Hypertension De- tection and Follow-up Program are good examples.ll A few health centers

68 PART I: THEORETICAL ISSUES have managed to complete annual or biennial household-by-household cen- sus listings of their communities and to use them for specific disease or risk-factor studies. Others have used vital statistics from traditional sources to plan their programs. Some are located in geographic areas that were selected for epidemiologic investigation by health departments or academic centers, and a few have active affiliations with such centers. The mere existence of epidemiologic projects does not necessarily mean, however, that the primary care practices themselves the routines of office practice, the work of health care teams, or data from outreach workers are collected in standardized ways according to a common protocol and added in as contributions to epidemiologic investigation. Neither does it necessarily mean that the results of population-based studies are system- atically reflected either in the programs of practitioners or in the work of community organizers and health educators. Epidemiology does not always reflect community involvement. Even where the will exists, barriers may be created by the pressures of acute care, limitations of funding, academic versus practitioner conflicts, or problems of the confidentiality of medical records. I have described these fallacies or imprecisions of definition at such length not to denigrate the activities they represent, each of which, by itself, is a substantial component of clinical community medicine in practice. Neither do I intend to set so rigorous a standard that we will be forced to conclude that "true" community oriented primary care does not now exist anywhere and is impossible of achievement. My purpose is to emphasize that if we are serious about COPC we cannot settle for less than all its essential components, linked by specific techniques as described by Hark, Ben- nett,~3 and others. It would be as dangerous to the development of COPC as it has been, on occasion, to the general understanding of"community medicine" if we are overgenerous in defining it. CRITERIA FOR COMMUNITY ORIENTED PRIMARY CARE With these fallacies in mind, let us turn to the recent definitions of COPC. Kark has defined it as a clinical practice that brings together those aspects of personal health care and of community medicine that are suitable for application in primary care. Some basic features include: . complementary use of epidemiologic and clinical skills; a defined population; . programs designed to deal with the health problems of the community or its subgroups in the primary care framework;

COPC in the American Context 69 . community involvement in both governance and implementation of the practice; . geographic, fiscal, and cultural accessibility; and . integration of curative, rehabilitative, preventive, and promotive health care. Madison and Shenkin emphasize the orientation/awareness dimension in their definition of a "community-responsive" practice as: . . . one which assumes a larger than ordinary share of responsibility for safe- guarding the health of the community, and which follows through on this re- sponsibility of taking action beyond the traditional mold of treating the com- plaints and problems of patients as they approach the practice one-by-one. Such action must start from the consciousness of community the notion that there exists some denominator of people from which come those who present at the practice seeking care. The community with which the practice is concerned may be socially defined (e.g., a country, a town, a neighborhood, all members of a local union, all migrant agricultural workers and their families within a two- county area) or it may be a mere collectivity of the practice's clients whether or not they emerge as a social grouping. In either case this consciousness of com- munity together with the awareness of its general health status and some of the problems that affect it is what allows the practice to formally plan activities aimed at designated target populations (e.g., prenatal care, health education programs, nutrition counselling, the care of groups of people at specific risk or sharing a common affliction.~4 At first glance, these definitions seem strikingly familiar. There is little new about calls for epidemiologic investigation, for the incorporation of behavioral science knowledge into clinical practice, or about the idea of community-as-laboratory. The initial proposals for neighborhood health centers, among many examples, spoke explicitly of defined populations, epidemiologic surveillance, and the merger of"public health" concerns with those of patient-centered clinical practice. They cited demographic data as denominators, used indicators of health status to characterize entire pop- ulations, and clearly were based on a consciousness of community. They were comprehensive in their definitions of health care, proposed the use of multidisciplinary health teams, stressed involvement of the community, and emphasized the removal of geographic, financial, and other barriers to access. Similarly, epidemiologic investigations of discrete communities have be- come almost commonplace in the United States. The classic Tecumsehi5 and Framinghami6 studies are only the most familiar of many examples. Some of these investigations have originated in health centers the East Boston studies of chronic lung disease,~7 the Rochester studies of pediatric

70 PARTI:THEORETICALISSUES illness,18 the Baltimore studies of streptococcal infection19—and have been community-based rather than limited to populations of health center users alone. The recruitment and training of community members as outreach workers has characterized many epidemiologic and primary care projects for at least two decades in the United States, three decades in the United Kingdom (for example, Cochrane's studies of the pneumoconioses in the Welsh min- ing valleys in the early 1950s), and for still longer at some health centers in developing nations. Is COPC, then, merely a repetition of these projects, a return to the 1950s and 1960s after all? I think not. What, then, is new about these definitions of COPC? I suggest that it is the synthesis, the assembly of these familar components into an ongoing whole and the insistence that all these elements of community orientation, demographic study, epidemiologic investigation, personal medical services, en?>iror~mental intervention, community organization, and health education be performed loy the same practice or team, or at least by a small number of practices and health agencies working as a single system (not just "coordinated". It is not just having all the parts, but closing the loop that links them. It is this synthesis that would permit the conduct of a daily primary care practice to become part of an epidemiologic investi- gation, or permit epidemiologic data to be used as the basis for the addition of specific new routines to office practice, tO community outreach, or tO health education. Community oriented primary care, then, is an approach to medical prac- tice that undertakes responsibility for the health of a defined population, by combining epidemiologic study and social intervention with the clinical care of individual patients, so that the primary care practice itself becomes a community medicine program. Both the individual patient and the com- munity or population are the focus of diagnosis, treatment, and ongoing surveillance. In COPC as in conventional primary care, for example, the goal for an individual hypertensive patient is detection, reduction of elevated blood pressure, and ongoing control; but, in a community oriented primary care practice, there is a further goal of determining the distribution of blood pressures in the population served (or potentially served) and intervening to shift the curve of that entire distribution to the left. In addition to the stock of biomedical knowledge, which is the core of every clinical practice, this requires the incorporation of at least two additional bodies of knowledge and their pragmatic application in practice: epidemiologic science and be- havioral science. The former is necessary for community diagnosis, problem definition, and a strategy of intervention. The latter is necessary to foster community participation in diagnosis and problem definition and to accom- plish changes in community knowledge, attitudes and behaviors, and med- . ... . lca . care utlllzatlon.

COPC in the American Context 71 The lack of this functional synthesis in practice has meant, over and over again, that the potential contribution of one or another of the components of a community oriented practice goes to waste because the feedback loop fails to close. Repeated and extensive epidemiologic studies described the changing nature of childhood illness in Rochester, but, as Pless and Pekeles20 discovered, that did not make any discernible difference in the actual per- formance or practice orientation of Rochester pediatricians. Epidemiologists at a health center may study the distribution of respiratory illness in a community in relation to environmental factors in the homes, but that in itself does not assure that there will be a systematic effort on the part of the health center's primary care teams to inquire about those risk factors, nor does it necessarily lead to organized feedback of information tO the community itself in an effort tO reduce or eliminate those at risk. A city health department may conduct an elegant study of the distribution of teenage pregnancies or low-birth-weight infants in a large poverty area; a hospital or health center in that area may use the data in organizing itS outreach, family planning, prenatal care, and pediatric services. But that is not the same as a structured, reliable process of planned intervention by all of the area's primary care practitioners. It does not mean that protocols of definition, reporting, and treatment will be followed, that continuing surveillance will occur, or that evaluation and modification of existing pro- grams will be possible. In hypertension control, several studies of primary care practices have shown that only about 50 percent of men in their forties had their blood pressures recorded even once over a 10-year period.2i An audit of the care of known diabetics in 38 primary care practices found that 52 percent were not getting supervision from any source, and 40 percent had had no retinal examinations during the previous 2 years, let alone the hours of teaching necessary for the education of patients in the nature of their disease.22 Similar results were found in samples of patients with epilepsy and with lower respiratory tract disease. Until recently, community-based studies in the United States showed that half of those with blood pressures in the range mandatory for treatment were not known, half of those known were not treated, and half of those treated were not controlled. In hypertension, at least, we now know that when the care of identified patients is referred to individual practitioners in an uncoordinated system, there is a real and measurable cost in preventable mortality. These gaps and failures are not caused solely by incompetence, or by willful refusal to care about community health. If we are to be more than merely hortatory, we must recognize that they are also the direct result of our definitions of medical professionalism the roles and tasks that doctors define as their work—and of the organization, structure, and financing of the health care system in the United States.

72 PART I: THEORETICAL ISSUES COPC AND THE UNITED STATES SYSTEM: A PROBLEM LIST There is a major difficulty, for us, with these definitions of COPC. They are inconsistent with the political economy of mainstream American medical care. They are written in other voices, describing other rooms in the house of medicine. We do not have regionalization of primary care, with registered patients and clearly defined populations eligible to use a specific practice, and there is no way for a single practice to "accept responsibility for the health of a community," in most instances, even if it wanted to. We have multiple competing providers, selling personal health services to individuals or small groups, not communities. These diverse providers private prac- titioners, hospital-based or free-standing medical groups, hospital-based out- patient units and emergency rooms, community health centers and the occasional health maintenance organization—are linked loosely, if at all, through referral mechanisms, but not for purposes of data-sharing, program development, surveillance, or risk-factor reduction. The reimbursement system offers almost no incentive for cooperation, but many for competi- tion. Reimbursement is overwhelmingly for acute episodic curative care rather than for preventive or health-promotive services, let alone for epi- demiologic and demographic studies, household surveys, outreach efforts, community organization, or health education. Most American communities are not anyone's defined population for medical care. Most American consumers of medical care—the term itself reflects the structure of the system—do not regard themselves as part of anyone's defined population. For most people, a sense of belonging to a community does not extend to the process of seeking medical care; there is no perception of shared risks, problems, or goals, except in the face of major environmental hazards or a widespread lack of access to care for geographic or financial reasons, or because of health manpower shortages. A single family may regularly consult a pediatrician, an internist, and one or two subspecialists, unconnected with each other and located outside the immediate community. In urban areas, a single city block may house a thousand such families, using several thousand physicians and a dozen hos- pitals among them. Outreach efforts and household surveys may be seen by such families as an aggressive intrusion and an invasion of privacy; they have not decided to be part of any practice's community program. And the clientele of any one practice may be drawn from a dozen areas, different neighborhoods and communities, and be as diverse as any clientele of marketplace shoppers. Information on the diagnoses, risk-factor distri- butions, or medical care utilization of such a clientele, even if a practice cared to calculate and analyze them, would refer to no recognizable com-

COPC in the American Context 73 munity denominator and yield no community-based rates. By provider and consumer alike, medical care is seen in the main as a commodity, not as an intervention in the health status of a community. This is as true of groups and organized primary care providers as it it is of solo practitioners. In implicit recognition of the political economy of health care, the approach by such groups to the "community" tends not to consider states of health or needed interventions, but is couched instead in terms of targeted mar- keting, market potential, and market penetration. A further barrier tO the development of COPC is the extraordinary mobility of American populations. U.S. census studies show that between 1975 and 1976, 40 percent of the population moved at least once: 72 percent of those 25 to 29 years of age, 63 percent of those 20 to 24, 60 percent of children 1 to 4 years old, 51 percent of children aged 5 to 9, 21 percent of noninstitutionalized adults aged 55 to 64, and 18 percent of those aged 65 to 74.23 These data, if anything, understate mobility, since they count the number of people who have moved, not the number of moves. The epidemiologic studies necessary for effective COPC are much more difficult when the denominators are in constant flux. Something more is involved here, however, than the organization and financing of care. For three decades, the British have had a system more rational than ours: a national health service, capitation payment of physicians rather than reward for redundant and expensive procedures, a crude kind of regionalization, relatively stable practitioner lists with small turnover rates, and the removal of financial barriers to access. As in the United States, there has been an increase in utilization of physician services by the poor, to approximate or even exceed utilization by the more affluent (though not when controlled for state of health; the sicker poor are now only seeing physicians at the same rate as the healthier wealthier). Yet the problems of health manpower shortages in the inner cities of Great Britain, and the difficulties of relating primary care practices to the needs of low-income areas, are strikingly similar to those in the United States. What is more, a recent study of inequalities in health status in the United Kingdom showed a pattern of persistent and sometimes widening differ- ences in mortality between the social classes.24 The study notes that "despite the creation and the influence of the National Health Service, the health of those in the lower social classes has improved much more slowly than the health of the more affluent." The "lack of improvement and in some respects deterioration" of working class health has been striking over the last 20 years, particularly with regard to the long-term effects of inadequately treated childhood disease; the greatest social class differences are in pre- ventive services and child health. If the mortality rates of the wealthy had

74 PART I: THEORETICAL ISSUES obtained among the poor, 74,000 lives of people under 75 would not have been lost during 1970-1972. This estimate includes nearly 10,000 children and 32,000 men aged 15 to 64. It would be easy to interpret these data simply as supporting that radical critique of scientific medicine that argues that medical care itself can have little or no effect on the incidence and prevelance of disease in populations and that the power of the social, physical, and biological environments is all-determining. But as Hart has argued,6 the likelier explanation is that scientific medicine- in its fullest sense of anticipatory care and planned efforts at risk reduction has not been applied to whole populations, be- cause the current organization of medical care does not support such efforts and physicians are uninterested. So long as the practitioner remains in the shopkeeper role, focused on episodic curative activities, the outcomes are not very different: Increased curative medical activity in the United States generates profits and in Britain generates taxes, but in neither case does health status improve. A measureable contribution of clinical practice to improvement in the health status of populations can hardly be expected until there is real regionalization, reward for preventive services, a merger of"public health" and clinical medicine concerns, more community med- icine training of physicians and other health workers, and the provision of outreach and epidemiologic resources to practitioners. Thus, for the long run, the widespread implementation of COPC in the American house of medicine will require transformations both in the struc- ture of the system and the orientation of its work. Some would suggest then that rigorously defined COPC must await the evolution of a fully regionalized, totally accessible, preventively oriented noncommodity health care system. Instead I wish to focus our attention on something less than that millennium. What do we do until the evolution comes? STARTING WHERE WE ARE, WITH THE PEOPLE AND PROGRAMS WE HAVE If we list the existing models of COPC that meet most of the Kark and Abramson criteria, attempt to close the loop between community-based epidemiologic investigation and the interventions of providers, and include all the components of clinical community medicine practice, we discover that they share a number of characteristics. Most of them are overseas. Almost all of them exist in systems of medical care that provide wide access to care and remove fiscal barriers, rather than in entrepreneurial market- place systems. Even where this is not so, whether in Western industrialized nations or developing countries, they serve clearly defined communities in the true social sense of that term, and they are usually the major (if not

COPC in the American Context 75 the only) source of primary care for those communities. Both the popu- lations and the providers the staffs—are relatively stable, with low turn- over. Most of these COPC practice models are linked to an outside source of expertise and have additional special funding for epidemiologic and behavioral science study of their communities: an academic department of a medical or public health school, a health department, an epidemiology research unit, a medical research council. It follows that these are the settings and characteristics we should look for first, even if we cannot duplicate all of them, in selecting opportunities for the further development of our own versions of COPC in the United States. I say "further development" even though I have argued that we have few if any existing American community practices that meet the definitional criteria for COPC (unless we are to revert to fallacious or partial definitions). Rigor need not induce nihilism; we already have many practices that pres- ently have some or many of the elements of COPC practices that, despite the difficulties and limitations imposed by our medical care system, are already partway there. A substantial number of them are in the kinds of settings that might permit the rational further development and evaluation of COPC. We have reason to believe that they are already effective in terms both of cost control and of impact on health status in their com- munities. As I hope to show subsequently, we now have evidence that even a partial shift toward organized, community-based care and a preventive/ anticipatory orientation—a change of structure and a change of heart—can have highly significant effects on health outcomes. The reports of the Na- tional Health Service Corps and the Rural Practice Project to name just two—are alive with evidence that there are many health workers, in many programs, struggling to develop community oriented practices. It makes sense, then, to start where we are, with the people and programs we have, in furthering the development of COPC. Some of these practices with the best potential for COPC are publicly funded; others are in the private sector. A disproportionate number are in underserved areas that have proved unprofitable for medical entrepreneurs. Where they are urban, those with the best potential serve well-defined communities that are relatively homogenous and tend to be socially or geographically isolated. In rural or small-town settings, some are the only providers of care. They include community health centers, singly or in networks; urban and rural health initiative projects; migrant health centers; rural and small-city group practices; and community hospital-based primary care practices. Since community health centers are the most numerous and the best- studied of these (indeed, they are by now a distinct, if small, part of the total U.S. health care system), we should look briefly at their history and

76 PART I THEORETICAL ISSUES development, their achievements and failures, with a special focus on three questions. To what extent did they achieve COPC? What accounts for their success or failure in this respect? What would be necessary to change or add now to further the process? COMMUNITY HEALTH CENTERS AND COPC: HISTORY AND IMPACT It is hardly surprising that the initial community health center suggestions were written in the language of COPC, for as I indicated at the outset they were derived directly from COPC models overseas.25 At the same time, they were extensions and reformulations of either proposals in the United States, dating back at least to the recommendations of the Committee on the Costs of Medical Care in 1932, and they stood on the shoulders of traditional public health clinics and such special ventures as the Navajo- Many Farms project.26 The first health center proposal to the Office of Economic Opportunity27 stated that its purpose was "to intervene . . . in the cycle of extreme poverty, ill health, unemployment and illiteracy by providing comprehensive health services, based in multidisciplinary community health centers, oriented to- ward maximum participation of each community in meeting its own health needs and in social and economic changes related to health." The proposed health services were to "include preventive, curative and health education programs in new patterns of medical care organization." They were to "emphasize the formation of community health association . . . to stimulate change in family and community knowledge and behavior relating to the prevention of disease, the informed use of available health resources, and the improvement of environmental, economic and educa- tional factors related to health." Community health action was also defined as including "the training of local personnel" and "the conduct of both descriptive and analytic research on health levels and needs . . . and evaluation studies." The proposal was based on the premise that: Conventional approaches to health improvement . . . that deal only with narrow definitions of health and illness are unlikely to make major changes. The need is not merely for the provision of more preventive and curative health services, but also for the development of new organizational patterns to make the distri- burion of such services uniquely effective.... The need is not for the distribution of services to passive recipients, but for the active involvement of local popu- lations in ways which will change their knowledge, attitudes and motivation. The central focus is . . . community-based health improvement. All of the first wave of health centers (in Boston, Mississippi, Chicago,

COPC in the American Context 77 Los Angeles, Denver, and New York) shared this orientation. They pro- posed to have defined communities, to focus on the community as a whole from a base in the community. They planned tO use epidemiologic skills in community diagnosis and surveillance, tO provide comprehensive curative and preventive care, to remove barriers to access, to foster active community involvement, to define health care broadly, and to form health teams. Now, some 17 years later, there are 872 such centers, serving some 4.2 million people; of these, according to a 1976 survey,28 71 percent were poor, 80 percent were minority, 49 percent had no employed family mem- ber, and 41 percent were under lain sum, the population that has the highest health risks; the greatest burden of illness, disability, and preventable death; the least access to primary care; and the highest rates of hospitali- zation. Efforts to describe and evaluate community health centers now constitute a substantial body of studies. These studies show that, for their client populations, community health centers bring dramatically increased access to primary care, and in some instances utilization by a large proportion of their target populations. At the Bunker Hill Health Center in Charlestown, Massachusetts, for example, in a single year services were used by 52 percent of the 16,800 people in the target population, including 75 percent of the children and adolescents; most were continuing users of the center.29 Health centers sharply lowered the use of emergency rooms. For primary care services, they were com- petitive or significantly lower in cost than hospital outpatient departments, clinics, and large prepaid group practices. Perhaps their most striking and best-documented effect was in lowering the rate of hospital admissions, achieving hospitalization at earlier stages of disease, reducing the lengths of hospital stay, and lowering the number of hospital days per capita. More than 30 studies show reduction in admission rates as high as 44 percent and reduction in hospital days per capita ranging from 25 percent to as high as 62 percent.30 One recent analysis, based on surveys in five communities (Atlanta; Bos- ton; Charleston, South Carolina; Kansas City; and East Palo Alto) involving some 20,863 persons, showed that annual days of hospitalization per capita were 50 percent lower for community health center users than for those using outpatient departments and emergency rooms as their primary source of care and 31 percent lower than those who used private physicians as their primary source, holding constant the effects of age, sex, race, edu- cation, income, insurance coverage, and health status.3i Another recent study compared Medicaid beneficiaries (AFDC recipients), using commu- nity health centers as their primary source of care, with similar Medicaid recipients using other sources of care in each of three communities. Hos- pitalization rates of health center users were only 52 percent of nonuser

78 PART I: THEORETICAL ISSUES rates; their patient days per capita were only 60 percent as high. Outpatient department and emergency room use was dramatically lower among the health care users.32 As might be expected, given these patterns, total per capita costs to Medicaid of community health center users were significantly lower for ambulatory care, for hospitalization, and for all medical care. The total costs per person per year were 6 percent, 31 percent, and 45 percent lower in the three communities. There is no reason to believe that these costs savings were the result of reductions in the scope or quality of services. On the contrary, the range of community health center services was usually broader, and repeated audits have shown the quality of health center services to equal those of traditional providers. Perhaps the most important studies, although they are methodologically the most difficult, are those that demonstrate a significant effect of health centers on the health status of their target populations. One recent multiple regression analysis of data from comparable counties, comparing those with and those without a community health center, suggested that, overall, the health centers had accomplished a significant reduction in infant mortality rate, particularly for blacks, and in neonatal mortality.33 Overall, the re- duction attributed to health centers was 2 deaths per 1,000 live births for blacks—or 10 percent of the black infant mortality rate in these counties. Reducing the excess mortality rate of black babies had been identified as a goal of public health policy for a number of years. The study noted that "community health centers have the potential to make a substantial con- tribution to the achievement of this goal." Moreover, this can be done at a very favorable cost-benef~t ratio in comparison with other programs to reduce infant mortality, such as the construction and subsidization of neo- . . . . natal intensive care units. Other studies have suggested striking reductions in infant mortality in rural southern counties served by community health centers,34 in a health center population in Denver,35 and in Dade County, Florida.36 A New York study reported a 37 percent decrease in the perinatal mortality rate over 4 years, a 29 percent decrease in the prematurity rate, and an accom- panying decrease in neonatal mortality.37 Finally, a survey of low-income census tracts in Baltimorei9 over a 10-year period showed a 60 percent reduction in the incidence of rheumatic fever—a change attributed to early detection and treatment of streptococcal infection in those tracts served by community health centers. We can contend with good reason, then, that health centers: . have been highly effective in increasing access to primary care;

COPC in the American Context 79 . have changed patterns of primary care utilization in desirable ways; . have reduced hospitalization; . have reduced costs; . have maintained quality of care; . have achieved good "market penetration" and continuous coverage of their target communities; and . have made measurable (and sometimes striking) improvements in the health status of populations at very high risk of illnesses. But at present we can say almost nothing specific about the extent to which these results are the consequence of the use of elements of COPC in the centers' programs, or about the relative impact of different elements. In fact, different health centers have varied widely, one from another and over time, in the extent to which they employed epidemiologic analysis, used health care teams, mounted community organization and health ed- ucation efforts, completed risk-factor surveys, or organized campaigns for environmental change. Variation in COPC: Two Examples Two brief examples will illustrate the range of variation that has always existed. In one case, a health center was organized with the explicit goal of meeting a community's needs for primary care medical services and at the same time developing an epidemiologic research program for studying high prevalence chronic diseases in the total community. In the other case, a health center accomplished little in the way of continuing community surveillance and epidemiology, but made major efforts at community ori- ented environmental, health education, and training programs linked to primary care delivery. The East Boston (MA) Neighborhood Health Center developed as a specific partnership between the community, which badly needed accessible primary care services, and the Channing Laboratory, Affiliated Hospitals Center, Inc., of Harvard Medical School, one of the nation's most pro- ductive epidemiologic research centers. The center notes that: As early as 1966, East Boston was identified as an ideal community for longi- tudinal studies of high prevalence chronic diseases such as hypertension, chronic lung disease and bacteriuria because of its geographic isolation, table population (less mobility than any other area of Boston) and strong sense of family and community.... The community based total population studies which have been developed and conducted in East Boston all have been done under the aegis of and by the staff of the East Boston Neighborhood Health Center. The Health Center is governed by a Board of Directors made up of community residents who receive their health care from the center. They have reviewed and approved

80 each study which has been conducted. process the following criteria have been . . . PART I: THEORETICAL ISSUES In this Community Board's review applied to epidemiologic research done in the community (1) Is the topic of research important to them as individuals and as a community? (2) Are the research methods acceptable as applied to themselves, their families and their neighbors, in terms of comfort, convenience, safety, and expected benefits? (3) Will some specific measurable benefit accrue to the community as a result of participating in the research program, in terms of identifying and providing referral and/or service for those with health or social needs, in terms of making new or improved services available for the community or in terms of improving the ability of the Health Center to attract funding for improved services in the future?38 In the 10 years between 1970 and 1980, staff of the center and colleagues at the Channing Laboratory (many have joint appointments) have published more than 60 scientific papers on the East Boston community: studies of hypertension (the center is one of the participating sites in the National Hypertension Detection and Follow-up Program), bacteriuria in women, oral contraceptive use and bacteriuria, oral contraceptive use and fasting triglycerides, plasma cholesterol and HDL cholesterol, household aggre- gation and household risk factors in chronic nonspecific lung disease, sur- veillance techniques for respiratory illness, and familial aggregation of chronic bronchitis. In the area of hypertension alone, the East Boston studies have included familial aggregation of hypertension, longitudinal studies of blood pressure in childhood, studies of blood pressure in newborn infants and their mothers, and methods of community hypertension screening. At the same time, the health center has offered services in internal medicine, pediatrics, adolescent medicine, obstetrics/gynecology/family planning, emergency service, home care, dental service, social service, nu- trition, and public health nursing, together with the usual support services. Its "market penetration" of the community is extraordinary; there are only two other primary care providers in the community, and last year the center provided 111,000 visits to 27,000 persons out of the total East Boston population of 32,000 people. The center conducts a total household-by-household census of the com- munity every 2 years. Some of the center's staff provide only direct primary care services, others are exclusively involved in epidemiologic research and analysis, and others do both. A major part of the funding for the census, the surveys, and epidemiologic analyses comes from research grants rather than from the medical services budget drawn from federal health center grants and third-party reimbursement. The center's publications do not describe in detail the ways in which the community oriented feedback loop is closed: the incorporation of practice data into the epidemiologic work, the transfer of epidemiologic information to center practice, the routines of risk factor surveillance in providing pri- mary care to patients, or the linkage of all of these to community organi-

COPC in the American Context 81 cation and health education efforts or specific environmental interventions. Clearly, however, the mixtures of staff appointments and funding for both research and service suggest that this takes place. The Delta Health Center, in contrast, was designed to serve a population of some 14,000 rural black residents in a 500-square-mile area of northern Bolivar County, Mississippi. More than half of that population was clustered around the base town of Mound Bayou and nine other small communities; the rest were scattered in rural areas. The population was characterized by extreme poverty, high unemployment as a consequence of the mechani- zation of cotton agriculture, low educational levels, an extremely high infant mortality rate, and heavy burdens of both infectious and chronic illness. There was a high dependency ratio: a large and relatively stable population of young children and the elderly and a shifting population of young and middle-aged adults, particularly men, moving back and forth (to places as far away as Chicago) in search of work. The environmental hazards were extreme. More than 75 percent of the dwellings were unfit for habitation, without protected water supplies and with surface privies for sanitation and unshielded small stoves for heat; many had no electricity. Cotton agriculture meant that exposure tO pesticides was frequent. Malnutrition was a major problem, and support services (welfare, food stamps, etc.) were minimal to nonexistent. The physician-to-population ratio was very low, and access to care was severely limited by fiscal barriers and lack of transportation. The center had a strong affiliation with a medical school, but the school was 1,500 miles away. No special funding was available for demography or epidemiologic research. A total community census was accomplished once, early in the center's development, but never repeated; a community-based epidemiologic survey of malnutrition in children was completed, but did not lead to ongoing surveillance. Studies of medical care utilization and of environmental hazards were conducted regularly in the three sectors into which the target area was divided. In these circumstances, only a very small fraction of the center's resources was devoted to epidemiology. The major effort, aside from the direct provision of personal health services tO individuals and families, went into other programs. These included: Clinical Services Nutrition Services Family Practice Medicine, Pediatrics, Ob-Gyn, Emergency Services, Minor Surgery, Com- munity Health Nursing and Nurse-Midwi- fery, Home Health Services, Homemaker Services, Mental Health Services (individual and group counseling, diagnostic psycholog- ical, and educational testing) Emergency Food Program, Food Stamp and

82 Environmental Services PART I: THEORETICAL ISSUES WIC Programs, Organization of Cooperative Farm, Nutrition Counseling Well-digging and Hand-Pump Installations, Construction of Sanitary Privies, Home Care Package for Acute and Chronic Illness (po- table water supply, chemical commode, hos- pital bed, and washing machine), Home Man- agement Counseling, Housing Repair (roofs, screens, steps, stoves), Vector Control, En- vironmental Laboratory, Environmental Health Education Community Health Action Local Health Associations, Community De- velopment, Transportation Network, Legal Services, Day Care and Pre-Headstart Pro- gram, Maternal and Child Health Outreach (high-risk pregnancies and newborns), Health Education Social Casework, (assistance in welfare, food stamp, Medicaid and Medicare eligibility), Family Services for Youthful Offenders, Community Programs for the Isolated Elderly Social Services It was an explicit goal to transfer as many of these programs as possible to local community management. Thus, the North Bolivar County Farm Cooperative, Inc., ultimately owned, managed, and operated a 600-acre farm, collectively worked by members of some 1,000 families. Visits to the health center for personal health services in any time period were usually exceeded by individual participation in local community health association activities or by community development, health education, housing repair, and other environmental programs. One study showed that, on the average, some 3,000 individuals each month had contact outside the health center, in the community, with field staff. Since the primary care health teams that served each sector included not only the clinicians, but also sanitarians, social workers, health educators, and other field staff, there was fairly regular and accurate transfer of information between clinical and community pro- grams. Perhaps the most important of the center's activities, in the longer run, was the least conventional. On the premise that the community's own human resources were its most important asset for change in health status, the health center provided, facilitated, or arranged for the preprofessional or professional training of community residents. These programs ranged from high school equivalency certification and college preparatory courses at the center to arrangements that sent 13 local residents to medical school, about

COPC in the American Context 83 20 to nursing programs at the LPN and RN levels, and enabled others to obtain certification as sanitarians, physical therapists, medical record librar- ians, x-ray technologists, and the like. Altogether, more than 100 people participated; more than half are back in Mississippi, many in Bolivar County and many at the center. East Boston and Mound Bayou, perhaps, represent the extremes of di- vergent approaches to COPC in the community health center movement. One is an epidemiologic model and the other a community development model, though both are organized around the provision of primary care clinical services to defined communities. Hundreds of other community health centers (and a modest number of health maintenance organizations and rural primary care practices) are located toward the center of the spec- trum and represent varying opportunities for the further development of COPC; the diversity is such that no single, uniform model for COPC development will suffice. A very substantial body of experience in health center, rural practice, and group practice programs has been accumulated over the last two decades, but—despite the richness of the documentation of their overall impact- there has been very little systematic evaluation of the effectiveness of the separate components of COPC in changing health status. A new round of experimentation and innovation is in order. SOME SPECIFIC PROPOSALS What should be the general direction and content of steps to further the development of COPC in the United States? What follows are a few general proposals, very conventionally grouped into (1) education and training and (2) service delivery. EDUCATION AND TRAINING A number of undergraduate medical educational programs focused on COPC are already in existence at the University of New Mexico, the University of Arizona, the University of Nevada, and other schools chiefly serving rural areas, and at the City College of New York, serving inner-city areas. In addition, students at any medical school, given motivation and oppor- tunity, are likely to find elective clerkships in the United States or overseas that will give them an introduction to community-based epidemiologically oriented practices. Undergraduate programs in COPC, like later forms of training, may suffer from lack of contact with practices in the community and from the marginal role of many departments of community medicine in traditional medical schools. What may be more important is the long gap between undergraduate medical education and clinical practice a gap filled not only with intensive (and, I hasten to emphasize, necessary) technical

84 PART I: THEORETICAL ISSUES education but also with what I have elsewhere described as the latent curriculum of medical education,39 emphasizing tertiary care, subspecialty practice, and the rewards of the prevailing structure of the medical care system. Most medical students learn epidemiology as a didactic field, un- leavened by the admixture of clinical cases or by contact with the problems of a real defined community, in their second year. Six or more years later, when they begin practice, it has often been forgotten. Schools that em- phasize primary care, or serve defined communities or otherwise orient themselves toward population-based medicine, may nonetheless have little involvement with community and little influence on the structure of the local medical care delivery system. We need to know more about the impact (if any) of undergraduate training on the system and on the production of change agents with M.D. degrees. At least as important is the training of COPC health workers other than physicians: nurses and nurse practitioners, administrators, social workers, and community organizers. Without opportunities for working in teams and without field areas in defined communities, their education is likely to be restricted to the acquisition of traditional technical skills for traditional technical roles. Graduate medical training may offer richer opportunities, particularly if preventive medicine residencies are reunited with clinical practice and if family medicine residency training includes significant amounts of time in practices serving defined communities. This is the optimal time for the teaching (or reteaching) of epidemiology and for the demonstration of its use in the assumption by a practice of responsibility for a community's health status, and not just that of individual patients. The status of schools of public health in the United States continues tO be troubled. They are only now beginning tO define COPC as a specific area of interest. Even more than medical schools, they lack defined com- munities in which they have committed themselves to work with all primary care providers. But there is no intrinsic barrier to such affiliations, and- given them—curricula could be devised for two kinds of 1-year programs: the traditional combined M.D.-M.P.H. study (but preferably after the third year of medical school, to permit prior participation in clinical work) and a merger of M.P.H. study with a residency year or years. The importance of academic links to community oriented practices has already been men- tioned. In addition to links with medical school departments, as described by Kass and Taylor,38 Morrell and Holland,40 Deuschle and Bosch,5 and others, such links should also be forged between schools of public health and organized settings of primary care delivery in defined communities. A special problem, and a special opportunity, is represented by the Na- tional Health Service Corps (NHSC). Had it grown and developed as

COPC in the American Context 85 planned in the late 1970s, there would have been, within a few years from now, some 20,000 corps physicians, dentists, and other health workers in the field, many in settings suitable for COPC and with some of its elements already in place. The early experience of the corps, and the testimony both of its administrators and its field staff, indicate the deficiencies of under- graduate and graduate training as preparation for the community dimensions of corps work. The NHSC—on the assumption that it will ultimately grow and flourish—needs its own educational and research center, playing a role for corps personnel analogous to the role played by the CDC for Epidemic Intelligence Service officers. Alternatively, the same functions could be provided for corps personnel by a regionalized network of academic de- partments on contract to teach, trouble-shoot, circuit-ride, provide formal continuing medical education for COPC, and assist in the conduct of re- search at NHSC sites. I have said little about the content of undergraduate or graduate training for COPC, beyond the need for experience in real primary care practices in real communities. The requirement for epidemiology is obvious. The social sciences, usually taught in relation to the management of individual patients or with diffuse reference to cultural differences between com- munities, have a different meaning to physicians confronting the realities of house-to-house surveys, community organization, and health education in the world outside the hospital or health center. The structure and dy- namics of team practice are already taught in some residency programs, but deserve much wider exposure, as do management, program-planning, and fiscal skills. This list approximates the training given to physicians with clinical experience who are to become community medicine district officers in Britain's National Health Service: epidemiology, operations research, the organization of medical care, and management. But, I believe it would be a terrible and regressive mistake in the United States to create a special category of physician, removed from clinical practice, to carry responsibility for COPC (and, by implication, immediately to relieve everyone else of responsibility for it); tO do so would lead inevitably, as in Britain, to the charge that this is a make-work job, for those who can't work as clinicians, that makes unnecessary work for those who can. If the proposal for a center for the corps is to be taken seriously, profes- sional organizations with experience and a stake in the field might be asked to form a study group to consider it, with participants including (but not limited to) the American Academy of Family Practice, the American College of Preventive Medicine, the Association of American Medical Colleges, the Institute of Medicine, and most important- representatives of the Rural Practice Network, the National Association of Community Health Centers, and the various professional societies focused on ambulatory/primary care.

86 PART I THEORETICAL ISSUES The Society of Public Health Educators, social scientists, and epidemiolo- gists, obviously, should be included as equal partners. SERVICE PROGRAMS In addition to community health centers, migrant health centers, and rural practice project sites, health care programs with potential for COPC include health maintenance organizations, rural group practices associated with larger established groups, and community hospital-based primary care groups. If such practices are to begin, or further, COPC, they will need help with the special costs of epidemiologic study, census-taking, sample-drawing, sur- veillance, and follow-u~costs of the kind paid for with research funds in the national HDFP studies but unlikely to be generally available. There are other costs: the cost of standardizing diagnostic criteria, training personnel in uniform methods of examination and reporting, COStS tO assure compa- rable medical record information, and the like. Special costs but special opportunities lie in the use of the microcom- puter technology for COPC. PROMIS and other models already exist for the recording and aggregation of morbidity recording in primary care. Soft- ware is now available to interface dissimilar computer systems in a single network. Microcomputers have already been used to create automated problem-oriented records for a primary care clinic in Israel4i and for re- cording and analyzing patient data in prenatal care in Great Britain.42 Microcomputer technology may make possible, at low cost, an extension of the kind of cooperative efforts made by the Mayo Clinic, the-chief provider of primary care services to Rochester, Minnesota, and Olmsted County, and virtually all the other primary care providers serving the area's population, to create a pooled diagnostic register for the area.43 The Mayo Clinic makes 885,000 diagnoses per year, of which about 20 percent pertain to local residents; to these are added the diagnoses made by almost all the physicians in the county. The coverage is extensive. Olrnsted County has 95,000 residents (of whom 61,000 are in Rochester); in any single year, about 80 percent of that population is seen by one of the participating physicians. In any 3-year period, the figure reaches 95 percent for most age-groups. In rural and small-city areas with a limited number of practices, providers could use microcomputer technology to pool their diagnoses. Such cooperation could make available, at very low cost, a comrnunitywide profile of diagnoses and an approximation of rates, even allowing for all the epidemiologic impurities that flow from unstandardized examination, reporting, and recording. If risk-factor data were systematically recorded and added to such files, every practice in the community, whether presently

COPC in the American Context . 87 community oriented or not, would have an invaluable picture of the pop- ulation's needs. Davis,44 summarizing the data on community health centers, has argued cogently for the provision of care to Medicaid and other low-income pop- ulations on a direct care funding basis, rather than by piecemeal reimburse- ment to a nonsystem of multiple providers. Direct care and Medicaid cap- itation could include allowances for some of the costs of COPC. Use of some of the funding in preventive medicine block grants by organized primary care providers could make possible some funding for demographic, outreach, and other elements of COPC. An unsolved problem, finally, is the question of COPC efforts in large urban areas with shifting populations and multiple unconnected providers. Collecting partial information on an initial defined area, continuing sur- veillance there, and moving on to additional defined areas makes sense only if there is some reasonable expectation that the denominator will ultimately approximate the community's total population, so that community-based rates can be calculated, and if that population is reasonably stable over time. CONCLUSION: A NOTE ON DREAMS AND NECESSITIES The suggestion that COPC may be a romantic dream has particular poig- nance now. We are in a period of such regression that we will have to fight continually simply to preserve what we already have, let alone move for- ward. In ordinary times, innovation like that of the 1960s is followed by periods of attrition; ideas from new programs on the margins diffuse into the mainstream, but at the same time, as the "new" programs become established, they begin to conform to mainstream ideologies and forms of medical care. This may be the natural history of innovation in community i. medicine. But today we are confronted with something more: a radical restatement of the problems of health care, a definition of the marketplace as the solution rather than a part of the problem, and an emphasis on cost containment almost without reference to health needs or any impact on health status. Health care is even more vulnerable than other sectors to a Social Dar- winism that encourages the survival of the fittest particularly the tertiary- care institutions that now dominate the medical marketplace. The conse- quences of reduced access to care (whether it is called a procompetition strategy or simply openly presented as budget-cutting of the kind that threatened in 1981 to remove 1.2 million people from access to the services of community health centers) may be heightened by the reappearance of malnutrition and increased environmental hazards for some segments of the population.

88 PART I: THEORETICAL ISSUES In such times, we may have to limit our COPC research and demon- stration projects while the current wasteful attempt to rely primarily on the sale of personal medical services for improvement in health status runs its course. The evidence suggests that this attempt will increase total costs for medical care, even if it reduces costs to government, and that it will have no positive impact on health status. Yet, from what has been shown above, there is already powerful evidence of what could be saved in both human and financial costs by a different approach. To the extent that these findings are generalizable, then COPC will, sooner or later, be recognized as a practical necessity. In the interim, the value of furthering COPC in the United States, on an experimental or demonstration basis, seems to me to be clear. In doing so, we may even further the evolution of the health care system. As in biological evolution, it does not matter whether the gradualists are correct, and we are in for a long, slow process of the accretion of small changes, or whether the punc- tuationalists are right, and we are at the start of some discrete but discon- tinuous burst of change. COPC, is, for our purposes now, both a romantic dream and a practical necessity. REFERENCES 1. Kark, Sidney L., and Guy W. Stewart, eds. (1962) A Practice of Social Medicine. London: E. and S. Livingstone. 2. Pearse, I.H., and Crocker, L.H. (1943) The Peckham Experiment: A Study in the Living Structure of Society. London: Allen and Unwin. 3. Pickles, William N. (1938) Epidemiology in Country Practice. Bristol: John Wright and Sons. 4. Seipp, Conrad (1963) Health Care for the Community. Paper in Selected Papers of~ohn Grant. Baltimore: Johns Hopkins University Press. 5. Deuschle, Kurt W., and Bosch, Samuel I. (1981) The Community Medicine- Primary Care Connection. Isr. jr. Med. Sci. 17:86-91. 6. Hart, Julian Tudor (1981) A New Kind of Doctor..J. R. Soc. Med. 74(December): 87 1-83. 7. Mullan, F. (1980) Community Practice: The Cake-Bake Syndrome and Other Trials. .1 Am. Med. Assoc. 243~161:1832-3 5. 8. Geiger, H.J. (1974) Community Control—or Community Conflict? Pp. 133- 143 in R.M. Holister, B.M. Kramer, and S. S. Bellin, eds. , Neighborhood Health Centers. Lexington: D.C. Heath. 9. Gordon, Teoffry B. (1969) The Politics of Community Medicine Projects: A Conflict Analysis. Med. Care 7(6):419-28. 10. Salber, Eva J. (1981) Where Does Primary Care Begin? The Health Facilitator as a Central Figure in Primary Care. Isr. l. Med. Sci. (17):110-11. 11. Hypertension Detection and Follow-up Program Cooperative Group, Division of Heart and Vascular Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health (1977) Blood Pressure Studies in Fourteen Com- munities..J. Am. Med. Assoc. 237(22):2385-91.

COPC in the American Context 89 12. Kark, S.L. (1981) The Practice of Community Oriented Primary Health Care. New York: Appleton-Century-Crofts. 13. Bennett, ad., ed. (1979) Community Diagnosis and Health Action. London: MacMillan. 14. Madison, D.L., and Skenkin, B.N. (1978) Leadership for Community-Respon- sive Practice. The Rural Practice Project, Chapel Hill, N.C. 15. Francis, T., and Epstein, F.H. (1965) Survey Methods in General Populations: Studies of a Total Community, Tecumseh, Michigan. Milloank Mem. Fund Q. 43:33-42. 16. Dawber, T.R., Kannel, W.B., and Lyell, L. (1963) An Approach to Longitudinal Studies in a Community: The Framingham Study. Ann. N.Y. A cad. Sci. 107:539- 56. 17. Tayger, I.B., Rosner, B., Tishler, P.V., Speizer, F.E., and Kass, E.H. (1976) Household Aggregation of Pulmonary Function and Chronic Nonspecific Lung Diseases. Am. Rev. Resp. Dis. 114:485-92. 18. Pless, I.B., and Satterwhite, B.D. (1975) Chronic Illness. Chapter in R.J. Hag- gerty, K..~. Roghmann, and I.B. Pless, eds., Child Health and the Community. New York: John Wiley & Sons. 19. Gordis, L. (1973) Effectiveness of Comprehensive Care Programs in Preventing Rheumatic Fever. N. Engl. ]. Med. 289~7). 20. Pless, I.B., and Pekeles, G. (1981) Applications of Health Care Research to ~ 1 · 1 1 ~ ~ 1 1 ~ · · ~ 1 1 · ~ ~ Child Health Services: A Problematic Relationship. Isr. I. Med. Sci. 17:192- 200. 21. Fleming, D.M., and Lawrence, M.S. (1981) An Evaluation of Recorded Infor- mation About Prevention Measures in 38 Practices. }. R. Coll. Ger;. Pract. 31:615-20. 22. Yudkin, T.S., et al. (1980) The Quality of Diabetic Care in a London District. ]. Epidemiol. Common. Health 34:277-80. 23. U.S. Department of Commerce, Bureau of the Census (1980) Geographical Mobility. Current Population Reports Series P-20, No.353. Washington, D.C.: U.S. Government Printing Office. 24. Department of Health and Social Services (1980) Inequalities in Health: Report of a Working Group. London: Department of Health and Social Services. 25. Geiger, Ho. (1958) Family Health in Three Cultures: Implications for Medical Education. M.D. Thesis. Library of the School of Medicine, Case-Western Reserve University, Cleveland. 26. Adair, T., and Deuschle, K.W. (1970) The People's Health: Anthropology and Medicine in a Navajo Community. New York: Appleton-Century-Crofts. 27. Geiger, H.~. (1972) Tufts Comprehensive Community Health Program. Pro- posal to the Office of Economic Opportunity, February 1965. The full outline of the proposal cited here is available in H.J. Geiger, A Health Center in Mississippi A Case Study in Social Medicine. Chapter in L. Corey, S.E. Salt- man, and M.F. Epstein, eds., Medicine in a Changing Society. St. Louis: C.V. Mosby. 28. Davis, K. Gold, M., and MaKuc, C. (1981) Access to Health Care for the Poor: Does the Gap Remain? Ann. Rev. Public Health 2:159-82. 29. Orso, C.L. (1979) Delivery Ambulatory Health Care: The Successful Experi- ence of a Neighborhood Health Center. Med. Care 17(2):111-26. 30. Davis, K. (1981) Primary Care for the Medically Underserved: Public and Private Financing. Report presented at the 1981 American Health Planning Association and National Association of Community Health Centers Sympos-

90 PART I: THEORETICAL ISSUES ium on Changing Roles in Serving the Underserved, Leesburg, Va., October 11-13. 31. Freeman, H.K., et al. (1981) Community Health Centers: An Initiative of Enduring Utility. Institute for Social Science Research, University of California, Los Angeles. Duggar, B.C., Balicki, B., and Zuvekas, A. (1981) Costs and Utilization Patterns for Comprehensive Health Users. Presented by TRB Associates at the Medical Care Section, American Public Health Association Annual Meeting, Los An- geles, November 2. 33. Goldman, F., and Grossman, R. (1981) The Responsiveness and Impacts of Public Health Policy: The Case of Community Health Centers. Presented at the Medical Care Section, American Public Health Association Annual Meet- ing, Los Angeles, November 2. Anderson, R.E., and Morgan, S. (1973) Comprehensive Health Care: A South- ern View. Southern Regional Council, Atlanta. 35. Chabot, Andre. (1971) Improved Infant Mortality Rates in a Population Served by a Comprehensive Neighborhood Health Program. Pediatrics 47. 36. Vaughan, B.~. (1968) Maternal and Infant Care Projects: Results in Dade County, Florida. South. Med. I. 61 June). 37. Gold, M.R., and Rosenberg, T.R. (1974) The Use of Emergency Room by the Population of a Neighborhood Health Center. Health Serv. Rep. 38. East Boston Neighborhood Health Center (1980) A Decade of Epidemiologic Research in East Boston: A Bibliography. Boston: East Boston Neighborhood Health Center. 39. Geiger, Ho. (1971) The Latent Curriculum of Medical Education. Am. I. Dis. Child. 40. Morrell, D.C., and Holland, W.W. (1981) Epidemiology and Primary Health Care. Isr. J. Med. Sci. 17:92-99. 41. Margolis, Carmi Z., et al. (1981) Shuval Automated Problem-Oriented Record: An Off-Line Record for a Primary Care Clinic. Isr. I. Med. Sci. 17:173-78. 42. Lilford, R.J., and Chard, T. (1981) Microcomputers in Antenatal Care. Br. Med. J. 283(August 22):533-36. 43. Kurland, Leonard T., and Molgn~rd, Craig A. (1981) The Patient Record in Epidemiology. Sci. Am. 245(0ctober):54-63. 44. Davis, Karen (1981) Reagan Administration Health Policy..~. Palolic Health Policy 2(41:312-32.

COPC in the American Context Discussants 91 David A. Kindig For our discussion definitional clarity is clearly in order. The two papers jUSt presented challenge us to consider a concept that goes beyond com- munity-based primary care. The additional aspect that the Kark/Abramson definition of community oriented primary care (COPC) requires is the practitioners' involvement in epidemiologic studies of their community in order to obtain data that feed back into the goals and activities of their practice. The significant element here is not only being aware of what is going on with one's patients as a group, but also of health issues and health risks in the community outside of one's practice. This addition means that the health status and concerns of those who do not come into your office are as important to you as those who do. This is what I took to be the essence of the original OEO philosophy, which this conference brings into focus again. Dr. Geiger points out that the epidemiologic studies per se are not new; they have been carried out in a variety of settings. He makes the critical point that it is the synthesis of primary care practice and com- munity epidemiology that forms this unique concept of community oriented primary care. I will not spend my time commenting on the exciting potentials that this concept anticipates, not the least of which is the opportunity for the re- juvenation of professional idealism at the grass roots level, which seems so scarce in these times. Rather, I would like to focus on some of the difficulties that may be encountered in a more widespread implementation of COPC into practice settings across the country or world. One conceptual difficulty is that the COPC model described by Drs. Kark and Abramson appears to require defined nonoverlapping commu- nities with organized practices responsible for an entire community or segment of a community. This may be the case in some small towns or a rare inner-city area devoid of services, but beyond these, the medical care system is comprised of various provider groups and patient allegiances that would seem to make it very difficult to define a practice "community." This is true at least for the purposes of including in the epidemiologic studies that portion of the community that is not enrolled in the practice. This is a serious problem. Such a series of nonoverlapping areas or perhaps pop- ulation groups exclusively assigned to one group of providers is not the usual situation in the large number of cities, towns, and rural areas of our country.

92 PART I: THEORETICAL ISSUES This criticism, however, may be applying the model too literally. It is probably not possible or even desirable to insist that every primary care practice be community oriented in this way. What would be desirable would be to have a modest number of such "pure" practices in place while others who provided quality primary care to whoever came through their doors attempted to do some epidemiology on this group of patients and in the community at large, either as extensions of their practice or in conjunction with other practices in the same area. What kind of settings are best suited to this purpose, and what would be the role of major health care institutions such as medical schools, hos- pitals, and academic health centers in such practices? I have tackled these questions in a number of ways since the early 1960s, when I, along with others, began trying to get a major midwestern medical school to consider providing primary care services in its immediate community and later as a part of the growing student health movement. At that time, we found most major institutions extremely resistant to such ideas, primarily because the concept did not fit into the common understanding of the mission of a medical school or teaching hospital. In those rare institutions that were open to such concerns, there was precious little experience or expertise in primary medical practice or community outreach and sensitivity so that first moves, even though well intentioned, were often not successful. The situation is different today, with departments of family medicine and community or social medicine established in most academic centers and certain institutions having distinguished themselves as leaders in the estab- lishment of neighborhood health centers, area health education centers, and primary care medical and interdisciplinary education. However, it is not clear that this change over a 20-year period means that we now have in place established institutions that will be eager to pick up and implement the challenges of COPC? Why is this so? It is tempting to identify the lack of resources resulting from the current economic situation as a primary factor, and it certainly plays an important role. Most institutions, faced with significant cutbacks in all sources of revenue, are struggling to preserve the basic core academic and service programs. New oportunities in COPC or other areas of academic endeavor will not even get a serious review in many places. But what if resources were not limited would the possibility of institutional sponsorship be increased? It would certainly be more likely, although many administrators have become increasingly skeptical of federal or private start-up funds that leave the institution holding the bag when the 3- or 4-year developmental period is over. Certainly, changes in patient care reimbursement so as to include the costs of such activities would encourage additional institutional involvement or sponsorship.

COPC in the American Context 93 But is this a desired outcome? Are concepts such as COPC suited for institutional sponsorhsip, or are they better suited to a more independent community-based location and governance? My current thinking and ex- perience would lead me to the view that intrinsic characteristics of most major health care institutions are not conducive to the growth and devel- opment of such new and different undertakings. Medical shcools and teach- ing hospitals are large and bureaucratic with enormous inertia and com- mitment to more traditional forms of patient care, teaching, and research. They rarely have a community focus or administrative competence in office- based care. The time, energy, and political skill required for such a significant reorientation are enormous. On the other hand, these institutions possess strengths. Much of the conceptual foundation of primary care delivery and epidemiology lies within our academic faculties, and the financial and or- ganizational support and stability that a strong institution can provide to a new concept or organization, once embraced, is not insignificant. If I were responsible for recommending institutional arrangements for maximum secure growth of community oriented primary care practices, I would first pick small delivery sites such as model family practice clinics, health maintenance organizations, and neighborhood health centers, who see such concepts as a clear part of the basic mission but who are also affiliated with academic centers for backup and consultation and support. The small-to-medium HMO is a most promising opportunity for such de- velopments at this time because of their focus on a defined population and because the epidemiology has the potential for increasing cost-effectiveness as well as quality. Any major health care institution considered for spon- sorship should clearly be able to demonstrate why such an activity is in itS enlightened self-interest—a motive for which I have growing respect. I am impressed with institutions whose history and philosophy, often from a religious base, give some security and guarantee that the time, energy, resources, and clout will be available when the academic and bureaucratic pitfalls mentioned earlier appear. Finally, I would like to make a brief observation on education for COPC, which is discussed much more extensively in the paper by Jo Boufford. Both Drs. Abramson and Geiger refer to the failure of the educational system in preparing students for such practice and suggest a number of remedies to address this. There is no doubt that students need more training in basic epidemiology and that, even today, adequate primary care expe- rience is lacking in many schools. I do not believe, however, that academic centers can adequately provide experiences in this synthesis of primary care and epidemiology that COPC envisions. It is counterproductive to expose students to inadequately developed or esoteric practice models prior to

94 PART I: THEORETICAL ISSUES their being established as effective patient care mechanisms. The educational demands may retard the growth and efficiency of the practice. The exposure of students to underdeveloped or inefficient practice can either turn them off totally or provide an image of practice that is not feasible in the real world. Proponents and advocates of COPC should set as their goal the devel- opment and implementation of 25-50 operating COPC practice models over the next several years. Perhaps foundations would fund the epide- miologic component that is the missing piece in many settings and that third-party reimbursement will not cover. When these are in place and seeing enough patients to be cost-effective and capable of assuming an additional education mission, I believe far-sighted academic centers will be ready and willing to organize and even pay for appropriate educational experiences. But to burden such innovative practice models at the outset with any significant educational responsibilities would threaten the practices in the short run and their future educational potential in the long run. I would urge that there be early linkages of academic centers with developing practices to provide managerial, professional, and research expertise that can later be expanded to an educational focus. Fred Diaz My purpose here will be to try to summarize some of the problems at the Florida Community Health Center (FCHC) and to identify, if any, the confusion over where we are going. I will start with the four main bases that were covered in Geiger's paper. One of them is that the COPC must have a local community tO provide itS services. I believe that here in the United States, probably contrary tO some other countries, "community" has been divided into two groups, those who can pay and those who cannot pay. Therefore, we have developed two systems of health services: one, which is based on a private practice model, and another one, which has evolved with some of the community oriented aspects in it and which has taken the form of community health centers and migrant health centers throughout the United States. In looking at this, there have been certain regulations that have been imposed on migrants and community health centers so that they can es- tablish their "community." Part of it comes from the criteria for medically underserved areas (MUM, which include a number of criteria that must apply if a facility is tO be started, and the other has to do with limited access to services by migrants or a mobile population with a particular need that no one else is addressing. Therefore, when community health centers and migrant health centers start out, there are overlaps. They usually represent

COPC in the American Context 95 situations that have been neglected and that have been undeveloped because of the economic structure, and then it does become difficult to really initiate COPC. A second point that has been alluded to is combining the personal health services of individuals and families with services to the community as a whole or its subgroups. Basically, when you deal with subgroups and I will be talking about subgroups of indigents or migrants or minorities you begin to also deal with another problem, which is that health is not their number one priority. Sometimes when dealing with the population as a whole and particularly with the subgroups, there are inherent problems that are built into the system that make it very difficult to achieve that community oriented practice. As a subgroup, indigents and migrants must be plugged into the mainstream of health. The way that has been done at the FCHC is by coordinating and integrating the services of various centers with providers of special services, hospitals, and public agencies to create a continuity of care for the individual, his family, and his community. In this area I do feel that we are providing COPC. This becomes rather difficult, however, because the reason the community health center or the migrant health center was started was because of economic problems with a partic- ular population. As an administrator or director of one of these units, one has to try to solve the economic problems and fit this population into hospitals, specialists' practices, and other community agencies. The reim- bursement process becomes crucial in determining how successful one is at coordination, integration, and initiation—a total community oriented effort. Community health centers and migrant health centers have probably been some of the forerunners in developing or working in the team concept. The economic structure has forced them to actually use a combination of physician, dentist, outreach workers, family health workers, and all supple- mental services that back them up. I think they are our models and I do believe that FCHC is one of those that has been able to very successfully put this team together in a cost-effective way. An average overall-per-visit cost of $22 to S24 is quite effective when one looks at private practice and considers all the services that we offer the patient. This aspect of migrant and community health centers has resulted in a well-integrated system. Now, because of the integration and this kind of teamwork, migrant and community health centers are not only forced to, but look eagerly towards, accepting National Health Service Corps phy- sicians, dentists, etc., in their settings. At one time they were given as a gratis contribution; they were repaying their medical school scholarships. This gave them a chance to really work in a community where the services were greatly needed. The picture is drastically changing. The services of

96 PART I: THEORETICAL ISSUES these health professionals are no longer free. There is little or no economic incentive for the centers, because now pay-backs must be made to the government for these scholarships and assignments. It does, however, help in rural health care settings, such as FCHC, because it does provide man- power for some of these shortage areas. The third point involves the de- velopment of methods of community diagnosis and surveillance, the de- velopment and evaluation of programs to modify the community's health- in other words, applied epidemiology. Federally funded community health centers and migrant health centers have been forced into some of that epidemiology by reporting requirements. These centers must collect certain data, produce statistics on numbers of people immunized and those who are not, and report on follow-up. This reporting ranges from a chalk mark every time a patient comes in and leaves the center to highly sophisticated computerized management information systems, as we have at FCHC. But we still fall quite short. We can correlate most any data in terms of prevalence and incidence within the population served. Basically, FCHC has more than 62,000 per- sons registered, and, as of this past year, it had more than 36,000 active users. It does create an excitement knowing that community oriented health care has tremendous potential. One of our reporting requirements addresses productivity. We run profiles on all of our medical providers and our dentists, and we do it by diagnosis. How many of a certain of diagnosis are seen? How many of them are newcomers and how many of them are repeated visits? This helps us to determine the kind of productivity levels that are achieved within the hours worked. These profiles also indicate the kind of prevalences that are within our population. We can break it out by age-groups, sex, ethnicity, zip code areas, etc. It has been very exciting. There has been an inherited problem, though, that leads us basically to the fourth point, and that is the application of the epidemiological skills needed to be able to really function under a true COPC. To be able to run the management information system, your data must be standardized so that whatever data is collected is the same in all your sites. Medical records must also be maintained in a standardized way. There must be very rigid interpretations, and they must be communicated to the providers so that you can rely on the data. For example, when a diabetic or a hypertensive comes in and is uncon- trolled, the right kind of code must be put down to indicate that he is an uncontrolled diabetic and an appointment has been set up for him within 3 weeks. If he doesn't appear for his follow-up visit, there is another com- puter-generated form that says this person did not return and has not been put into the control column, thereby closing that loop. It has been very difficult to set up this system, because many of the graduates that are coming out find this kind of regimen very difficult to

COPC in the American Context 97 adhere to. We currently have 11 National Health Service Corps assignees. By the end of this year, with the birthing center that we are putting in to one of the local hospitals, with certified nurse-midwives and obstetrician/ gynecologists, we will have more than 22 involved with our total network. That is an awful lot of training and an awful lot of people to orient to a specific type of practice. At FCHC we have found that it takes as much as 6 months to a year to orient the new graduate after he/she arrives. At that point he/she is in one or two dispositions. He is either really catching on to what this whole program is about in terms of the standards that must be adhered to, the kind of coding that must be done, the kind of practice models, his role as a physician in this kind of an institution or a community health center, putting his all behind it, getting very excited over it, and in the last year being very productive; or, he is totally disillusioned because this is not what he had in mind when he went through medical school. He finds it difficult to stay with the regimens of the kind of practice you need, and, therefore, during the last 6 months, his productivity level really drops off and the center becomes anxious for his rotation to be over and his obligation to the government fulfilled. Therefore, I do agree with the Kark/Abramson paper and the Geiger paper that there is a tremendous need to orient the medical students in epidemiologic aspects of medicine, particularly as they relate to migrant and community health centers as well as COPC practices in general. I feel also that there must be some kind of funding source that will actually bring in a team as described in Dr. Abramson's paper and that will give these centers the kind of support in the form of expertise that they need. The funding should also provide for involvement with medical schools both in terms of faculty and students, particularly students that have an obligation to satisfy and have chosen to go to one of the migrant or community health centers. This kind of involvement may pave the way to a more integral type of team. Nora Piore We cannot absolutely prove that those are in error who tell us that society has reached a turning point, that we have seen our best days. But so said all who came before us, and with jUSt as much apparent reason.... Macaulay, 1830 It is good to have the opportunity to join with you in this health care policy conference at a time when society indeed seems at a turning point. Whether or not our best days are behind us—which I doubt what brings us together in this assembly is the experience shared in those days, the insights gained,

98 PART I: THEORETICAL ISSUES and our common concern with making that experience relevant and useful in these difficult and confusing times. To help us distinguish what may be transient economic and political trends from more underlying and persistent changes in our mixed medical care economy, and to understand better the potential role that community ori- ented primary care (COPC) and the epidemiologic basis for its operation might play in contemporary society, it may be useful to go back to the roots of these concepts. In the early 1960s the nation embarked on a remarkable series of efforts to address the problems of poverty, discrimi- nation, and equal opportunity. The programs of the Great Society, as Henry Aaron has so well expressed it, were unparalleled by any peace time con- census about the nation's difficulties and the need to tackle them since the New Deal. Unlike the New Deal, which side-stepped the issue of health security, the agenda of the 1960s included a many-faceted approach to improving access to medical care—access to knowledge gained with public support for medical research, to care in hospitals built with public funds, to treatment from physicians trained in government-supported programs. In a single session, the Eighty-ninth Congress enacted more than two dozen pieces of health legislation. In addition to Medicare and Medicaid, a program of federal grants to voluntary and government institutions was adopted to bring federal resources to populations at particular risk—preg- nant women, children and youth, alcohol and drug abusers, the mentally ill, migrant workers, and other neglected segments of the population; and to stimulate new areas of service and new ways of delivering them—family planning, community mental health services, and neighborhood health cen- ters. 'the Congress declares that fulfillment of our national purpose depends on promoting and assuring the highest level of health obtainable for every person...." These words, in the preamble to the Public Health Service Amendments of 1966, laid the basis in that period of unprecedented eco- nomic growth for expectations that the nation is still struggling to fulfill, in the quite different climate of inflation, resource scarcity, and skepticism about government that prevails today. Efforts to reshape the health delivery system in accordance with these mandates took many forms. The neighborhood health center, close to and responsive to community residents—an idea that has emerged periodically in American history proved particularly attractive to those skeptical about the ability of traditional structures to respond to these new mandates. Less than 3 percent of total public spending went to these programs, while billions of Medicare and Medicaid dollars flowed through the traditional channels of hospital, outpatient clinics' and physicians' offices, and into a new type of provider soon to be named the "Medicaid Mill." Nevertheless,

COPC in the American Context 99 it was the more experimental margin of the public medical care enterprise that attracted more adventurous health professionals and planners. Among these were substantial numbers of the best and the brightest from the nation's universities and medical schools who enlisted to design and develop new health-providing institutions in rural areas and urban slums. Assembled at this conference are the veterans of this exceptional chapter of American medical care history, together with their younger colleagues and students. Out of the experience of the 1960s—exhilarating, frustrating, unique there evolved, and has since matured, a systematic set of convic- tions about the medical care enterprise in our society, a new iteration of views about the interface between medical and social intervention, about primary care and high-technology medicine, about society's responsibility for assuring access to health and medical care. These views, which some have described as the counterculture of Amer- ican medicine, have had a substantial impact on medical education and concepts of medical practice, particularly primary care, family medicine, and the role of new types of health professionals, and, while the vision of a network of a thousand neighborhood health centers spanning the nation never materialized, few hospital outpatient departments, emergency rooms, and even physicians' offices remained untouched by the criticism of crowded waiting rooms, long queues, lack of privacy, and impersonal and sometimes indifferent care. But by the 1970s, with constantly rising medical expenditures, a stagnant economy, and mounting federal and state budget deficits, attention that had been concentrated on access and quality turned to efforts tO curb rising health care expenditures and the search for incentives that would reduce what we now see as excessive use of services and unproductive investment of resources. Now it is another season. The voice of the turtle is no longer heard in the land, stilled by hostile political winds and overwhelmed by the mounting economic recession. One need not take a cataclysmic view of the current outlook to acknowledge that the climate of opinion, the mood of the coun- try, is no longer fixed on issues of equity and opportunity, but rather is concerned with inflation, unemployment, and the burden of taxes to pay for services to meet someone else's needs. This change in the national mood did not occur suddenly, one day in November, with a presidential election. Rather that election reflected storm signals, public uncertainties that had long been gathering. The deeply disturbing experiences of Vietnam, Wa- tergate, and the Iranian hostage crisis contributed to the loss of confidence in our ability to deal with inflation, lagging economic growth, and rising unemployment. Equally disquieting is the realization that the United States, deeply involved in a highly competitive global economy, cannot, as perhaps

100 PART I: THEORETICAL ISSUES it once could, rely on an economic recovery strategy geared solely to internal markets. In the face of these developments, we are unlikely soon to see a return to the search for a single, coherent national solution to these complex problems. That sums up the bad news. There is some good news, too. To begin with, we must not ignore the fact that despite the cutbacks that have occurred and the threat of further disruption in social welfare policies, 28 million Americans today are covered by Medicare and another 21 million by Medicaid. Despite retrenchment and possible further reshuffling of fed- eral, state, and local responsibilities, the important fact is that a floor of health care protection remains precariously in place. Further, there are some reasons to think that there are limits to how far back the clock can be turned. The amount of cost shifting that is occurring in the health economy indicates some limits to the extent to which denial and deprivaton of care can be tolerated, perhaps less because of public conscience and more because of the instinct for survival on the part of provider institutions. Whatever the motivation, the fact is that it is an accepted component of public policy in Maryland, in New Jersey, and now in New York that the bad debt and charity care losses of voluntary hospitals be at least in part absorbed by third-party payers and thence transferred to the cost of health insurance premiums. Whether this is a more equitable or efficient way of providing fiscal coverage for hospital care of low-income patients than the use of the public tax system can certainly be debated. But it promises that some inpatient and ambulatory care losses will be absorbed in this fashion. If or when this burden becomes untenable on the private insurance side, and inadequate as a way to pay for indigent care, the search for other fiscal mechanisms can be expected to resume. Another indicator of the ineradicable changes in the topology of medical care left from the 1960s is that by the end of the 1970s there had been a substantial increase and extensive geographical redistribution of health care capacity (equipment plant and manpower) in the country. Don Madison, in his paper for this conference, describes the difficulty experienced by a rural neighborhood health center today in maintaining a stable constituency in a community where there are now many competing providers and where those providers now advertise their wares. This presents a very different picture from our earlier view of the rural community health center as a rare and exotic plant, flowering in a landscape empty of health manpower and health care resources. Of course there remain areas where services are in short supply and people who cannot pay. But these observations suggest that the investments in health resources and manpower made in the last two decades have indeed changed the landscape. Perhaps the most important factor in the current climate is that concern with alternative strategies to deal with shrinking revenues for health services

COPC in the American Context 101 perforce claims the attention of federal, state, and local governments, as well as those in the public and private sectors who provide or purchase medical care. This now stems from practical pressures to make ends meet and to bring rising costs under control rather than from a search for a long- range coherent health policy for the nation. But these immediate pressures guarantee that there will continue to be a search for ways to organize and deliver health care that will max~nize the return on resources and anticipate and plan to meet the new demands on these resources that must be expected from changes in the demography of the population and the pattern of health and illness. In these circumstances the concept of community oriented primary care and the additional dimension of its essential relation to an epidemiologic data base become an effective and essential tool for addressing health policy issues in both conceptual and very practical ways. In the broadest conceptual sense, the development through the use of epidemiology of a systematized rational basis for the identification and prioritization of health care needs is central to any approach to health care planning, whether from a market or a regulatory point of view. From any point of view, a coupling of the ills that are prevalent with a knowledge of the state of the art in their prevention or amelioration sets the agenda for allocation of finite resources. Thus the COPC concept has much to contribute to improving the nation's capacity to make decisions on the basis of knowledge about what's out there to be treated and what is available to treat it with. Thus, despite the fact that little attention currently focuses on global national health proposals, the need for new mechanisms to operate in the health care economy occupies a central and visible place in the nation's concern. Of the administration's inner council deliberations about the form that the new federalism will take, the glimpses that one catches suggest that, even were there to be a state-federal trade-off between welfare and health care responsibilities, the details of the disposition of whatever health resources are to be allocated to a region or a state or a locality will be left to some lower level of government. Interestingly enough, the most recent version of a Kennedy-type national health insurance proposal also envisaged a structural format for health resources allocation in the nation linked to decentralized allocation of decision making, within whatever national re- distributive framework was agreed upon. Thus decentralized resource al- location decision making by region, by state, by community, or by individual provider would appear to be a likely component of evolving public health policy. The relevance of an epidemiologic data base at each such level of . . . . . . . . deClSlOn maKlNg IS OOVlOUS. To turn for a moment to more immediate opportunities to make use of an expanded epidemiologic framework, consider developments that are

102 PART I: THEORETICAL ISSUES likely to take place regarding the role of state and local health departments. Somewhat in eclipse since the 1960s, they have recently reemerged for two reasons: one, with the end of federal support of planning agencies, in many areas the health department remains the single available mechanism with the authority and the mandate to oversee the needs and resources of the community to take responsibility for marshalling professional and civic concern for the public health. In some places this role of the public health agency extends much further. In New York State it regulates resource allocation, determines reimbursement rates, and serves as the guardian of the public health. Much thought, obviously, will now be given to the role of health departments, and here again the concepts of epidemiologic sur- veillance, newly emphasized by the COPC movement, are the traditional way of work for public health. A second reason for the reemergence of health departments as important instrumentalities is the new emphasis on health behavior, prevention, and life-styles, again traditionally the health department's turf. Finally, we come to some specific new opportunities for the COPC movement to play a significant part in shaping immediate changes in the organization and delivery of medical care. As Medicaid funding is reduced, and states and localities have greater latitude to experiment with most cost- effective ways of providing care for the covered population, attention is increasingly turning to the development of capita/ion-based group practice arrangements for the care of low-income patients. In Massachusetts, under the leadership of Dr. Jerome Grossman and New England Medical Center, a coalition of eight community hospitals is working with the state of Mas- sachusetts to develop a system whereby these hospitals will contract with the state to provide total care for Medicaid beneficiaries who enroll on a capitation basis in the group practice plan offered by any one of the eight cooperating institutions. The theory behind this plan is that, given an iden- tif~ed enrolled population with known characteristics and needs, the group practice can plan to use the total sum available under the capitation contract in the optimum manner to provide needed services for the entire group. This in effect combines the principle of the Kaiser plan on the one hand and of the neighborhood health center system on the other. For the first time there will be the opportunity to test out on a large scale whether these ways of providing care can work for the Medicaid population. Moving from Massachusetts to the South, and from the initiative of a group of hospitals to the leadership of a state department of health, planning is under way in Tennessee to establish a primary care network of community health centers working in cooperation with public and private institutional providers. Explicit in the planning of this network is the development of a community data base that will include both the epidemiologic information

COPC in the American Context 103 and the identification of social service needs and social support networks that can be incorporated in a unified approach to meeting the needs of this population within the framework of diminishing public funds, commingling Medicaid and other public funds with private grants, third-party payments, and self-pay. A third illustration of the opportunity afforded by COPC is the devel- opment of ties between mainstream medical providers and experimental community health models that have too often operated at the margin of mainstream medicine. Montefiore Medical Center in the Bronx is providing the leadership to develop a prepaid health care network designed to offer comprehensive health care services tO Medicaid and other low-income res- idents of the Bronx. Under this plan, a coalition of community health centers for primary care services would be linked with specialty and inpatient ser- vices furnished by participating hospitals, with enrolled Medicaid and low- income patients covered by a negotiated Medicaid capitation rate. These are but three examples of many that are beginning tO surface as fiscal pressures force providers and communities to search for cost-effective systematic ways to provide essential services within the limits of extremely constrained resources. Because of the involvement of public and voluntary mainstream providers, together with experimental community-based or- ganizations, these experiments can be expected to bring about the involve- ment of mainstream medical resources that have eluded past efforts to restructure medical care; adversity may prove tO be the foster parent, if not the mother of, invention. At a time when, unexpectedly, there are new opportunities to extend the benefits of community oriented primary care, one cautionary word may be in order. It has to do with the nature of the scientific revolution in medicine, which in the last generation has drastically reduced some costs while increasing others by providing new ways of healing larger numbers of people who previously could not be helped at all. Many attribute a large share of the increase in health expenditure to these scientific advances. It is not so clear that improved primary care can achieve the necessary savings to balance off such rising costs. However much health education, prevention, and prompt care can accomplish to prevent, delay, or achieve a net reduction in morbidity, there is bound to remain a substantial and irreducible volume of serious and expensive illness, the crux of the dilemma of rising health care costs. It behooves primary care advocates to be prudent in claims of the extent to which investment in primary care can reduce the need for more advance forms of treatment, with the present state of our knowledge, if they are not to jeopardize their credibility.

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