Numerous state and federal programs and policies aim to improve rural health care. This study compares access to and quality of medical care in urban and rural areas from the perspective of physicians and patients, using a broad set of indicators taken from the 2000-2001 Community Tracking Study (CTS) Physician and Household Surveys. Across most dimensions examined, access and quality in rural areas-even rural counties not adjacent to metropolitan areas-were either equivalent or superior to that provided in urban areas. However, rural residents have greater difficulty obtaining mental health services and generally face greater financial barriers to care.
Despite pessimistic predictions and some notable exceptions, the health care safety net grew stronger over the past six years. Given considerable community variation, however, this analysis indicates that policymakers can apply a number of lessons from strong and improving safety nets to strengthen those that are weaker, particularly as the current economy poses new challenges.
More than four years after September 11, 2001, bioterrorism preparedness remains a high priority for federal, state, and local governments. With reasonably flexible federal funding, communities have strengthened their ability to respond to public health emergencies, according to assessments by stakeholders and market observers. Collaborative relationships developed for bioterrorism preparedness have proved useful in addressing other threats, such as natural disasters and infectious disease outbreaks. Major ongoing challenges include funding constraints, inadequate surge capacity, public health workforce shortages, competing priorities, and jurisdictional issues.
Since the terrorist attacks of 11 September 2001, emergency preparedness has become a top priority in metropolitan areas, and some of these areas have received considerable federal funding to help support improvements. Although much progress has been made, preparedness still varies across communities, with the larger ones exhibiting stronger response capabilities, and some weaknesses are evident, particularly in the areas of communications and workforce education. Experience with other public health emergencies, strong leadership, successful collaboration, and adequate funding contributed to high states of readiness. Important challenges include a shortage of funding, delay in the receipt of federal funding, and staffing shortages.T h e t e r r o r i s t at tac k s of 11 September 2001, together with the subsequent anthrax attacks, exposed weaknesses in the public health infrastructure and drew U.S. policymakers' attention to the need for strengthened public health emergency preparedness at the local level. 1 Localities have had more than two years to improve emergency preparedness capabilities, and many have received new federal funding to support these efforts. Recent studies have indicated that local emergency preparedness has improved since 9/11, but gaps still remain. 2 These studies have identified strengths and weaknesses of organizations such as hospitals and local health departments; however, few recent national evaluations have been undertaken using the community as the unit of analysis. Community-level analysis is important because preparation for terrorist attacks involves many organizations in a community (such as law enforcement, health care, and transportation). Also, using a more qualitative approach allows for the capture of market and policy factors that can affect preparedness.In this paper we describe states of preparedness for public health emergencies in twelve nationally representative metropolitan areas in late 2002 and early 2003. Since public health received a boost in support and funding after the 2001 attacks, this is an important point in time for communities and policymakers to reflect on emergency preparedness. We discuss changes in funding for public health activities over the past two years and the involvement of various local agencies and organizations. We also discuss progress and goals in six Centers for Disease Control and Prevention (CDC) focus areas designed to improve local public health jurisdictions' pre-
gue that the model we used underestimated the value of HIV counseling and testing as well as prevention case management. We doubt that the results of our analyses would be qualitatively different if we had used QALYs, rather than HIV infections prevented, as our outcome measure, for two reasons. (1) QALYs would apply to all interventions (not just HIV counseling and testing). (2) Any improvement in QALYs beyond those caused by preventing infections would require medical treatment of HIV infection, which is not part of counseling and testing. Underestimating the number of infections potentially prevented by partner notification would also have no impact on the benefits of HIV counseling and testing, a completely different intervention.Prevention case management is an extremely intensive and expensive intervention whose efficacy has yet to be established. In contrast, it is well established that needle exchange is effective in preventing HIV transmission, and it should be part of a comprehensive strategy. The CDC does not support needle exchange because it is prohibited by federal law. But unreasonable legal restrictions should not stop the CDC from going on record about the benefits of needle exchange.Janssen and McKenna also claim that the CDC's "portfolio" of interventions includes "almost all of those identified as cost-effective." However, funds are not allocated among these interventions on the basis of cost-effectiveness; some highly cost-effective interventions receive fewer funds than do less costeffective interventions. To repeat our main point: The CDC should allocate its prevention funds in a rational way that maximizes the preventive benefit. If CDC program planners do not agree with the details of our cost-allocation model, then they should develop-and use-their own model. Nonprofit Drug CompaniesWe agree with Victoria Hale and colleagues that nonprofit pharmaceutical organizations offer a promising model for drug development (Jul/Aug 05). Through our research, however, we conclude that this model should not be limited to cultivating drugs for orphan or endemic diseases in developing countries.Nonprofit pharmaceutical organizations, developed similarly to the model proposed by Hale and colleagues, could help improve access to affordable and innovative drugs for patients in the United States as well as around the world. In recent years, the for-profit pharmaceutical industry has tended to focus on products that are not especially innovative but do generate a high economic return. As noted by the authors, nonprofit organizations make research decisions on the basis of their mission, and they are not stymied by stakeholder or profit expectations. In addition, with the increased scrutiny of relationships between National Institutes of Health (NIH) scientists and for-profit drug companies, nonprofit companies could be the answer in translating the work of NIH bench scientists into new drug therapies without creating conflict of interest.Increased development of such companies could also lead to positive ...
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