the appropriateness of such involvement and the
manner in which it was to be achieved.
Slince the beginning of the New York City fis-
cal crisis in 1974, the City's Department of Health
(DOH) has undergone drastic reductions in its
budget that have severely affected its levels of ser-
vices and personnel. In order to understand the
full impact of these cuts, however, it is necessary
to see them against a backdrop of long standing
tensions which have marked the Department's
history.
The basic question underlying many of these
tensions concerns the definition of the proper
role of a local health department. To this day,
around the country, this question remains a
source of real debate.
According to a recent report, one quarter of
all reporting local health departments today render
"personal health services" (that is, treatments
to individual patients) and this proportion has
grown steadily in this century. Such services
may take the form of well-person care only (child
health exams, immunizations, PAP smears), or
well-person and sick-person care provided to spe-
cific categories of the population (child health or
geriatric care), or care for a particular problem (tu-
berculosis). In some cities, the provision of per-
sonal health services extends to the provision of
comprehensive ambulatory care-both routine
acute care (primary care) and preventive services.
(Newark, Boston, part of Atlanta, Denver, and
Detroit all have some form of comprehensive am-
bulatory care system run by their city or county
health departments).
In some localities, health departments are the
only providers of such services as family planning,
maternal and child care, home care, school health
and chronic disease programs. In many localities,
health departments are the only providers of
free personal services for poor people. In 1975,
such services accounted to 72 percent of all
expenditures (or $2 billion annually) by state
health agencies (1).
The New York City DOH has historically been
at the forefront of providing these direct personal
health services. But the progress in offering them
has not been linear. Throughout its long and dis-
tinguished history, the expansion of DOH func-
tions to include direct personal services has been
a source of tension and controversy concerning
With the onset of the fiscal crisis, such services
have again come under attack. A key element in
the conflict is that, since health department ser-
vices are targeted for poor people, they are often
"poor programs"-that is, they receive only mar-
ginal support in the best of times. In 1974, less
than five percent of the $41.7 billion of tax
money expended for health services in the U.S.
was allocated to health departments. As a result,
health department programs are often the "last
funded" and the "first de-funded."
On the other hand, most of today's health care
dollar is allocated to the hospital sector. This in-
cludes a growing role for hospital-based pre-
ventive and primary ambulatory care. There are,
however, serious questions about the appropriate-
ness of the hospital as a base for such services.
Hospitals, in general, are not oriented toward
preventive care or health promotion, but to
acute care; their orientation is often to diseases,
not whole people; to individual cures rather than
community problems; and to keeping beds full of
people, not keeping people out of beds.
It has also become increasingly clear that
basing services in hospitals is likely to increase
overall costs. Hospital costs in particular have
driven health costs skyward in recent years.
Moreover, it is not clear that hospitals have the
capacity to handle increased ambulatory ser-
vices. Last year in New York City, over a million
and a half people used DOH clinics. It is ques-
tionable whether hospitals, whose outpatient de-
partments and emergency rooms are already over-
crowded, could handle such an increased load.
Health departments are unique among Ameri-
can health providers. Their epidemiologic orienta-
tion and statutory mandates to cover whole
communities put them in a unique position to
monitor not only the quality of services deliv-
ered, but also the appropriateness of the mix.
Hospitals, in contrast, tend to monitor only the
needs of those that use them, rather than the
needs of the community as a whole.
According to Dean Myron Wegman, "It might
be well to build on the principle used in record
keeping in many Child Health Stations, of tab-
ulating not only the immunizations performed,
but rather the number of eligible children whose
immunization status is not satisfactory. The idea
of measuring tasks undone instead of counting 7