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Illness and mortality related to heat and worsening air quality are core public health concerns associated with climate change projections. We examined the historical relationship between age- and cause-specific mortality rates from 1980 through 2006 and heat events at the 99th percentile of humidex values in the historic period from January 1, 1970 to December 31, 2006 in the greater Seattle area (King, Pierce and Snohomish counties), Spokane County, the Tri-Cities (Benton and Franklin counties) and Yakima County; the relative risks of mortality during heat events were applied to population and climate projections for Washington State to calculate number of deaths above the baseline (1980–2006) expected during projected heat events in 2025, 2045 and 2085. Three different warming scenarios were used in the analysis. Relative risks for the greater Seattle area showed a significant dose-response relationship between heat event duration and daily mortality rates for non-traumatic deaths for persons ages 45 and above, typically peaking at four days of exposure to humidex values above the 99th percentile. The largest number of projected excess deaths in all years and scenarios for the Seattle region was found for age 65 and above. Under the middle warming scenario, this age group is expected to have 96, 148 and 266 excess deaths from all non-traumatic causes in 2025, 2045 and 2085, respectively. We also examined projected excess deaths due to ground-level ozone concentrations at mid century (2045–2054) in King and Spokane counties. Current (1997–2006) ozone measurements and mid-twenty-first century ozone projections were coupled with dose-response data from the scientific literature to produce estimates overall and cardiopulmonary mortality. Daily maximum 8-h ozone concentrations are forecasted to be 16–28% higher in the mid twenty-first century compared to the recent decade of 1997–2006. By mid-century in King County the non-traumatic mortality rate related to ozone was projected to increase from baseline (0.026 per 100,000; 95% confidence interval 0.013–0.038) to 0.033 (95% CI 0.017–0.049). For the same health outcome in Spokane County, the baseline period rate of 0.058 (95% CI 0.030–0.085) was estimated increase to 0.068 (95% CI 0.035–0.100) by mid-century. The cardiopulmonary death rate per 100,000 due to ozone was estimated to increase from 0.011 (95% CI 0.005–0.017) to 0.015 (0.007–0.022) in King County, and from 0.027 (95% CI 0.013–0.042) to 0.032 (95% CI 0.015–0.049) in Spokane County. Public health interventions aimed at protecting Washington’s population from excessive heat and increased ozone concentrations will become increasingly important for preventing deaths, especially among older adults. Furthermore, heat and air quality related illnesses that do not result in death, but are serious nevertheless, may be reduced by the same measures.

Dr. Roger A. Rosenblatt explains that rural patients increasingly demand access to the same spectrum and quality of care as their urban counterparts. Effective rural systems must be based on a menu of core services, delivered largely by generalists in settings linked to regional centers. Urban Americans tend to view the rural United States as a larder, a playground, or a place to retire. But although agriculture now employs less than 3 percent of the nation's workforce, more than 50 million people — 20 percent of our population — live in places defined as rural by the 2000 Census. Inhabitants of rural areas are generally older, poorer, and less likely to have health insurance than inhabitants of urban areas. Enormous regional variation masks the fact that rural America contains pockets of deep poverty; of the nation's 500 poorest counties, 459 are in rural areas. 1 Rural . . .

Not the crime, but the getaway, what Rosenblatt remembers. Running out of the living room, through the center foyer, out the kitchen door, then throwing himself on the cold marble backstairs of their apartment in 36 Gramercy Park, and sitting there awaiting his punishment. He is concerned, perplexed, as though he is a patient referred to him with an undiagnosable disease. Why did he hit his baby brother without provocation. Why did he hit him so hard, his wailing flooded the eight rooms of their apartment, following him out the kitchen door and echoing up and down the staircase. So he sits there shivering, stunned by his own cruelty. His father is very nice with him. When he sees his helplessness, he leads him back into the apartment. He does not even make him apologize to his brother, who would no more appreciate his apology than understand the reason he hits him in the first place.

Summary points There is a relative shortage of physicians in rural areas of America The more highly specialized the physician, the less likely he or she will settle in a rural area The preference of women for urban practice may pose a problem for the future recruitment of rural physicians Although managed care systems can recruit physicians to rural areas, systems are growing slowly in rural areas and their doctors may be of little use to the working poor who have neither Medicaid nor conventional health insurance Possible solutions to the problem of physician shortages in rural areas include changing the medical education system so that it trains more physicians who choose rural practice, changing the reimbursement strategies of Medicare and Medicaid, and changing the existing federal and state programs EFFECT OF SPECIALTY CHOICE AND DISTRIBUTION Nothing affects the location decision of physicians more than specialty. INFLUENCE OF MANAGED CARE Managed care is a major emerging influence on the delivery of rural health care.\\n 8 , Table 1 Key factors in improving the delivery of telemedicine to rural areas Resolution of the professional licensure regulations, allowing physicians in metropolitan areas to make their expertise available to remote rural areas, even across state lines Clear protocols for a unified technologic infrastructure to reduce costs and to allow rural providers to have the option of communicating with multiple providers of these distant services without being captives of any single information provider Reasonable reimbursement by third-party payers for providing medical services at a distance Given the realities of the current system, future efforts should concentrate on improving the fit between need and services, enhanced coordination--and reduced duplication--of services provided, better identification of students to ultimately serve in the NHSC and state programs, and improved effectiveness and efficiency of governmentally sponsored health care services, including those of rural health clinics. 9 The wide variety of programs available--and the natural variability in the way they are organized and administered--leads to enormous complexity in the provision of services.

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Most local health departments or districts are small and rural; two thirds of the nation's 2832 local health departments serve populations smaller than 50,000 people. Rural local health departments have small staffs and slender budgets, yet they are expected to provide a wide array of services during a period when the health care system of which they are a part is undergoing change. This study provided quantitative, population base data on the supply and composition of the rural public health force in 3 extremely rural states. The study focused on the relative supply of personnel in the principal public health occupational categories, differences across the states in staffing levels and difficulties in recruiting and retaining personnel. (Quotes from originaltext)

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Birth certificates are a major source of population-based data on maternal and perinatal health, but their value depends on the accuracy of the data. This study assesses the validity of information recorded on the birth certificates for women in Washington State who were considered to be low risk at entry into care. Birth certificates were matched to data abstracted from prenatal and intrapartum clinic and hospital records of a sample of 1937 Washington State obstetrical patients who were considered to be low risk at the beginning of their pregnancies. Accuracy of a variety of pregnancy characteristics (e.g., complications, procedures) on the birth certificate was analyzed using percentage agreement and sensitivity with record abstracts as the \"gold standard.\" Next, we weighted the data from each source to produce estimates of pregnancy characteristics in the population. We compared these estimates from the two data sources to see whether they provide similar pictures of this subpopulation. Missing data for specific items on the birth certificates ranged from 0% to 24%. The birth certificate accurately captured gravidity and parity, but was less likely to report prenatal and intrapartum complications. The population estimates of the two data sources were significantly different. Because birth certificates significantly underestimated the complications of pregnancies, number of interventions, number of procedures, and prenatal visits, use of these data for health policy development or resource allocation should be tempered with caution.

OBJECTIVES: This study examined differences among obstetricians, family physicians, and certified nurse-midwives in the patterns of obstetric care provided to low-risk patients. METHODS: For a random sample of Washington State obstetrician-gynecologists, family physicians, and certified nurse-midwives, records of a random sample of their low-risk patients beginning care between September 1, 1988, and August 31, 1989, were abstracted. RESULTS: Certified nurse-midwives were less likely to use continuous electronic fetal monitoring and had lower rates of labor induction or augmentation than physicians. Certified nurse-midwives also were less likely than physicians to use epidural anesthesia. The cesarean section rate for patients of certified nurse-midwives was 8.8% vs 13.6% for obstetricians and 15.1% for family physicians. Certified nurse-midwives used 12.2% fewer resources. There was little difference between the practice patterns of obstetricians and family physicians. CONCLUSIONS: The low-risk patients of certified nurse-midwives in Washington State received fewer obstetrical interventions than similar patients cared for by obstetrician-gynecologists or family physicians. These differences are associated with lower cesarean section rates and less resource use.

OBJECTIVES: This study sought to ascertain the effects of poor local access to obstetric care on the risks of having a neonate diagnosed as non-normal, a long hospital stay, and/or high hospital charges. METHODS: Washington State birth certificates linked with hospital discharge abstracts of mothers and neonates were used to study 29809 births to residents of rural areas. Births to women from rural areas where more than two thirds of the women left for care were compared with births to women from rural areas where fewer than one third left for care. RESULTS: Poor local access to providers of obstetric care was associated with a significantly greater risk of having a non-normal neonate for both Medicaid and privately insured patients. However, poor local access to care was consistently associated with higher charges and increased hospital length of stay only if the patient was privately insured. CONCLUSIONS: These results indicate that local maternity services may help prevent non-normal births to rural women and, among privately insured women, might decrease use of neonatal resources.