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ATLANTA METROPOLITAN AREA
COMPREHENSIVE HEALTH PLANNING
PROPOSAL
VOLUME III
TASK FORCE REPORTS
A“
Submitted by
METROPOLITAN ATLANTA COUNCIL OF LOCAL GOVERNMENTS
20 June 1969
This is an incomelete edition of VOLUME III,
PROPOSAL FOR COMPREHENSIVE
HEALTH PLANNING
Other work is in process of completion.
TABLE OF CONTENTS
Responsible
Task Force Staff Member
Manpower Branton
Mrs. Frances Curtiss, Chairman
Manpower Shortages in Allied Health Professions
Home Health Care Roberts
Edwin G. Evans, M. D.' Chairman
Health Problems Compounded with Socio—Economic Bush
Problems
Mrs. Ella Mae Brayboy, Dr. P. w. Dowda, Chm.
Maternal and Child Health, Family Planning Levine
Dr. Conrad, Chairman
Better Mental Health for the Atlanta Area Smith
James A. Alford, M. D., Chairman
Control of Air, Water Pollution_and Waste Disposal Alexander
Bernard H. Paley, M. D., Chairman
Proctor Creek — Case Study of Multiple—Impact Alexander
Health Hazards .
Otis W. Smith, M. D., Chairman
Public Health - Budgets, Boundaries and Personnel Thompson
Wm. F. Thompson, Chairman
Vector Control Alexander
Mrs. Helen Tate, Chairman
Emergency Health Services — The Systems Approach Alexander
Dr. George Wren, Chairman
Prevention of Accidents Alexander
Mr. Max Ulrich, Chairman
Medical and Dental Service/Information and Referral Bush
Dr. Robert Wells, Chairman .
Alcohol and Drug Abuse Smith
Mr. Bruce Herrin, Chairman
Balancing the Costs of Health Care Bush
Mrs. Harriet Bush, Chairman
Coordination of Planners Bush
Mrs. Harriet Bush, Chairman
Suicide Prevention - Crisis Intervention Smith
W. J. Powell, Ph. D., Chairman .
Mental Retardation Program Needs Smith
Mr. G. Thomas Graf, Chairman
Parks and Recreation Alexander
Rehabilitation Branton
Mieczyalaw Peszczynski, M. D., Chairman
Environmental Effects on Social and Economic
Processes Alexander
Mr. Clifton Bailey, Chairman
Environmental Effects on Mental Health Alexander
Mrs. Faye Goldberg, Chairman
Table of Contents, Cont'd.
Task Force
Home Sanitation
Mrs. Helen Tate, Chairman
Food Service Program
Mr.
G. DeHart,
Chairman
Responsible
Staff Member
._I_,_._.———
Alexander
Alexander
Page
46
48
FOREWORD TO VOLUME III
The descriptive reports in this volume represent the efforts of some 27
"task forces" organized to assist the comprehensive health planning staff
in identifying the Atlanta area's health problems in sufficient detail
to project the scOpe of the first year of effort by the permanent planning
staff. Several hundreds of area citizens, both health providers and
health consumers contibuted their time, expertise, and insights in the
preparation of these reports. Although in many cases, the task force
reports were quite detailed and voluminous, all have been condensed for
inclusion in this volume. The points of view expressed in these reports
are those of the task forces themselves, and their recommendations deal
with the specific problem areas, rather than with the total community
health situation. As input to the total planning process, these are valuable
documents, and the staff expresses great appreciation to the task force
chairmen and members.
Manpower Shortage in Allied Health Professions
SUMMARY:
EXISTING VACANCIES WILL INCREASE ALARMINGLY WITH POPULATION GROWTH UNLESS
MORE INDIVIDUALS ARE ATTRACTED AND RETAINED. THESE PROFESSIONS SHOULD BE
UPGRADED AND PUBLICIZED: EDUCATIONAL OPPORTUNITIES SHOULD BE DEVELOPED,
AND TRAINING PROGRAMS COULD USE FINANCIAL SUPPORT. SYSTEMATIC EVALUATION
OF EXISTING AND FUTURE NEEDS AND RESOURCES SHOULD BE DETERMINED AND UTILIF
ZED AS THE BASIS FOR A COMPREHENSIVE EFFORT T0 CORRECT THESE DEFICIENCIES.
Problem:
Demand grows faster than supply. Why?
—-While existing vacancies are distressing,
—-Popu1ation increases create new needs;
——Public and professional awareness of these professions
is minimum;
——Required education (B.A. or corresponding degree) is not
within the financial reach of many;
--Professiona1 dedication is exacting;
Y E T
VOCATIONAL BENEFITS,
CAREER OPPORTUNITIES AND
PRESTIGE are inadequate.
-4Training programs are still in the development stage in Georgia;
——Communication and coordination needed to unite all related
health care groups behind a study and solution of this problem
is lacking;
——Funds to deve10p programs, Sponsor students; for research and
patient care are not available.
——Accurate assessment of all needs - present and future, has not
been made.
Resources:
There are clinical, medical, rehabilitation facilities which provide
practical training, and while the number is increasing, further expansiOn
will be necessary.
One graduate and two undergraduate programs in Allied Health Profess—
ions are presently under development, but these will require time to grow
and graduate trained individuals. Even these, however, cannot fulfill
the number or variety of available positions. 2
Solutions:
Undertake systematic analysis of the entire problem to serve as a
realistic basis for planning and corrective action.
Provide financial support, develop career incentives, arouse public/
professional interest in and for thesa professions.
Develop transportation and communication networks in all areas:
patients, employers, health professionals, institutional, organizations
and associations, public and private agencies.
Empahsize broad health service rather than: crisis oriented care.
Improve and expand hospital and rehabilitation facilities to assist in
training and improve use of present personnel.
Mount an aggressive campaign to recruit and retain — even recall —
existing personnel.
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NUMBER OF REGISTERED ALLIED PROFESSIONAL PERSONNEL IN GEORGIA AND IN T1115:
I I ATLANTA METROPOLITAN AREA
Georgia Metropolitan Area
4,000, 000¢——- population —.p 1,300,000
135_ Physical Therapists—75
9,092 (3,267}i'—Nurses—-—-fi3,865 (1,477)
40"“— Oceupational Therapists—#19
1,000—— Social Service—+500
(100 students included)
175; Speech Pathologists flTS¥
{i (inactive)
4(pub1ic schools included)
Ml
Home Health Care
SUMMARY:
THE PAUCITY OF HOME HEALTH SERVICES IN THE ATLANTA AREA LEAVES MANY
PATIENTS WITHOUT NEEDED CARE, CREATES SERIOUS BOTTLENECKS IN INSTI-
TUTIONS, AND LIMITS PHYSICIANS IN THEIR CHOICES OF SETTINGS WHERE
PATIENTS CAN RECEIVE ADEQUATE CARE. THE ANSWER LIES IN THE AMAL~
GAMATION OF ALL PROVIDER AGENCIES.
Text Outline:
* We DO have:
i duplication, fragmentation, and threats of further
proliferation;
i increasing service needs due to upward trends in popu—
lation growth, longevity, institutional costs and man-
power shortages;
seven agencies serving fewer than half of the patients
who need services;
obvious gaps in services to the sick and disabled at
home,
fairly adequate services for protecting the general
community health, and
interest and concern for better coordination, primarily
due to activity under-special projects over the past
three years.
DO NOT have:
a a central coordinating and research unit;
I the most efficient, economical, and effective utili-
zation of our limited supply of personnel;
a whole-hearted cooperation and trust among agencies,
institutions, other providers, and consumers;
i insurance exchange to provide payment for home care in
lieu of hospital care;
i a structure to provide central information, liaison, and
easy access to care;
i designated responsibility for the expansion and develop-
ment of comprehensive personal care services at home; and
a a well balanced range of services.
-K Specific charge to comprehensive health planning:
* Long Range: agressive action to amalgamate s11 agency
previders of home health services; and
i Immediate: central coordination and establishment of
research and education programs in home
health services.
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Meeting Health Problems Compounded with Socio—Economic Problems
S UTu‘HithY :
THE POOR AND DISADVANTAGED SUFFER INEQUITIES IN HEALTH LEVELS AND CARE
EiUND‘rIR EXISTING INSUFFICIENT, INCONSISTENT AND UNCOORDINATED ARRANGEMENTS
EWUICH ALSO'DO NOT CONSIDER THE ALMOST INSEPARABLE SOCIAL, ECONOMIC AND
CULTURAL PROBLEMS. A SYSTEM BASED ON IMPROVING LIVING CONDITIONS, HEALTH
EDUCATION, AND CITIZEN PARTICIPATION WOULD PRODUCE MORE PERMANENT RESULTS
WHILE MORE EFFECTIVELY UTILIZING PUBLIC FUNDS.
Problem:
Poor sanitation, inadequate and improper diet invite and perpetuate
health problems.
The under and improper use of health services and resources lend to the
seriousness and aggravation of health services and problems.
Quality of housing and overcrowding are related to certain diseases,
accidents, and mental disorders.
All of these primary social and physical conditions are character-
istic of the economic poor.
Health care tends to be piecemeal, poorly supervised, and uncoordinated.
Current Resources:
Public Health Department programs, services, facilities
Federal outlays of $465,453,901 in 1968 (HEW, HUD, 0E0)
' Charity hospital with more than one thousand beds
Local and State Government contributions
Over twenty health-centered voluntary agencies
Solution:
A health centered approach to these problems should:
nplan together with other social institutions, programs, and movements
to develop adequate and safe living conditions in the areas of homelife,
housing and neighborhood, transportation, health and general education,
business and industry, legal arrangements, health resources, etc.; and
nencourage the development and improvement of medical resources and
programs to meet technological, organizational, cultural, geographical,
numerical considerations of what our society needs.
Trends:
Indications are that as things go, "the sick get poorer and the poor
get sicker." In turn, it is their voice which is seldom heard and
frequently not interpreted into programs designed for them.
PROBLEMS IDENTIFIED FDR COMPREHENSIVE HEALTH
PLANNING BY A SAMPLE OF LOW—INCOME RESIDENTS
Meeting 1 2 3
6 7
Problem County G F G F F
8 1
Present 24 15 10 8
HEAUTH
Knowledge of Services
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Trash, litter, refuse
Emer1enc Care
Discrimination at Hospital
Insufficient Personnel
Inadequate Services
Sewage
Garbage and Hats
Limitation of Charit Care
Special Envioronmental Heed
Health Problems Total
HEALTH RELATED
Finances
Transportation
{Garbage Service
Code Enforcement
Housing
Street Lightin:
Eire Hydrants
Housekee in
Mental Releasee Employment
Health Related Problems Total
All Problems Total
G=Gwinnett County =mild concern
F=Fu1ton County =high concern
Problem Indicators:
ATLANTA (SMSA) , 1960:
Overall:
Families with income under $3,001
Unsound housing units
In Depressed areas:
Families with income under $3,001
Persons per residential acre
Non-white:
Percent of total population
Median income
Median years of education
Title: Better Mental Health for the Atlanta Area
SUMMARY:
MENTAL HEALTH PROBLEMS GENERALLY ARE CAUSED BY STRESSES AND STRAINS ON PERSONS AND ARE DUE TO ENVIRONMENTAL,.
PHYSICAL, SOCIAL, ECONOMEC, EDUCATIONAL AND OTHER FACTORS. ONE OUT OF TEN PERSONS COULD BENEFIT BY RECEIV-
ING SOME FORM OF MENTAL HEALTH SERVICES. BUSINESS AND INDUSTRY BUFFER HEAVY LOSSES FROM THE IMPACT OF
MENTAL ILLNESS ON EMPLOYEES AND THEIR FAMILIES. SURVIVAL OF OUR DEMOCRATIC INSTITUTIONS IN THIS HIGH ENERGY
NUCLEAR AGE MAY WELL DEFEND ON MOBILIZING THE RESOURCES OF EVERY COMMUNITY TO FIGHT AND PREVENT MENTAL DIS- '
ORDERS AND TO PROMOTE POSITIVE MENTAL HEALTH.
Problem:
130,000 inhabitants of the metropolitan area (10% of population) could lead happier more effective lives
if they had the benefit of modern mental health services.
Ten percent-of school children have handicapping emotional and psychological problems. These children
need help towards self-realization.
Heavy loss by business and industry in the metropolitan area due to impact of emotional and psychological
disturbance on worker and family, can be drastically reduced by a comprehensive system of modern mental health
services.
Greater involvement of general hospitals, physicians, and psychiatrists is essential to proper develop-
ment of mental health programs.
Insurance coverage not yet adequate.
More MANPOWER must be made available; better use should be made of present personnel and new sources of
manpower explored.
Mental health services must be brought to the people rather than administered for the convenience of the
"establishment".
Full development of comprehensive community mental health centers in the ATLANTA AREA is 3 TOP PRIORITY.
Total resources of every community should be mobilized to treat and rehabilitate victims of mental
illness, to PREVENT mental disorders, and to produce a climate conducive to better mental health for all.
a
Physicians could and should be first line of defense against mental illness, but their medical train-
ing has not prepared them for this role. The outpatient clinics, as a rule, are severely understaffed.
A crucial barrier to the developing mental health program is lack of trained personnel.
Current Status:
No general hospital in the Atlanta Area accepts patients who are mentally ill. Exceptions: Emory
University operates a psychiatric unit of twenty beds for patients selected for teaching purposes; and
Grady Memorial Hospital has a psychiatric unit of thirty-six beds for emergency short-term patients.
The public schools' staff, while improving in number and qualifications, is still inadequate.
The State Retardation Center is under construction.
Psychiatric units as components of comprehensive community mental health centers are under construc—
tion, as follows: Clayton County Hospital (25 beds); DeKalb General Hospital (d4 beds); and Northside
Hospital, Fulton County (25 beds).
There are four private psychiatric hospitals in the Atlanta Area (SHEA).
The State Regional Hospital (Atlanta) has been constructed and is being activated to serve fourteen
counties.
The State of Georgia has built the Georgia Mental Health Institute for the primary purpose of
”training and research".
Possible Solutions:
The full development of at least ten proposed comprehensive community mental health centers in the
Atlanta Area will alleviate for the present many of the problems when they become operational.
More MANPOWER must be made available, better use should be made of present personnel and new
sources of manpower should be explored.
Total reliance must not be placed on hospitals, clinics, or mental health professionals to do the
"job" of dealing with mental health problems; but rather every resource in the community, such as the
schools, the churches, the courts, the health and welfare agencies, etc., should be fused with and
oriented in basic principles of mental health, that each will be a positive force that will help create
a climate conducive to better mental health for all.
COMPREHENSIVE
COMMUNITY MENTAL HEALTH PROGRAM
COMMUNITY
HEALTH SERVICES
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Control of air, water pollution and waste disposal vital to Atlanta
Area future.
SUMMARY:
THE CONSERVATION OF ENVIRONMENTAL RESOURCES OF AIR AND WATER AND THE RELATED
CONTROL OF WASTE DISPOSAL ARE FUNDAMENTAL CONTRIBUTORS TO HEALTHFUL LIVING.
IN THE ATLANTA METROPOLITAN AREA THE CRITICAL PROBLEM IS ONE OF AREAWIDE PLANNING
AND IMPLEMENTATION IN TERMS OF PRESENT AND PROJECTED POPULATION NEEDS.
Problem:
Present water resources will be adequate for future needs only if handled
properly on a planned basis. Waste water, solid waste, and air pollution are
compounding problems as a result of lack of overall planning and coordination
among governmental bodies. Pollution of rivers and streams threatens health,
recreation and wildlife. Automobile graveyards, rodent-infested litter and
dump areas illustrate to the observer an increasing solid waste problem, Air
quality control is insufficient for future needs as projected.
Resources:
Local governments and governmental agencies, collaborating organizations,
University projects (capacially the Comprehensive Urban Studies Program of Georgia
State College), and planning agencies have Sufficient resources to creatively
deal with the problem, given funds and responsibility.
Solutions:
Dissemination to governments and others of the exhaustive study prepared for
Atlanta Region Metropolitan Planning Commission, and implementation of its
recommendations.
Increased coordination of those concerned with the problem and able to
enforce recommendations.
Conscious, deliberate effort at communicating extent and import of the
problem to the public. Recruitment of volunteers for active support.
Regulations for usage and control developed and enforced.
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POLLUTED STREAMS
Proctor Creek - Case Study of a Multipleulmpact Health Hazard
SUMMARY: -
PERIODIC FLOODING OF PROCTOR CREEK, A HIGHLY POLLUTED WATERWAY IN SUBURBAN
ATLANTA, RESULTS IN CONTAMINATION, DROWNINGS, INCREASE IN NUMBER OF PESTS,
DESTRUCTION AND LOSS OF PROPERTY. REDUCTION IN POLLUTION AND FLOOD LEVELS
MUST BE SOUGHT TO IMPROVE OVERALL CONDITIONS IN THE NEIGHBORHOOD.
Problem: _
An area involving 1200 residences and 6000 families encounters the
following problems as direct result of pollution and flooding of the creek:
Seven drownings in six years.
Illnesses directly related to pollution.
Sewage backup and overflow conditions in homes.
Uninhabitable basements resulting from constant sewage backup.
Severe, oppressive odors.
Proliferation of pests, insects, rats.
PrOperty erosion, damaged building foundations, loss of large articles
in floods.
Fire hazard from oil and other flammable materials in creek.
Current Resources:
Georgia Water Quality Control Board, Public Works Department of Atlanta,
the Corps of Engineers, and area industrial plants.
Solutions:
Alternative plans and detailed study of cost alternatives and benefits
will be necessary for improvements of the creek and adjacent areas. Possi-
bilities include:
Channel improvements, floodwalls, enclosure, zoning restrictions.
Controlled access to prevent drownings.
Clean stream beds and banks of unsightly and hazardous objects that block
stream flow.
Separation of sanitary and storm sewers.
Make area adjoining stream part Of a lineroe regional park.
Evacuate residents and fill creek.
Indict companies contributing to pollution.
SNACK .
'HOU-SEHOLDS'NOT CONNECTED TO PUBLIC WATER
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‘ OPEN SEWERS ’
Public Health, Budgets, Boundaries and Personnel
___I.__I_a________.__i____.________i___________
SUMMARY: .
THE NUMBER OF PERSONS TREATED WITHIN PUBLIC HEALTH SERVICES, ALMOST
WITHOUT EXCEPTION, IS DIRECTLY RELATED TO THE COUNT OF MANPOWER,
FACILITIES, AND POPULATION OF A GEOGRAPHICAL AREA RATHER THAN TO
COMMUNITY HEALTH. OF COURSE, THIS IS A CONVENIENT ARRANGEMENT OF
OUR MARKET ECONOMY AND JURISDICTIONAL SUBDIVISIONS. IF SERVICES WERE
BASED ON MORE EXTENSIVE INVESTIGATION AND DOCUMENTATION OF HEALTH
NEEDS RATHER THAN A CAPACITY TO PROVIDE SERVICES, PRESENT RESOURCES
AND EFFORTS COULD BE MORE EFFECTIVE.
Problem:
Programs in Public Health are dependent upon both county and
state funds and budgeting policies.
While these policies do take into account health needs and demands,
they are directly affected by grant-in-aid formula.
As grant-in-aid monies are received on a local level, local dir-
ectors are required to decide on where local Onatching) money, furn-
ished by the county governments, will be spent.
A thorough analysis of cammunity consumer needs has not been
developed.
It is patently impossible for the same individual to both operate
and objectively evaluate program areas.
Confining program Operations along county lines has adversely
affected certain state health programs.
Reciprocity is provided for and_is even discouraged by budgets.
A planning agency could:
Broaden the voice of decision in programs to include lay, govern-
mental, and professional consumers as well as providers.
Share the burden of public health officials in allocation decisions.
Extend planning and establish communication across county lines in
such programs as water and air control, industrial hygiene, sanitation,
etc.
Title: Emergency Health Services - The Systems Approach
SUMMARY:
PRESENT EMERGENCY HEALTH SERVICES DEFEND UPON DECISIONS OF MANY INDEPEND-
ENT LOCAL AUTHORITIES. LACK OF COORDINATION AND COMMUNICATION, AS WELL
- A3 LACK OF INFORMATION ON WHAT CARE IS AVAILABLE AND HOW TO UTILIZE IT
RESULT IN OMISSIONS, DUPLICATIONS AND DISSERVICE TO THE PUBLIC.
Problem:
There is much adequate emergency health care being planned and
provided (especially for disaster and mass casualty) but uncoordinated
efforts are resulting in dynamic deficiencies:
NEEDS Unfulfilled in some vital areas
STAFFING numbers
‘ Inadequate quality
FACILITIES distribution
SERVICES Incomplete and often tardy
Restricted to some classes
Part—time death follows no clock
INFORMATION Fragmented in—service and to the
public who often most need to know
TRAINING Insufficient for public self-help or
service personnel needs
TRANSPORTATION Dangerous clogged urban corridors
delay help/cause accidents
FINANCING Marginal and less in urban areas
COMMUNICATION Infrequent between the private and
public power structures most involved
in health services
PLANNING Duplications & uncoordinated efforts of all
Omissions 6—county area groups;
emergency health programs;
Unimaginative reluctant public and pro~
fessional acceptance of new methods
Needed:
One comprehensive system administered by one community—wide
representative agency.
.1
Solution:
The Systems Approach: The involvement of all health-concerned institutions,
organizations -- including governmental units and officials, both 1egisla~
tive and executive under the experienced guidance of health professionals.
The Goal: One central agency, one overall plan, to provide total, ade-
quate emergency health services and care throughout the community.
Objectives:
* Increase staffing and facilities
tFTovide adequate ambulance service
iTrain the public in first~aid and medical self—help
lEstablish hospital affiliated neighborhood health care centers
#Initiate two—way radio communication between hospitals, fire,
police, hospitals, and other emergency care units
$Hold actual disaster and mass casualty exercises
EMERGENCY SERVICES
1960 1970 1980 1990 2000
4,000,000
3,000,000
2,000,000
Population
,1
1,000,000
Total Population; Atlanta Five-County Source:
Atlanta Region Metropolitan Planning Commission
Emergency Health Services in the Atlanta Area???
Health care is divided into a number of-categories. One of the most
important of these is emergency health care. The following:
Hospital emergency room care
Emergency care in physicians' offices
Emergency care in_neighborhood health centers
Emergency care in industrial situations
First aid training of the public
Accident prevention
Ambulance services
Marking of evacuation routes
Helicopter evacuation and landing facilities
Emergency psychiatric and acute alcoholic care
Poison control and poison control centers
Blood banks
Communications between institutions and organizations
providing emergency health care
Public information on sources of emergency health care
Education and continuing education of personnel providing
emergency health care
Disaster and mass casualty reception
are not emphasized and organized in the Atlanta area.
Prevention of Accidents Can Significantly Reduce Area Toll of Deaths
and Injuries
fiflNNAEZi
ACCIDENTS CONSTITUTE A MAJOR HEALTH PROBLEM, RESULTING IN STAGGERING ECONOMIC
AND MANPOWER LOSSES. PUBLIC APATHY, THE MOST IMTORTANT OBSTACLE T0 PREVENTION,
MAY BE OVERCOME BY WELL PLANNED USE OF RESOURCES AVAILABLE IN VOLUNTARY SAFETY
CONTROL, LEGISLATION, IMTROVED COMMUNICATION FOR EDUCATIONAL PURPOSES, AND
PLANNING FOR BETTER SAFETY PHYSICAL FEATURES IN THE MOVEMENT 0F PEDESTRIANS
AND VEHICLES.
Problem:
An ever-increasing flow of traffic has led to more and more collisions,
injuries, and deaths. Nearly 50% of hospital beds are occupied by accident
victims. National figures indicate annual economic losses in 132 million days
bed-disability, 94 million days work less, 11 million days school loss, 22
million hospital bed days, and a total estimated cost of 12 billion dollars.
Home, traffic, and other accidents are most often incurred by those least able
financially and socially to bear the burden. This may chiefly be the result
of compounded difficulties ~- poor education, hazardous environment, low income.
Current Status:
Mortality statistics indicate the problem has reached epidemic proportions.
Accidents are the leading cause of death to persons under the age of 44, and
rank fourth as cause of death in all ages, following heart disease, cancer,
and stroke.
Obstacles:
A major challenge is that of changing the viewpoint of those who still
think of accidents as uncontrollable events. Public apathy exists, in this
more than any major area, largely as a result of ineffective communication
between experts and lay people. Indicative of this is fear of loss of per-
sonal freedom when strict preventive legislation is proposed.
Solutions:
1. Increased cooperation between safety councils, legislators, and mass
media for planning and communication.
2. Increased nae and standardization of drivers education in schools and
defensive drivers courses in adult organization.
3. Increased financial support for safety-involved organizations.
4. Research into human behavior aspects of safety/accident problems.
5. Better street and highway design in the Atlanta Area.
6. Elimination of unnecessary roads and streets in order to provide for
better pedestrian and vehicle movement.
7. Planned program of railroad, street and pedestrian "grade separation" in
the Atlanta area.
8. Institution of a streetlighting program.
_ 24 -
MAJOR FACTS ABOUT ACCIDENTAL INJURIES AND DEATHS-1968
(Statistics provided by: Epidemiology and
Surveillance Branch Division of Accident
Prevention,State of Georgia)
Following are estimates of the annual toll of accidents for the United
States:
Persons killed 112 thousand
Persons killed motor vehicle 53 thousand
Persons injured 52 million
Persons injured,moving motor vehicle over 3 million
Persons bed—disabled by injury 11 million
Persons receiving medical care for injuries 45 million
Persons hosPitalized by injuries 2 million
Days of restricted activity 512 million
Days of bed-disability 132 million
Days of work loss 90 million
Days of school loss 11 million
Hospital bed-days 22 million
Hospital beds required for treatment 65 thousand
Hospital personnel required for treatment 88 thousand
Annual cost of accidents $16 billion
Annual cost of accidental injuries $10 billion
It is estimated that the prevalence of physical impairments caused
by injuries in the non—institutionalized population of the United
States is over 11 million.
Medical and Dental Service/Information and Referral
SUMMARY:
INFORMATION ON THE HEALTH SERVICE NETWORK IN THIS AREA IS FRAGMENTED
AND UNCOORDINATED. REFERRAL PROCEDURES LACK STANDARDIZATION. CHANGING
POPULATION AND INDUSTRIAL CHARACTERISTICS SUGGEST RE-APPRAISAL OF CUR-
RENT AREAS OF CARE CONCENTRATION AND COORDINATION. MANY OF THE CAUSAL
FACTORS ARE BEYOND THE CONTROL OR EVEN THE PURVIEW OF THE PRACTITIONER.
A CENTRAL PLANNING AGENCY COULD GATHER, MAINTAIN AND DISSEMINATE THE IN—
FORMATION BOTH CARE PROVIDERS AND USERS NEED.
Problem:
Direct health care involves doctors, dentists, other health workers,
hospitals, health centers, associations, programs and community organi-
zations. The patient enters the system at any point, in highly varied
states of health, wealth, intelligence and experience. Both parties
suffer strain and are inefficiently serviced due, in part, to incomplete,
haphazard information and referral systems.
Atlanta Has: Health characteristics that are frequently below
National par, consistently below those of Northeast
metropolitan areas, but that rate favorably with other
parts of the South.
Population increases and related rising health service
demands that are offsetting past numerical gains in
medical personnel, facilities and agencies.
Aggravated problems of age, youth and working women
arising from rapid urbanization and industrial growth.
Complex administrative, educational and personnel
procedures resulting from complicated Federal pro—
grams and financing.
One large hospital supplying_quality care to a vast
but limited number of indigent sick of two counties.
Patients needing some types of care cannot be adequate-
ly treated, and even nonmal sicknesses exceed the
plant's capacity.
Medical societies and voluntary agencies making out-
standing efforts in community health planning and
implementation for several but incomplete areas.
Atlanta Needs:
Formal communication between demands and provisions of
services. Increased and more efficient use of existing
personnel and facilities.
Broader and more intense coverage of community health
problems.
26
SELECTED CHARACTERISTICS OF METRO ATLANTA WHICH AFFECT MEDICAL SERVICES
More older persons Domiciliary and extended care, treat-
ment for special diseases and impair-
ments. third-party payment
More younger persons Treatment for infectious diseases. in—
cluding venereal disease. accidents.
impairments, handicaps, maternal and
child care.
*Urbanization and industriali-
cation
Special groups Special deliveries of care (migrants.
veterans, etc.)
Affluence Greater quantity and quality of care.
Poverty Public provision of care.
Congestion Epidemiological control.
Suburbanization Geographical redistribution.
Formal groups Special interests.
Mobility Fragmented care.
Work shifts Full time availability.
Working females Convenience. special diseases.
Organization and Bureaucrati- Third-party payment, insurance, pre—
zation payment
Federalization Public programs and financing
Medical centers, schools Personnel demands
special institutions
Technological advancement Development of medical science
Greater expectations from public
mediums of broader communication
III I FIIII I ”III I I II“ I I III | I I III | I IIII | I "II | I IIII II I III PI II I I III: I I [III I lII' | I III” I IIII | I III! | IIIIl | I III | IIII I [Illlll Fl IIIJ 'IIIIIIIIIIIlIIIII IIrIIITIIIIllIIIII llll I IIIII I llllll lIllIl lIIIIl | IIII1 IIIIIIIIIIIII IHII'I
Title: Alcohol and Drug Abuse — Causes Human Suffering
SUMMARY:
RECOGNIZED AS THIRD LARGEST HEALEH PROBLEM, BUT CHARACTERIZED BY NEGLECT, STIGMA AND REJECTION. PUNITIVE
REACTION TO PROBLEM MUST YIELD TO A CONSTRUCTIVE APPROACH OF ASSISTING THE PERSON T0 RECOUP AND REGROUP
HIS PSYCHOLOGICAL RESOURCES FOR A MORE ADEQUATE RESPONSE TO LIFE'S RESPONSIBILITIES AND OPPORTUNITIES.
Problem:
Atlanta area (SMSA) leads nation in rate of arrests for public intoxication.
Largest market in world for bootleg whiskey.
Area has estimated 50,000 victims of alcoholism.
$5 million expended annually for local care of victims of alcoholism and their families.
$12 million annual loss to local industry due to alcoholism; absenteeism, accidentsI lowered efficiency, etc.
Human suffering due to alcoholism cannot be estimated.
General Hospitals of area reluctant to accept victims of alcoholism as patients. Ditto doctors.
No facilities for treatment of drug addicts.
Current Resources:
Are limited in scope. The Georgian Clinic division of the Georgia Mental Health Institute and limited
private programs, serve the entire state population. This service is incidental to the institute‘s research
and training mission. The Emory University Vocational Rehabilitation Alcohol project which has served the
chronic court offender alcoholic will probably be discontinued due to expiration of a three—year federal grant
program. The Georgia Division of Vocational Rehabilitation provides limited rehabilitation services for alco-
holics. A start has been made in the Atlanta Region (SMSA) toward preventing alcohol drug abuses through inte—
grating services for individuals with the plans for comprehensive community mental health programs.
Treatment, care and rehabilitation of victims of alcoholism and persons addicted to drugs must be incorpor-
ated in the services of the proposed comprehensive mental health centers of the area. including some adjacent
counties.
Additional reliable data is needed on the extent, nature and Scope of the local problems of alcohol and
drug abuse on a basis upon which to plan effective and innovative programs for prevention. control, treatment
and rehabilitation of alcohol and drug abuse.
-‘K Changing attitudes and concerns of communities by information, education and consultation.
-’[ More effective enforcement of drug laws and regulation of drugs.
Trends:
Since most authorities and federal officials embrace the view that alcohol and drug addiction is a
problem of living and probably symptomatic of an emotional illness that should be treated (a non-criminal
circumstance) it logically appears that newly developing programs associated with community mental health
centers will evolve as well as a thrust toward improving conditions in deprived neighborhoods where ad-
diction is most common.
Goals and Objectives:
The Georgia Legislature has expressly recognized alcoholism as a disease and declared it to be a
public health problem with administrative responsibility for alcoholic rehabilitation given directly
to the Division of Mental Health of the State Department of Public Health and indirectly to the County
Boards of Health and Public Health Departments. Comprehensive programs for alcohol and drug abusers
can be developed in conjunction with or as an integral part of comprehensive mental health programs.
The range of services that will be provided by the community mental health programs are very nearly
the range of services required for dealing with alcohol and drug problems. The goals of these pro-
grams and services will be: (1) improved health and prevention of disease; (2) separation of the
alcohol and drug abuser from alcohol and drugs; (3) repairing the physical and emotional damage and
preventing further damage; (4) changing community institutions, programs and services to meet the
special needs of the alcohol and drug abuser. While federal funds will be helpful in launching pro—
grams, state and local governments cannot presently rely upon federal funds for long-range support,
although such continued federal support may well represent the only hepe for programs for the alco-
hol and drug abuser in Georgia.
Balancing the Costs of Health Care
SUMMARY:
THE COSTS OF MEDICAL CARE ARE RISING SHARPLY, EVEN MORE THAN THE COST OF
LIVING. ILLNESS, DISABILITY AND PREMATURE DEATHS CREATE DISPARATE COSTS -
BOTH DIRECT AND INDIRECT - TO FAMILIES ACCORDING TO CIRCUMSTANCES WHICH
THEY CANNOT APPRECIABLY CONTROL: INCOME AND OCCUPATION, TYPE OF DISEASE
AND TREATMENT.
Problem:
The costs of health make it prohibitive to some families and ultimately
contributes to poorer health and additional costs to the community.
Current Status:
1. Federal assistance is directed to special groups of persons: Aged,
maternal and infant, indigent, etc.
2. Federal programs are developed around certain diseases and disabilities:
Crippled children, tuberculosis, blindness, cancer, venereal disease,
etc.
3. Middle—income groups use physicians' services at a lower annual rate
than other income groups.
4( Certain businesses and industries promote health and coverage from
debilitating health expenses.
5. The costs of health insurance rises with the cost of medical care,
capecially hospital rates.
Possible Solutions:
The rising cost of health may be stabilized and the entire community
brought into its purview within an area plan which can:
1. Review the eligibility requirements of tax-supported health services.
2. Reduce the demand on rare skills by providing information and referral
services to providers and consumers.
3. Recommend the wider inclusion of extra-hospital services in insurance
policies.
4. Promote the assembling of complex equipment, professional skills and
services to provide for extensive, continuous, non—domicilary treat-
ment. . ’
5. Encourage architectural and organizational modernization in hospitals.
-30—
NUMBER OF DISABILITY DAYS" PER PERSON PER YEAR
BY FAMILY INCOME, TYPE OF DISABILITY AND AGE
In the Unlled sum. July teas-June 1001'
T
E COSTS All llnder $3.000- $5.0 00- 5?.000- $1 0.000
Incomes“ $3.000 4.000 0.000 0.000 and over
RESTRICTED ACTIVITY -
All ages . 15.4 27.5 15.3 13.7 12.3 11.9
OF BEING UNHEALTHY Under 17 yam 9.9 _ 9.2 9.1 9.9 9.7 10.1
_ 1? - 24 years 9.5 12.5 9.5 9.0 9.5 7.9
25 - 44 years 13.8 24.5 17.0 14.1 11.9 11.3
45 - 64 years 21.4 43.5 25.5 19.0 15.9 14.5
55 years and over 35.2 39.5 29.2 35.2 34.5 29.0
BED DISABILITY .
All age: 5.5 9.7 5.9 5.3 4.4 4.6
Under 17 yeare - 4.3 5.1 4.2 4.5 ' 4.0 - 4.2
17 - 24 years - 4.1 4.5 4.4 4.0 4.5 3.5
25 - 44 years 4.5 9.0 5.5 4.5 4.1 3.9
45 — 64 years 6.9 14.3 . 7.5 5.3 4.9 4.9
65 years and over 11.9 . 13.2 0.2 ' 12.9 10.? 12.5
WORK-LOSS DAYS AMONG
CURRENTLY EMPLOYED'“
All ages 5.4 7.9 5.7 5.9' 4.4 4.6
Under 1? yearn -- — — —- —~ —
17 - 24 years _ 3.9 4.7 4.5 4.3 4.2 2.7
25 - 44 years ' 4.5 9.1 5.5 5.3 3.7 4.2
45 - 54 years 5.6 10.3 7.9 7.3 5.5 5.7
65 years and over 6.3 7.0 7.9 5.0 ““ 5.?
'Retere Io disebllltv because of acute endlor chronic condlllone.
"Includes unknown Income.
“'Beeed on currently employed population 17+ years 01 age.
““F-Igure does not meet standards or relieblilty or preclelon.
Source: United State. Netlonet Health Survey. United States Department or Heeltl'l.
(deem end Welt-m.
INCREASES IN MEDICAL CARE AND OTHER MAJOR
GROUPS IN THE CONSUMER PRICE INDEX
In the United statue. 1051-59 — 1997
All Items _19%
Food _'5*
Apparel _ 14%
Housing — "$6 13.”: COSTS
Transportation _ 15%
Medical c... —m
Personal Care — 18%
Readinzand _ 20*
Recreation 0]? BE ING HEALTHY
one: Goods _ 18*
and Services‘
°Gornprlm tobacco. alcoholic beverages. legal eervloee. burlel eervleoe. kinking 1m. etc.
Source: 0.8. Department or Labor, Burl-ll ol Lebor Stellellce.
-31-
Coordination of Planners
SUMMARY: -
A COMMUNITY-WIDE HEALTH PLAN CANNOT SUCCEED WITHOUT STRONG COORDINA-
TION OF ALL INTERNAL AND EXTERNAL SPECIALIZED PLANNERS. THE VARIETY
AND INTERDEPENDENCY OF MODERN PLANNING AGENCIES REQUIRE A CAREFULLY
CONSIDERED LONG-TERM BASIS FOR BENEFICIAL INTERACTION AND EXCHANGE
WITHOUT LOSS OF CREATIVE AUTONOMY. PRESENT SHORT-RANGE, INFORMAL,
INCOMPLETE COORDINATION, WHICH CAN RESULT IN DUPLICATIONS AND
OMISSIONS, SHOULD BE STRENGTHENED BY A COMPREHENSIVE, CONSENSUAL
LONG-RANGE PLANNING FRAMEWORK.
Text Outline:
; Reasons for coordination:
:}The informal, unstructured coordination among local
planners are inadequate to the pace of change in the
modern community.
l-Present planning coalitions are arranged around
limited groups and mainly for short range goals.
*While there are 60 agencies listed as serving
the physically disabled, the gaps and overlaps
are only suggested, the interrelationships are
not well established.
I}(fities are receiving increasing amounts of federal aid
and attention yet no projective framework for land—use,
transportation' services, health cars, etc., has been
adopted by relevant providers.
Physical and pOpulation rearrangements are widespread
and require accompanying service rearrangements.
fir How coordination could be achieved:
fl-Provision of channels of communication and programs of
active cooperation by:
n-exchanging of skills and controls (personnel, data,
funds, etc.);
n-use of computer based techniques; .
» interlocking decision-making arrangements;
I overlapping of common jurisdictions; J
l-organized contacts on multiple levels of staff; and
n-meetings, conferences, mailing lists.
PROFILE OF HEALTH AND HEALTH RELATED PIANNING AGENCIES
Agency (Coded)
10 ll 12 13 14 15 16
Characteristic (Yes =.)
EIEI
EII
II
El
EIIEIEIIIJEIEIIEI w
El
CID
IEI
II
EIEI
II
EIEI
.DDDD Permanent
EIIIII can,
EIEIEEIEI'. - .. ..
EEmE Directl related to health
I I iAdvisory function
Dunn Implementing function
mu Collects health data
m. Direct evaluation rocedure
m. Uses outside consultations
Reports on request
E]
El
El
I
El
El
EEIB
HEEIHIEE
"II | I IIIII I III" I "III I III" I | IIIIII IIIIII I I "III I I-Il II III" I | IIIII I II "II I I "III I III“ I IIIFI I I I'll I | IIII I I I I II II I I l-Itl I I till I | | IIIIII I IIIKI I I III. I ' 1.1!“ II I- II I II
I
I
I
E-n Reorts ublished (health
mediate future lans
Formal intera enc r a '
F
inance intcra enc cooni.
IDUDDIID-l Formal p1annin_ structure .
III: I IIIII I I II“ II II IIIII I IIIII I IIIII I I II
EXTENT AND DIRECTION OF INTERCHANGE AMONG A SELECTED GROUP OF PIANN'ERS
PLANS WI TH
EHHIEEHEEEEEHE
Note:
listing may be found in the Appendix.
Numbers and letters are coded for names of agencies.
CONS ULTS
HHEEHEEEEIEE
A decoded
Suicide Prevention — Crisis Intervention
SUMMARY:
THE MAGNITUDE, URGENCY AND COMPLEXITY OF SUICIDAL AND PSYCHIATRIC CRISES
MAKE THEM PUBLIC HEALTH PROBLEMS. THE TRAGEDY, CHRONIC RECURRENCE AND
OFTEN LENGTHY HOSPITALIZATION CONNECTED WITH THESE EMERGENCIES CAN BE
AVERTED OR ALLEVIATED BY CONSISTENT PREVENTIVE CARE. THE PROPOSED COMMUNITY
COMPREHENSIVE MENTAL HEALTH CENTERS COULD EFFICIENTLY PROVIDE THESE NEEDED
MULTI-DISCIPLINE SERVICES.
Problem:
- Past reluctance of the general lay and medical public to openly become
involved in the recognition, research, cooperation and sympathetic_treatment
these crises demand.
Suicide nationally, ranks among the top ten causes of death; is fourth
in cause for all male deaths between 20-45, and is second highest cause
among college fatalities.
In the Atlanta Metropolitan Area, the suicide rate exceeds the National
average by about 25%.
For each actual death by suicide, 8-10 serious attempts occur.
_Psychiatric crises--that often end in suicide or physical violence to
others, can often be foreseen by trained personnel in the complex web of
social, economic, cultural and health problems that aggravate mental insta-
bility.
IThe essence of time demands quick reaponsive help.
l-The desperate bewilderment requires easily available aid.
I-The constant danger needs constant service, on a 24 hour basis.
*Follow—up of all cases is basic.
Current Resources:
Only two Georgia counties, Fulton and DeKalb, are served by a suicide-
prevention, crisis'intervention center. Coordinated with Grady Memorial
Hospital psychiatric services and the respective County Health Departments,
the program has two multi—discipline crisis_teams available 24 hours a day.
A total of 4,375 patients were treated in 1968.
A unique telephone service, also manned 24 hours a day, 7 days a week,
was set up to cover ten counties, on a toll-free basis. The "staff" includes
a psychiatrict, a clinical psychologist, a psychiatric nurse, three public
health nurses, two sociologists, and six "lay counselors."
Solution:
The fastest possible implementation of the ten proposed Community Mental
Health Centers in the Metropolitan Atlanta Area, with the backup of Georgia
Regional HOSpital-Atlanta.
*To: Prevent crises before they occur.
Eradicate the social stigmas of the problems.
Enlist full support of all medical and political units.
Make effective use of current knowledge and resources.
- 34 -
FELToN—DeKALB EMERGENCY MENTAL HEALTH SERVICE
CASES BY COUNTY - FIRST 13 MONTHS
Fulton ......... 1530 44.1% Gwinnett ......... 45 1.3%
DeKalb... ...... 622 17.9% Douglas 10 .3%
Cobb ... 130 3.7% ... 57 1.6%
2.0% 1009 29.1%
PSYCHIATRIC SERVICES — GRADY MEMORIAL HOSPITAL
January - December, 1968
I Emergency Patients
II Inpatients
III Outpatients
IV Consultations:
A. Medical Inpatient Service 356
B. Pediatrics 166
C. Obstetrics 757
V. Drug Clinic
Opening July, 1968-December, 1968 303
VI. Crisis Service
Opening August 19, 1968—December, 1968 421
VII. Psychiatric Day Center
Opening November 4, 1968-December, 1968 36
MENTAL RETARDATION (MR) PROGRAM NEEDS: MORE, BETTER, EARLIER,
MORE ACCESSIBLE
SUMMARY:
MENTAL RETARDATION IS ONE OF THE FOREMOST HEALTHI SOCIAL AND ECONOMIC
PROBLEMS IN THE METRO ATLANTA AREA. PUBLIC SCHOOLS PROVIDE LESS THAN
50% OF THE SERVICE NEEDS OF THE EDUCABLE MR CHILD, AND APPROXIMATELY
50% OF THE SERVICE NEEDS OF THE TRAINABLE MR CHILD. MINIMAL SERVICES
ARE OFFERED THE PRE—SCHOOL AND POST SCHOOL RETARDATE. DIAGNOSTIC AND
EVALUATION CLINICS, EDUCATION AND TRAINING PROGRAMS AND ADULT SERVICES
MUST BE GIVEN PLANNING EMPHASIS. SERVICES ARE WASTED HOWEVER UNLESS
PLANS ARE MADE TO INSURE DELIVERY OF THESE SERVICES TO THE CONSUMER.
A TRANSPORTATION PLAN MUST THEREFORE BE A VITAL PART OF PROGRAM DESIGN.
The Problem: The MR person is one who, from childhood, experiences
unusual difficulty in learning, and is relatively ineffective in
applying what he has learned to the problems of life. He needs Special
training and guidance to make the most of his capacities.
Current Status: In Metro Atlanta, there are an estimated 42,647 re-
tarded persons. At the present time, only 6,804 individuals by our
survey are receiving education and training, residential services,
vocational rehabilitation or other adult services from apprOpriate
community agencies.
Needs: While all the metropolitan area school systems offer some
services for mentally retarded children, many are not served.
Private residential facilities serve only non-ambulatory neurologically
impaired children. Vocational Rehabilitation works with retardates en—
rolled in public school special education programs, and with a limited
number of MR frOm the community at large. Expansion of all these pro-
grams is needed. Day training facilities for the severe and moderate
pre-school, severe school age,-and severe find moderate adults should
be established.
Structure of Planning Organization: The responsibility for area wide
mental retardation planning should rest in a 6 county planning body
made up of representatives from the 6 local health districts. Each
district would appoint 6 representatives, drawn from vocational re—
habilitation, the health department, family and children's service,
public schools, assOCiations for retarded children, and recreation
departments. An ma specialist should be employed.
mmmm ' ADAPTATIONi WWW . .
‘eamqumuamn; rdmmuan
.. .. .- ._ ,\’o. _"-"I=
Estimated Number of MR Persons in the 5 County Area**
Level of Retardation Chronological Age Range
0 - 5 6 - 17 18+ Total
Mild 5409 9554 24506 39469
Moderate 305 537 1375 2217
Severe 108 191 493 792
Profound 22 42 105 169
Grand Total 42,647
Existing Services in the 5 County Area**
Public Schools Private Schools Residential Voc. Adult
EMR TMR EMR TMR Private-Public Rehab. Act.
5151 37? 40 225 106 120 703 82
Organizational Chart** -
Comprehensive Health Planning
Metro Atlanta MR Planning Committee
FULTON GWINNETT ' CLAYTON
One Re-resentative from each field
Voc. Rehab. Voc. Rehab. Voc. Rehab.
Health Dept. Health Dept. Health Dept.
FACS FACS FACS
Schools Schools Schools
ARC ARC ARC
Recreation Recreation Recreation
MR Specialist
Secretarial Staff
* 1. Conceptual Visual Aid: Interaction of Multiple Factors.
(From Richmond, J. B., and Lustman, S. L., J Med Educ 29:23
GMay) 1954).
** Douglas County not included in the above 5 county tables and charts.
_ -37-
Voc. Rehab.
Health Dept.
FACS
Schools
ARC
Recreation
Voc. Rehab.
Health Dept.
FACS
Schools
ARC
Recreation
Title: Parks' and Recreation‘s Lag in FacilitiesI Services and Manpower.
SUMMARY: _
GREATER RECOGNITION, FINANCIAL SUPPORT AND PARK/RECREATION PLANNING SHOULD BE GIVEN THE
GROWING DEMANDS FOR RECREATION AND PARK FACILITIES, PROGRAMS AND SERVICES THROUGHOUT THE
I ATLANTA AREA, (SMSA). IT BEHOOVES LEGISLATOR, RECREATION AND PARK EXECUTIVES TO OBSERVE
AND CORRECT THE PRESENT LAG OF FACILITIES SERVICES AND PROFESSIONAL MANPOWER NEEDS IN THE
-FASTEST GROWING CITY IN THE SOUTHEAST.
Problem:
Unfortunately, Atlanta does not have the park system and recreation program it needs
and deserves. There is:
lack of good public relations absence of public information
on parks and recreation
lack of public and city support
past segregation and apathy
inadequate local financing of current integration
rising cost of land lack of a comprehensive plan
to guide park and recreation
insufficient maintenance development
insufficient acreage lack of standards at the state
and local level.
staff personnel occupying position
without proper training
Possible Solution:
To provide recreation programs and facilities in all neighborhoods of the city.
\
To encourage housing project and apartment owners to include recreation facilities.
To insure close supervision of staff and a good in-service training program for staff
members that are not professionally trained.
To recruit professionally trained personnel for staff position.
To provide a well—balanced program for all ages, with a wide variety of interests.
To involve residents in planning and Operation of public recreation.
To provide minimum standards for all recreations programs.
Trends:
These are not theoretical standards. A survey done in 1965 showed that 49 out
of 189 cities met the acreage standards. As part of this study, comparisons were
attempted with other cities the same size as Atlanta. Overlapping governmental
jurisdiction made these comparisons difficult, but it appeared that out of 20 simi—
lar cities, 15 to 7 had more park acreage per pepulation than Atlanta. About one-
half met the acreage standards.
Inadequate open space. ;
Inadequate Planning.
Lack of interest at the Board of Aldermen level.
Diverted funds-