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Frank Hope has walked with a limp since contracting polio in 1950. When he watches his daughter run after her young toddler, he feels a sense of gratitude that the era of vaccination has protected his child and grandchild from such a disabling infection. He recalls the excitement that gripped the nation as the Salk polio vaccine was first tested and then adopted into widespread use. In Frank’s mind, these types of scientific breakthroughs attest to the wonders of the US health care system.

Frank’s grandson attends a day care program. Ruby, a 3-year-old girl in the program, was recently hospitalized for a severe asthma attack complicated by pneumococcal pneumonia. She spent 2 weeks in a pediatric intensive care unit, including several days on a respirator. Ruby’s mother works full time as a bus driver while raising three children. She has comprehensive private health insurance through her job but finds it difficult to keep track of all her children’s immunization schedules and to find a physician’s office that offers convenient appointment times. She takes Ruby to an evening-hours urgent care center when Ruby has some wheezing but never sees the same physician twice. Ruby never received all her pneumococcal vaccinations or consistent prescription of a steroid inhaler to prevent a severe asthma attack. Ruby’s mother blames herself for her child’s hospitalization.


People in the United States rightfully take pride in the technologic accomplishments of their health care system. Innovations in biomedical science have almost eradicated scourges such as polio and measles and have allowed such marvels as organ transplantation, “knifeless” gamma-ray surgery for brain tumors, and intensive care technology that saves the lives of children with asthma complicated by pneumonia. Yet for all its successes, the health care system also has its failures. For example, asthma is a leading cause of hospitalization in childhood. Proper health care can markedly reduce the frequency of severe asthma symptoms and of asthma hospital admissions. In cases such as Ruby’s, the failure to prevent severe asthma flare-up is not related to financial barriers, but rather reflects organizational problems, particularly in the delivery of primary care and preventive services.

The organizational task facing all health care systems is one of “assuring that the right patient receives the right service at the right time and in the right place” (Rodwin, 1984). An additional criterion could be “… and by the right caregiver.” The fragmented care Ruby received for her asthma is an example of this challenge. Who is responsible for planning and ensuring that every child receives the right service at the right time? Can an urgent care center or an in-store clinic at Wal-Mart designed for episodic needs be held accountable for providing comprehensive care to all patients passing through its doors? Should parents be expected to make appointments for routine visits at medical offices and clinics, or should public health nurses travel to homes and day care centers ...

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