Editorials
Injuries a n d D e a t h s F r o m G a n g Violence: They A r e P r e v e n t a b l e
Injuries and Deaths From Gang Violence: They Are Preventable
H Range Hutson, MD See related article, p 1291.
Deirdre Anglin, MD William Mallon, MD
Day-Night D i f f e r e n c e s A r e N o t Always D u e to C i r c a d i a n C o n t r o l J Woodland Hastings, PhD Charles A Czeisler, PhD, MD
Universal Access: Its P o t e n t i a l I m p a c t on E m e r g e n c y Medicine Thomas P Well, PhD
Public P o l i c y a n d the E m e r g e n c y D e p a r t m e n t Robert M Williams, MD, FACEP
The Effectiveness of 911 Norman E McSwain, Jr, MD
The A v o i d a b l e D e l a y Roberto Malacrida, MD W Douglas Weaver, MD
INTRODUCTION A 21-year-old man presented by paramedic ambulance after being shot by unknown assailants while walking down the street. The bullet crossed through both orbits, enucleating his left eye, and leaving him legally blind in his right eye. A 3-year-old girl was walking to the store with her father when gunfire erupted. While running for cover, he noted a limp, lifeless, bleeding body in his arms. The girl was later pronounced dead at a nearby hospital, secondary to a through-and-through gunshot wound to the heart. A 55-year-old man was shot in the chest while sitting in the park with friends. He was pronounced dead at the scene by paramedics. He was one month from retirement. A 16-year-old boy was struck by gunfire coming from a vehicle. The bullet entered in the right scapular region, crossed the apex of the right lung, fractured the fourth, fifth, and sixth cervical vertebrae, and left the patient quadriplegic at the level of C4. An 18-year-old pregnant woman was standing in front of her house with her husband, a known gang member, when they were shot by rival gang members in a moving vehicle. The bullet entered her left flank, shattering the superior pole of her left kidney, fracturing T10, and lodging in her right chest. She is now pregnant and paraplegic. What these people have in common is they were all actual victims of gang violence secondary to drive-by shootings within the past year. The number of injuries and homicides from drive-by shootings is increasing. Victims of gang violence consist of gang members as well as innocent bystanders.
DRIVE-BY SHOOTINGS AND GANG-RELATED HOMICIDES A drive-by shooting is defined as a shooting from a vehicle, in most instances by gang members at suspected gang members. The intent of a drive-by shooting is primarily to intimidate and terrorize other gang members and secondarily to kill.
OCTOBER1992
21:10
ANNALS OF EMERGENCY MEDICINE
1234187
EDITORIALS
Most commonly, drive-by shootings occur on the streets, parks, and into the homes of suspected gang members. 1 The most common reasons are retaliation for previous shootings, turf fights, arguments, and at times control over a p a r t i c u l a r criminal enterprise such as cocaine. During 1991 in the City of Los Angeles, 1,543 drive-by shootings were r e p o r t e d , resulting in 2,081 injuries and 141 deaths. 2 This calculates to an injury-to-death ratio of 15:1. In Los Angeles County (which is comprised of the City of Los Angeles as well as other municipalities) there were 3,857 drive-by shootings in 1991, which averages to 11 p e r day, or one every two hours. This resulted in more than 5,100 injuries in Los Angeles County. z Up to 50% of vicitms of drive-by shootings are innocent bystanders with no gang affiliation. 4 Clearly, because many children play in the streets and p a r k s , a large number of them are physically and psychologically traumatized by gang violence. In the past y e a r in the City of Los Angeles, there have been 32 pediatric homicides secondary to drive-by shootings, in which a number of children have been killed in the crossfire of gang violence. 2 In Los Angeles County, 1991 was another record year for gang-related homicides, with 771 representing a 12% increase over 1990. 3 Los Angeles County averaged 64 gangrelated homicides p e r month in 1991. At least one t h i r d of these homicides were secondary to drive-by shootings. More than 80% of all gang-related homicides involve a firearm. The most commonly used weapon is a 9-ram semiautomatic handgun. In Los Angeles County on three separate occasions in 1991, the weapon of choice was a machine gun. 3
THE MEDICAL COST OF 6 A N 6 VIOLENCE With the soaring incidence of drive-by shootings, the n u m b e r of injuries and fatalities translates into a staggering medical cost. In 1985, the total lifetime cost of injury (direct and indirect medical costs) by firearms was $14 billion. Because most victims of drive-by shootings are uninsured, this further taxes the already stressed t r a u m a systems. We estimate that the total medical cost of gang violence alone in Los Angeles County exceeds $1 billion annually. The civilian unrest in Los Angeles in April 1992 had the largest n u m b e r of fatalities of any m a j o r US civilian uprising since the Civil War. In the 1992 revolt, there were 58 fatalities and approximately 2,400 injuries. The total cost of the destruction from the revolt a p p r o a c h e d $750 million. By comparison, the annual cost of gang violence in terms of homicides, injuries, and total medical cost exceeds all deaths, injuries, and costs i n c u r r e d during the revolt in Los Angeles in 1992.
THE ROOT CAUSES AND SPREAD OF 6 A N 6 VIOLENCE To u n d e r s t a n d gangs and gang violence one must look at the conditions that lead to gang formation. The root causes include poverty, dysfunctional families, undereducation, racism, unemployment, and underemployment (the lack of a job that supports a family above the poverty line). Poverty and gangs go h a n d in hand. Between 1979 and 1990 the numb e r of children living in poverty increased 22%. 5 Barrio and ghetto youth are at the greatest risk of joining gangs,
88/1235
although most do not. Other reasons for joining gangs include the need for a sense of belonging, protection, status, and illegal monetary gains. The underlying cause of the recent escalation in drive-by shootings resulting in an increase in injury and death remains unclear. Most likely it is due to the greater use of firearms, worsening economic despair, and the appeal of the image of gang members. Poverty, despair, and the inability to imagine a future make some believe that gang violence is a form of inner-city suicide. Research has shown that drug trafficking is not a m a j o r causative factor. 6 Gang-related shootings are now widespread and no longer confined to the inner city. They are occurring in shopping malls, amusement p a r k s , hospitals, Southern California beaches, and elsewhere. With the increased popularity of gangs and gang migration, drive-by shootings are now occurring in such states as Tennessee, Colorado, Nebraska, Arizona, Mississippi, Florida, Oregon, Washington, New York, Oklahoma, Michigan, Wisconsin, Illinois, Maryland, Nevada, Wyoming, and Pennsylvania. 7 Daily, victims of drive-by shootings present to our ED and others in the County of Los Angeles. Until the root causes of gang formation and gang violence are effectively addressed, we expect a further increase in the n u m b e r of, and injuries and homicides by, drive-by shootings in the County of Los Angeles. Because most drive-by shootings occur in the barrios and ghettos of this nation, the resulting injuries and deaths do not receive the serious consideration they deserve. Society continues to ignore the problems that exist in the inner city, only to be haunted by them once they spill over into mainstream America. When these problems (eg, teen pregnancy, drug abuse, failing education systems, violence) are "discovered," they are endemic to the b a r r i o and ghetto communities and have reached epidemic proportions.
EMER6ENCY PHYSICIANS AND THE PREVENTION OF GAN6 VIOLENCE Clearly, law enforcement must be p a r t of the solution of gang violence. However, we must u n d e r s t a n d that gang violence is really the end result of social diseases that many of us see regularly in our EDs. Emergency physicians see firsthand the injuries resulting from drive-by shootings. We can no longer afford to sit idly, watching the carnage of gang violence mount. We must take an active role in ending this senseless waste of human potential. We can no longer afford to treat just the physical and psychological t r a u m a without addressing the causative social factors. We, as emergency physicians, must begin by educating ourselves and the medical community about the root causes of gang formation and the resulting violence. We must ally ourselves with community organizations that are proactive in preventing gang violence and other forms of violence in our communities. To reach all segments of the community, emergency physicians should advise the media that the numbers of injuries and deaths secondary to drive-by shootings are soaring. We should encourage the media to r e p o r t not only the violence but also the causative factors.
ANNALS OF EMERGENCY MEDICINE 2 1 : 1 0 OCTOBER1992
EDITORIALS
We must work with local, state, and federal legislators, emphasizing that the answer to gang violence is not just stronger punitive laws but getting them to allocate funds to alleviate the root causes. It should be clearly explained to lawmakers that gang violence is a preventable disease, worthy of their attention and funding. Along with others in the medical community, we as emergency physicians must address the issues of firearms and injuries and take a firm stance that handguns and assault rifles must be controlled. We should willingly support organizations that are working to pass laws to prevent children from sinking further into poverty because these are the children most at risk for gang involvement. Throughout America, children must be taught an a p p r o p r i a t e value system, encompassing a sense of personal pride, dignity, self-worth, accomplishment, and a healthy respect for all human life. Emergency physicians, community activists, family members, and others in the community can act as positive role models for our children. There must be a realization that whether we live in the inner city or in the suburbs, we are a nation of people who must show concern for the welfare of one another. Problems such as gang violence are touching us all directly and indirectly. For any solution to be effective, we must empower innercity communities to play a pivotal role in resolving these problems. It is essential that health care providers do not take maternalistic or paternalistic approaches when working toward solutions to these problems. The "benign neglect" of problems that exist in the inner city must come to an end. It is clearly much too costly, in terms of human life and health care dollars, to continue this approach. Only by implementing the above interventions can we hope to be safe from gang violence. HRangeHutson, MD DeirdreAnglin, MD William Marion, MD Departmentof EmergencyMedicine LosAngeles County/University of Southern Califomia Medical Center 1.Maxson CL, Gordon MA, Klein MW: Differences between gang and nongang homicides. Criminology1985;23:209-222. 2.Los Angeles Police Department, Gang Information Section: CrimeStatistics, 1991. 3.Los Angeles County Sheriff's Department, Operation Safe Streets: GangRelated CrimeStatistics,1991. 4. GatesIF, Jackson RK: Gang violence in LA. ThePoliceChiefNovember1990;20-22. 5.KidsCountDataBook:StateProfilesof ChildWeft-Being.Washington, DC, The Annie E Casey Foundation, Center for the Study of Social Policy, 1992. 6. Klein MW, Maxson CL, Cunningham LC: "Crack," street gangs, and violence. Criminology1991;29:701-727.
Day-Night Differences Are Not Always Due to Circadian Control See related a~tiele, p 1250. In the three decades since Halberg coined the word "circadian" (from the Latin circa, about, and dies, day), this neologism has largely replaced the terms diurnal, nychthemeral, and daily in referring to rhythmic 24-hour period variations.
OCTOBER1992 21:10
ANNALS OF EMERGENCY MEDICINE
Unfortunately, its usage is less restricted than was probably intended in the original definition, possibly because of an ambiguity in the meaning of the word "about," whether it means "approximately a day" or "encompassing a day." A key observation responsible for the term was that daily rhythms of different types and in many species "free r u n " when the environmental daily cycle (eg, light/dark) is excluded. Under such constant conditions, the period or cycle length of a circadian system is commonly not exactly 24 h o u r s - perhaps 23 hours or, as for sleep-wake cycles of human beings in isolation, 25 hours, thus approximately one day. By contrast, some daily cycles are truly and exactly daily, commonly by virtue of some exogenous daily environmental variable that affects them directly-. Remove the environmental variable and the exogenously driven cycle disappears, whereas a truly endogenous circadian r h y t h m persists, albeit with a slightly different period. Endogenous circadian rhythms are entrained to the 24-hour day by environmental cycles, a fact that may sometimes confound the distinction between exogenous and endogenous rhythms. Extreme care must thus be exercised in the interpretation and classification of biological phenomena that exhibit daily rhythms, whether it be the occurrence of cardiac failures, platelet aggregability (which peaks in the early morning hours), photosynthesis in plants, or bioluminescence in dinoflagellates. We do not know, for example, whether the endogenous circadian timing system contributes to the welldescribed daily variations in h e a r t rate and blood pressure. Given this caveat, the careful description of these daily variations may have important implications for both those at risk and their providers. J WoodlandHastings, PhD Department of Cellular and DevelopmentalBiology The Biological Laboratories Harvard University Cambridge, Massachusetts CharlesA Czeisler, PhD, MD Department of Medicine Brigham and Women's Hospital Harvard Medical School Boston, Massachusetts
Universal Access: Its Potential Impact on Emergency Medicine INTRODUCTION
A consensus has been reached among the major political forces in the health care field that reform must be enacted to provide basic physician and hospital benefits to more than 60 million Americans who are now without coverage some time during each year. 1 President Bush, many public officials, the American Medical Association, 2 the American Hospital Association, the Blue Cross/Blue Shield Association, and the Health Insurance Association of America all support the concept, although they are often far a p a r t on the details of providing universal access coverage. Those physicians who provide care in overcrowded emergency departments and treat many of those who are
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Injuries a n d D e a t h s F r o m G a n g Violence: They A r e P r e v e n t a b l e
Injuries and Deaths From Gang Violence: They Are Preventable
H Range Hutson, MD See related article, p 1291.
Deirdre Anglin, MD William Mallon, MD
Day-Night D i f f e r e n c e s A r e N o t Always D u e to C i r c a d i a n C o n t r o l J Woodland Hastings, PhD Charles A Czeisler, PhD, MD
Universal Access: Its P o t e n t i a l I m p a c t on E m e r g e n c y Medicine Thomas P Well, PhD
Public P o l i c y a n d the E m e r g e n c y D e p a r t m e n t Robert M Williams, MD, FACEP
The Effectiveness of 911 Norman E McSwain, Jr, MD
The A v o i d a b l e D e l a y Roberto Malacrida, MD W Douglas Weaver, MD
INTRODUCTION A 21-year-old man presented by paramedic ambulance after being shot by unknown assailants while walking down the street. The bullet crossed through both orbits, enucleating his left eye, and leaving him legally blind in his right eye. A 3-year-old girl was walking to the store with her father when gunfire erupted. While running for cover, he noted a limp, lifeless, bleeding body in his arms. The girl was later pronounced dead at a nearby hospital, secondary to a through-and-through gunshot wound to the heart. A 55-year-old man was shot in the chest while sitting in the park with friends. He was pronounced dead at the scene by paramedics. He was one month from retirement. A 16-year-old boy was struck by gunfire coming from a vehicle. The bullet entered in the right scapular region, crossed the apex of the right lung, fractured the fourth, fifth, and sixth cervical vertebrae, and left the patient quadriplegic at the level of C4. An 18-year-old pregnant woman was standing in front of her house with her husband, a known gang member, when they were shot by rival gang members in a moving vehicle. The bullet entered her left flank, shattering the superior pole of her left kidney, fracturing T10, and lodging in her right chest. She is now pregnant and paraplegic. What these people have in common is they were all actual victims of gang violence secondary to drive-by shootings within the past year. The number of injuries and homicides from drive-by shootings is increasing. Victims of gang violence consist of gang members as well as innocent bystanders.
DRIVE-BY SHOOTINGS AND GANG-RELATED HOMICIDES A drive-by shooting is defined as a shooting from a vehicle, in most instances by gang members at suspected gang members. The intent of a drive-by shooting is primarily to intimidate and terrorize other gang members and secondarily to kill.
OCTOBER1992
21:10
ANNALS OF EMERGENCY MEDICINE
1234187
EDITORIALS
Most commonly, drive-by shootings occur on the streets, parks, and into the homes of suspected gang members. 1 The most common reasons are retaliation for previous shootings, turf fights, arguments, and at times control over a p a r t i c u l a r criminal enterprise such as cocaine. During 1991 in the City of Los Angeles, 1,543 drive-by shootings were r e p o r t e d , resulting in 2,081 injuries and 141 deaths. 2 This calculates to an injury-to-death ratio of 15:1. In Los Angeles County (which is comprised of the City of Los Angeles as well as other municipalities) there were 3,857 drive-by shootings in 1991, which averages to 11 p e r day, or one every two hours. This resulted in more than 5,100 injuries in Los Angeles County. z Up to 50% of vicitms of drive-by shootings are innocent bystanders with no gang affiliation. 4 Clearly, because many children play in the streets and p a r k s , a large number of them are physically and psychologically traumatized by gang violence. In the past y e a r in the City of Los Angeles, there have been 32 pediatric homicides secondary to drive-by shootings, in which a number of children have been killed in the crossfire of gang violence. 2 In Los Angeles County, 1991 was another record year for gang-related homicides, with 771 representing a 12% increase over 1990. 3 Los Angeles County averaged 64 gangrelated homicides p e r month in 1991. At least one t h i r d of these homicides were secondary to drive-by shootings. More than 80% of all gang-related homicides involve a firearm. The most commonly used weapon is a 9-ram semiautomatic handgun. In Los Angeles County on three separate occasions in 1991, the weapon of choice was a machine gun. 3
THE MEDICAL COST OF 6 A N 6 VIOLENCE With the soaring incidence of drive-by shootings, the n u m b e r of injuries and fatalities translates into a staggering medical cost. In 1985, the total lifetime cost of injury (direct and indirect medical costs) by firearms was $14 billion. Because most victims of drive-by shootings are uninsured, this further taxes the already stressed t r a u m a systems. We estimate that the total medical cost of gang violence alone in Los Angeles County exceeds $1 billion annually. The civilian unrest in Los Angeles in April 1992 had the largest n u m b e r of fatalities of any m a j o r US civilian uprising since the Civil War. In the 1992 revolt, there were 58 fatalities and approximately 2,400 injuries. The total cost of the destruction from the revolt a p p r o a c h e d $750 million. By comparison, the annual cost of gang violence in terms of homicides, injuries, and total medical cost exceeds all deaths, injuries, and costs i n c u r r e d during the revolt in Los Angeles in 1992.
THE ROOT CAUSES AND SPREAD OF 6 A N 6 VIOLENCE To u n d e r s t a n d gangs and gang violence one must look at the conditions that lead to gang formation. The root causes include poverty, dysfunctional families, undereducation, racism, unemployment, and underemployment (the lack of a job that supports a family above the poverty line). Poverty and gangs go h a n d in hand. Between 1979 and 1990 the numb e r of children living in poverty increased 22%. 5 Barrio and ghetto youth are at the greatest risk of joining gangs,
88/1235
although most do not. Other reasons for joining gangs include the need for a sense of belonging, protection, status, and illegal monetary gains. The underlying cause of the recent escalation in drive-by shootings resulting in an increase in injury and death remains unclear. Most likely it is due to the greater use of firearms, worsening economic despair, and the appeal of the image of gang members. Poverty, despair, and the inability to imagine a future make some believe that gang violence is a form of inner-city suicide. Research has shown that drug trafficking is not a m a j o r causative factor. 6 Gang-related shootings are now widespread and no longer confined to the inner city. They are occurring in shopping malls, amusement p a r k s , hospitals, Southern California beaches, and elsewhere. With the increased popularity of gangs and gang migration, drive-by shootings are now occurring in such states as Tennessee, Colorado, Nebraska, Arizona, Mississippi, Florida, Oregon, Washington, New York, Oklahoma, Michigan, Wisconsin, Illinois, Maryland, Nevada, Wyoming, and Pennsylvania. 7 Daily, victims of drive-by shootings present to our ED and others in the County of Los Angeles. Until the root causes of gang formation and gang violence are effectively addressed, we expect a further increase in the n u m b e r of, and injuries and homicides by, drive-by shootings in the County of Los Angeles. Because most drive-by shootings occur in the barrios and ghettos of this nation, the resulting injuries and deaths do not receive the serious consideration they deserve. Society continues to ignore the problems that exist in the inner city, only to be haunted by them once they spill over into mainstream America. When these problems (eg, teen pregnancy, drug abuse, failing education systems, violence) are "discovered," they are endemic to the b a r r i o and ghetto communities and have reached epidemic proportions.
EMER6ENCY PHYSICIANS AND THE PREVENTION OF GAN6 VIOLENCE Clearly, law enforcement must be p a r t of the solution of gang violence. However, we must u n d e r s t a n d that gang violence is really the end result of social diseases that many of us see regularly in our EDs. Emergency physicians see firsthand the injuries resulting from drive-by shootings. We can no longer afford to sit idly, watching the carnage of gang violence mount. We must take an active role in ending this senseless waste of human potential. We can no longer afford to treat just the physical and psychological t r a u m a without addressing the causative social factors. We, as emergency physicians, must begin by educating ourselves and the medical community about the root causes of gang formation and the resulting violence. We must ally ourselves with community organizations that are proactive in preventing gang violence and other forms of violence in our communities. To reach all segments of the community, emergency physicians should advise the media that the numbers of injuries and deaths secondary to drive-by shootings are soaring. We should encourage the media to r e p o r t not only the violence but also the causative factors.
ANNALS OF EMERGENCY MEDICINE 2 1 : 1 0 OCTOBER1992
EDITORIALS
We must work with local, state, and federal legislators, emphasizing that the answer to gang violence is not just stronger punitive laws but getting them to allocate funds to alleviate the root causes. It should be clearly explained to lawmakers that gang violence is a preventable disease, worthy of their attention and funding. Along with others in the medical community, we as emergency physicians must address the issues of firearms and injuries and take a firm stance that handguns and assault rifles must be controlled. We should willingly support organizations that are working to pass laws to prevent children from sinking further into poverty because these are the children most at risk for gang involvement. Throughout America, children must be taught an a p p r o p r i a t e value system, encompassing a sense of personal pride, dignity, self-worth, accomplishment, and a healthy respect for all human life. Emergency physicians, community activists, family members, and others in the community can act as positive role models for our children. There must be a realization that whether we live in the inner city or in the suburbs, we are a nation of people who must show concern for the welfare of one another. Problems such as gang violence are touching us all directly and indirectly. For any solution to be effective, we must empower innercity communities to play a pivotal role in resolving these problems. It is essential that health care providers do not take maternalistic or paternalistic approaches when working toward solutions to these problems. The "benign neglect" of problems that exist in the inner city must come to an end. It is clearly much too costly, in terms of human life and health care dollars, to continue this approach. Only by implementing the above interventions can we hope to be safe from gang violence. HRangeHutson, MD DeirdreAnglin, MD William Marion, MD Departmentof EmergencyMedicine LosAngeles County/University of Southern Califomia Medical Center 1.Maxson CL, Gordon MA, Klein MW: Differences between gang and nongang homicides. Criminology1985;23:209-222. 2.Los Angeles Police Department, Gang Information Section: CrimeStatistics, 1991. 3.Los Angeles County Sheriff's Department, Operation Safe Streets: GangRelated CrimeStatistics,1991. 4. GatesIF, Jackson RK: Gang violence in LA. ThePoliceChiefNovember1990;20-22. 5.KidsCountDataBook:StateProfilesof ChildWeft-Being.Washington, DC, The Annie E Casey Foundation, Center for the Study of Social Policy, 1992. 6. Klein MW, Maxson CL, Cunningham LC: "Crack," street gangs, and violence. Criminology1991;29:701-727.
Day-Night Differences Are Not Always Due to Circadian Control See related a~tiele, p 1250. In the three decades since Halberg coined the word "circadian" (from the Latin circa, about, and dies, day), this neologism has largely replaced the terms diurnal, nychthemeral, and daily in referring to rhythmic 24-hour period variations.
OCTOBER1992 21:10
ANNALS OF EMERGENCY MEDICINE
Unfortunately, its usage is less restricted than was probably intended in the original definition, possibly because of an ambiguity in the meaning of the word "about," whether it means "approximately a day" or "encompassing a day." A key observation responsible for the term was that daily rhythms of different types and in many species "free r u n " when the environmental daily cycle (eg, light/dark) is excluded. Under such constant conditions, the period or cycle length of a circadian system is commonly not exactly 24 h o u r s - perhaps 23 hours or, as for sleep-wake cycles of human beings in isolation, 25 hours, thus approximately one day. By contrast, some daily cycles are truly and exactly daily, commonly by virtue of some exogenous daily environmental variable that affects them directly-. Remove the environmental variable and the exogenously driven cycle disappears, whereas a truly endogenous circadian r h y t h m persists, albeit with a slightly different period. Endogenous circadian rhythms are entrained to the 24-hour day by environmental cycles, a fact that may sometimes confound the distinction between exogenous and endogenous rhythms. Extreme care must thus be exercised in the interpretation and classification of biological phenomena that exhibit daily rhythms, whether it be the occurrence of cardiac failures, platelet aggregability (which peaks in the early morning hours), photosynthesis in plants, or bioluminescence in dinoflagellates. We do not know, for example, whether the endogenous circadian timing system contributes to the welldescribed daily variations in h e a r t rate and blood pressure. Given this caveat, the careful description of these daily variations may have important implications for both those at risk and their providers. J WoodlandHastings, PhD Department of Cellular and DevelopmentalBiology The Biological Laboratories Harvard University Cambridge, Massachusetts CharlesA Czeisler, PhD, MD Department of Medicine Brigham and Women's Hospital Harvard Medical School Boston, Massachusetts
Universal Access: Its Potential Impact on Emergency Medicine INTRODUCTION
A consensus has been reached among the major political forces in the health care field that reform must be enacted to provide basic physician and hospital benefits to more than 60 million Americans who are now without coverage some time during each year. 1 President Bush, many public officials, the American Medical Association, 2 the American Hospital Association, the Blue Cross/Blue Shield Association, and the Health Insurance Association of America all support the concept, although they are often far a p a r t on the details of providing universal access coverage. Those physicians who provide care in overcrowded emergency departments and treat many of those who are
1236/89
