McKeesport Aging Program a 3-year survey.The elderly population in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. is expected to expand by about 50 percent over the next two decades. (1) It, therefore, becomes increasingly important to identify areas of risk that can impact the safety, independence, and overall well-being of senior citizens. Promoting safety interventions based on identified areas of risk can enhance their quality of life and reduce their healthcare expenditures. [ILLUSTRATION OMITTED] The growing number of older adults concerns public safety officials. A common perception depicts them as more frequent victims of crime--particularly, more serious, violent crime--than other segments of the population. Perhaps, this results from media and public attention given to elderly victims of violence (2) and because of the mental and physical changes with aging that can compromise older people's abilities to anticipate, avoid, and escape crime. (3) Social isolation and depression also can contribute to their vulnerability. (4) Senior citizens, however, experience crime, especially violent crime, at a lower rate than younger persons. (5) Property crime constitutes the highest percentage of illegal activity against older people. (6) Victims age 65 and older report some types of crime, such as personal theft and personal violence, more often than younger individuals, (7) likely due to the greater negative impact these crimes have on their lives. BACKGROUND Most research on police issues with elderly individuals has focused on their fear of crime, decisions to report such occurrences, and perceptions of service, rather than on the frequency and nature of their contacts with police. (8) An exception, a study in one of four National Institute on Aging The National Institute on Aging is a division of the U.S. National Institutes of Health, located in Bethesda, Maryland. Formed in 1974, NIA's mission is to improve the health and well-being of older Americans through research. It is the primary U.S. sites for Established Populations for Epidemiologic Studies epidemiologic study A study that compares 2 groups of people who are alike except for one factor, such as exposure to a chemical or the presence of a health effect; the investigators try to determine if any factor is associated with the health effect in the Elderly (EPESE EPESE Established Populations for Epidemiologic Studies of the Elderly ), (9) used information from public health, medical, criminological crim·i·nol·o·gy n. The scientific study of crime, criminals, criminal behavior, and corrections. [Italian criminologia : Latin cr , and law enforcement personnel to analyze the prevalence and types of police interactions with older adults. In a random sample of 200 senior citizens from the New Haven New Haven, city (1990 pop. 130,474), New Haven co., S Conn., a port of entry where the Quinnipiac and other small rivers enter Long Island Sound; inc. 1784. Firearms and ammunition, clocks and watches, tools, rubber and paper products, and textiles are among the many , Connecticut, EPESE cohort of 2,182 elderly individuals, researchers found that 47 (24 percent) had 86 police encounters over a 7-year period (1985 to 1991). Forty-three percent of the contacts involved an older adult as a crime victim. Burglary, the most prevalent, represented 16 percent of all contacts. The next highest concerned mental health issues with 10 percent, followed by larceny larceny, in law, the unlawful taking and carrying away of the property of another, with intent to deprive the owner of its use or to appropriate it to the use of the perpetrator or of someone else. with 9 percent. Subject characteristics most associated with victims included being male and non-Caucasian. An 8-year follow-up of 1,800 senior citizens in the New Haven EPESE cohort yielded similar results: 523 (29 percent) had 1,056 police encounters. (10) Elderly people were victims in 61 percent of the incidents, complainants in 16 percent, perpetrators in 7 percent, and witnesses in 4 percent. The most prevalent crimes were larceny (17 percent), burglary (16 percent), auto theft (13 percent), vandalism (8 percent), and robbery (6 percent). Subject characteristics associated with victimization victimization Social medicine The abuse of the disenfranchised–eg, those underage, elderly, ♀, mentally retarded, illegal aliens, or other, by coercing them into illegal activities–eg, drug trade, pornography, prostitution. again included being male and non-Caucasian, as well as high functioning (no impairments in activities of daily living). The study concluded that older adults have substantial police contacts, primarily as crime victims, and that disparate crime and health data sets can be linked to inform the relationship between senior citizens' victimization status and their quality of life. (11) Persons age 65 and older have three times the risk of fire-related deaths and a higher rate of nonfatal fire-related injuries than younger adults. (12) The higher fire-related death and injury rates in elderly people likely are due to their reduced mental capacity to detect a fire or their compromised physical abilities to escape one. (13) Senior citizens living independently or in older homes with faulty wiring also face a greater risk of fire-related injury and death. (14) Defective heating equipment, space heaters, and electric blankets cause more injuries and deaths among elderly individuals than in the rest of the population. (15) Unsafe use of smoking materials constitutes the leading cause of fire deaths among older adults, (16) and cooking accidents represent the main reason for fire-related injuries in this age group. (17) Although many public safety agencies have special programs for senior citizens, (18) few communitywide studies on this segment of the population and its contact with these organizations exist. The authors, therefore, designed the McKeesport Aging Program (MAP) to gain such information about older adults' safety inside and outside their homes by examining contacts with fire and police agencies in McKeesport, Pennsylvania McKeesport is a city in Allegheny County, Pennsylvania, U.S., at the confluence of the Monongahela and Youghiogheny Rivers and is part of the Pittsburgh Metro Area. The population was 24,040 at the 2000 census. It is the 2nd largest city in Allegheny County behind only Pittsburgh. . Authorities in the community and surrounding areas have used the findings to direct and promote home safety, community education, and other programs for elderly residents. METHODS MAP, a multifaceted mul·ti·fac·et·ed adj. Having many facets or aspects. See Synonyms at versatile. Adj. 1. multifaceted - having many aspects; "a many-sided subject"; "a multifaceted undertaking"; "multifarious interests"; "the multifarious program, investigates and provides support for senior citizens living independently in McKeesport and surrounding communities. The authors conducted a 3-year (1995 to 1997) retrospective survey of police and fire department records to identify types of contacts involving elderly individuals (those at least 60 years of age). They chose McKeesport because of its demographics--a small, stable city 15 miles southeast of Pittsburgh. Of McKeesport's 24,000 residents, nearly 6,000 (25 percent) are age 60 and over, representing a high percentage of older adults compared with the state at 20 percent and the nation at 16 percent. McKeesport also has a racially mixed population of 72 percent Caucasian, 24 percent African-American, and 4 percent other. (19) Not a wealthy area, male residents 65 years of age and older have a median annual income of nearly $19,000 and females of the same age group approximately $12,000. (20) The authors carefully reviewed all police and fire department records that involved an individual at least 60 years of age or that referenced such a person. The institutional review boards of Allegheny General Hospital Allegheny General Hospital is a large urban hospital located in Pittsburgh, Pennsylvania, USA. Allegheny General Hospital, also commonly known locally by the acronym "AGH," was founded in 1885 in Pittsburgh's North Side, in the area formally known as Allegheny City. and the University of Pittsburgh approved the conduct of the survey and the materials used. Systematic data collection included sociodemographic information, such as age, sex, race, marital status marital status, n the legal standing of a person in regard to his or her marriage state. , medical history, and medication record, and details about the incident, such as why the call was placed, who placed the call (self or other and relation to victim), whether the elderly person was the offender, the specifics of the incident, and its resolution. The authors employed terms commonly used by law enforcement agencies A law enforcement agency (LEA) is a term used to describe any agency which enforces the law. This may be a local or state police, federal agencies such as the Federal Bureau of Investigation (FBI) or the Drug Enforcement Administration (DEA). to categorize cat·e·go·rize tr.v. cat·e·go·rized, cat·e·go·riz·ing, cat·e·go·riz·es To put into a category or categories; classify. cat the types of incidents. (21) Then, they separated them into either home safety related (HS) or personal health/safety related (PH). The HS category included fire hazards fire hazard fire n that's a fire hazard → das ist feuergefährlich fire hazard n that's a fire hazard → comporta rischi in caso d'incendio (gas leaks and smoke alarms) and home security issues (burglaries and vandalism). The PH group covered mental health problems (dementia and suicide), safety within the community (wandering and public intoxication Public intoxication, also known as "drunk and disorderly conduct" (sometimes, incorrectly, as "drunken disorderly"), is a summary offence in many countries. The laws regarding drunkenness vary wildly from one legislative body to the next and are open to a certain amount of ), and fatalities before safety personnel arrived. FINDINGS The authors grouped HS incidents into major categories by frequency of occurrence. Sixty-seven percent of police and 80 percent of fire department contacts involved home safety. The authors also divided PH incidents into major categories by frequency of occurrence. Thirty-three percent of police and 20 percent of fire department encounters related to personal health/safety. This retrospective review retrospective review, a posttreatment assessment of services on a case-by-case or aggregate basis after the services have been performed. , representing the first phase of MAP, yielded important information regarding two main categories of incidents: 1) issues related to the safety of dwellings and 2) those involving personal health and safety. The types and frequencies of incidents accorded with many previously published reports. Home Safety The majority of police department incidents related to home safety, and most involved nonviolent property crimes (burglary, vandalism, and auto theft or damage). These findings proved congruent con·gru·ent adj. 1. Corresponding; congruous. 2. Mathematics a. Coinciding exactly when superimposed: congruent triangles. b. with national trends indicating that elderly people are disproportionately affected by property crimes and relatively less by violent ones. (22) Nonviolent property crimes against senior citizens often receive little attention because they are not sensational. But, their frequency has indicated that they should be given prominence in home safety programs, similar to the emphasis on fire prevention. (23) Fortunately, the study revealed relatively few cases of financial exploitation (forgery forgery, in art forgery, in art, the false claim to authenticity for a work of art. The Nature of Forgery Because the provenance of works of art is seldom clear and because their origin is often judged by means of subtle factors, art , fraud, imposters, and scams), representing crimes that appear on the rise and, therefore, attracting the attention of law enforcement agencies and the media. Most of the fire department incidents concerned home safety, with a vast amount caused by food left cooking on the stove. This type of forgetfulness Forgetfulness See also Carelessness. Absent-Minded Beggar, The ballad of forgetful soldiers who fought in the Boer War. [Br. Lit.: “The Absent-Minded Beg-gars” in Payton, 3] absent-minded professor often is pathological, being a common sign of dementia and, therefore, a major health issue. Previous research has cited cooking-related fires and smoke inhalation Smoke Inhalation Definition Smoke inhalation is breathing in the harmful gases, vapors, and particulate matter contained in smoke. Description Smoke inhalation typically occurs in victims or firefighters caught in structural fires. as the largest cause of fire-related injuries among older adults. (24) The authors' findings underscored the importance of the kitchen as a danger area in home safety. Personal Health/Safety Thirty-three percent of police department incidents involved personal health and safety and included a variety of issues, such as death, disputes with other persons, intoxication intoxication, condition of body tissue affected by a poisonous substance. Poisonous materials, or toxins, are to be found in heavy metals such as lead and mercury, in drugs, in chemicals such as alcohol and carbon tetrachloride, in gases such as carbon monoxide, and or driving under the influence, mental health-related issues, and missing senior citizens. These findings have suggested the need for community programs that provide social and other contacts for older adults living alone. As well, public service agencies should include staff training on behavioral issues related to elderly individuals, including depression, suicide attempts, substance abuse, and dementia. In contrast, only 20 percent of fire department incidents related to personal health and safety, and most involved assists to police and emergency medical services An Emergency medical service (abbreviated to initialism "EMS" in many countries) is a service providing out-of-hospital acute care and transport to definitive care, to patients with illnesses and injuries which the patient believes constitutes a medical emergency. or concerned senior citizens' mental health. SUCCESSFUL PROGRAMS Some public safety agencies have succeeded with training programs targeted toward the needs of older adults. Short training sessions for community police officers in Aiken, South Carolina Aiken is a city in Aiken County, South Carolina and is part of the CSRA. The population was 25,337 at the 2000 census. It is the county seat of Aiken CountyGR6, and is the site of the University of South Carolina at Aiken. , increased their ability to recognize and address the health needs of senior citizens. (25) A training program for police officers in 11 New Jersey counties focused on understanding Alzheimer's disease Alzheimer's disease (ăls`hī'mərz, ôls–), degenerative disease of nerve cells in the cerebral cortex that leads to atrophy of the brain and senile dementia. and how to handle dangerous behaviors associated with it. (26) The Milwaukee, Wisconsin For other places with the same name, see Milwaukee (disambiguation). Milwaukee is the largest city within the state of Wisconsin and 25th largest (by population) in the United States. , Police Department organized a group of officers, the Gray Squad, who received specialized training in communicating with and being sensitive to concerns of elderly people. (27) Older adults who dealt with the Gray Squad, rather than regular officers, expressed greater satisfaction and had more positive attitudes about police in general. Public safety personnel must understand the age-related changes and the risks and concerns of elderly people. This increased awareness will facilitate more effective communication with many senior citizens. (28) The authors' findings indicated specific areas in which specialized training for public safety personnel can prove useful. Public safety officers are particularly well suited for partnerships with social service providers because they share a common goal, the welfare of the community. (29) Since 1988, a program called Triad has supported information exchange between the law enforcement profession and the elderly population in a number of communities. (30) Triad consists of a three-way effort among the sheriff, the police chief, and older or retired leaders in the area to enhance services. (31) FUTURE DEVELOPMENTS Uniform reporting forms will enable future studies to link personal information, medical history, and public safety encounters to better inform community programs that address the health and safety needs of older adults. (32) Potential obstacles, such as Health Insurance Portability and Accountability Act The Health Insurance Portability and Accountability Act (HIPAA) was enacted by the U.S. Congress in 1996. According to the Centers for Medicare and Medicaid Services (CMS) website, Title I of HIPAA protects health insurance coverage for workers and their families when (HIPAA (Health Insurance Portability & Accountability Act of 1996, Public Law 104-191) Also known as the "Kennedy-Kassebaum Act," this U.S. law protects employees' health insurance coverage when they change or lose their jobs (Title I) and provides standards for patient health, ) regulations, will require attention but should not prove insurmountable. Building on this retrospective review, the next phases of MAP, which include in-home safety and personal health surveys of older adults living independently in McKeesport and adjacent communities, are in progress. To date, 278 senior citizens have participated. The findings of these surveys accord with the fire and police record reviews, and community officials are using the data to mount home and health improvement programs. CONCLUSION While the issues brought to light by the McKeesport Aging Program are important for the elderly population in every community, they appear particularly relevant for smaller communities that have a high proportion of senior citizens with limited incomes. Financially strapped older adults often neglect both their home safety and their personal health. In this regard, local community agencies have relied on the data from this study to introduce and enhance community programs for elderly people. Based on the frequency of police and fire department contacts with senior citizens regarding safety in and around their homes, the city of McKeesport has started a home safety program for this population group. Local government grants have funded the installation of glass-block windows, deadbolt locks, smoke detectors, handrails, and handicap ramps, as well as sidewalk replacement, to qualifying participants. Prevention and intervention programs of this type can significantly improve both the quality of life for older adults and the security of the larger community. [ILLUSTRATION OMITTED]
Home Safety Incidents
Police Department Incidents (total = 731) %
Burglary (no contact with victim/mail tampering) 32
Vandalism 27
Auto related (theft/damage) 20
Robbery (theft with force/violence) 9
Suspicious activity 4
Financial exploitation (forgery/fraud) 4
Imposters (scams/cons) 2
Assistance with fires 2
Fire Department Incidents (total = 40) %
Smoke related (food on stove, 68
smoking near alarm)
Utility problems (gas leak) 15
Person stuck in elevator or in house 12
Suspicious noise 2.5
Person locked out of apartment 2.5
Personal Health and Safety Incidents
Police Department Incidents (total = 426) %
Dead on arrival 21
Disputes with others (domestic, harassment) 20
Intoxicated/driving under the influence 17
Mental health (confusion, completed suicide) 13
Seniors missing 10
Assaults on seniors 6
Check on welfare 6
Assistance to fire department, EMS 2
Reported gun shots in neighborhood 2
Dog bite 2
Abuse/neglect by caregiver 1
Fire Department Incidents (total = 10) %
Assistance to police department, EMS 50
Mental health (confusion, attempted suicide) 40
Dead on arrival (smoking while using oxygen) 10
The authors thank the city of McKeesport, including its mayor, police chief, and fire chief, for providing access to police, fire, and emergency medical services records. Three successive administrations have supported the McKeesport Aging Program. Mary Ganguli, M.D., M.P.H., provided valuable consultative advice on the design of the study and the preparation of this article. Financial support was provided by an anonymous community donor. In November 2003, parts of the study were presented at the 56th Annual Scientific Meeting of the Gerontological ger·on·tol·o·gy n. The scientific study of the biological, psychological, and sociological phenomena associated with old age and aging. ge·ron Society of America in San Diego, California “San Diego” redirects here. For other uses, see San Diego (disambiguation). San Diego is a coastal Southern California city located in the southwestern corner of the continental United States. As of 2006, the city has a population of 1,256,951. . Endnotes (1) U.S. Census Bureau Noun 1. Census Bureau - the bureau of the Commerce Department responsible for taking the census; provides demographic information and analyses about the population of the United States Bureau of the Census , Census 2000 summary file for McKeesport city, Allegheny, Pennsylvania
(2) J. Lindesay, "Elderly People and Crime," Reviews in Clinical Gerontology gerontology: see geriatrics. 6 (1996): 199-204. (3) S. Benson, "The Older Adult and Fear of Crime," Journal of Gerontological Nursing 23 (1997): 24-31. (4) A.L. Falzon and G.G. Davis, "A 15-Year Retrospective Review of Homicide in the Elderly," Journal of Forensic Science The application of scientific knowledge and methodology to legal problems and criminal investigations. Sometimes called simply forensics, forensic science encompasses many different fields of science, including anthropology, biology, chemistry, engineering, genetics, 43 (1998): 371-374. (5) Supra A relational DBMS from Cincom Systems, Inc., Cincinnati, OH (www.cincom.com) that runs on IBM mainframes and VAXs. It includes a query language and a program that automates the database design process. note 2; U.S. Department of Justice, Bureau of Justice Statistics Noun 1. Bureau of Justice Statistics - the agency in the Department of Justice that is the primary source of criminal justice statistics for federal and local policy makers BJS , Office of Justice Programs, Crimes Against Persons Age 65 or Older, 1992-1997 (2000); retrieved on May 6, 2004, from http://www.ojp.usdoj.gov/bjs/pub/pdf/cpa6597.pdf; and U.S. Department of Justice, Bureau of Justice Statistics, Office of Justice Programs, Victim Characteristics (2003); retrieved on May 6, 2004, from http://www.ojp.usdoj.gov/bjs/cvict_v.htm. (6) U.S. Department of Justice, Bureau of Justice Statistics, Office of Justice Programs, Definitions (2003); retrieved on May 6, 2004, from http://bjsdata.ojp.usdoj.gov/dataonline/Search/Crime/definitions.cfm. (7) Supra note 5 (Crimes Against Persons Age 65 or Older, 1992-1997). (8) Supra notes 2 and 3; and R.G. Zevitz and A.M. Gurnack, "Factors Related to Elderly Crime Victims' Satisfaction with Police Services: The Impact of Milwaukee's 'Gray Squad,'" The Gerontologist ger·on·tol·o·gy n. The scientific study of the biological, psychological, and sociological phenomena associated with old age and aging. ge·ron 31 (1991): 92-101. (9) M.S. Lachs, C. Bove, M.H. Wearing, et al, "The Clinical Epidemiology of Crime Victimization in Older Adults: A Multidisciplinary Pilot Study," Journal of Elder Abuse Elder Abuse Definition Elder abuse is a general term used to describe harmful acts toward an elderly adult, such as physical abuse, sexual abuse, emotional or psychological abuse, financial exploitation, and neglect, including self-neglect. and Neglect 13 (2001): 79-90; and M.S. Lachs, R. Bachman, C. Williams, et al, "Crime, Health, and Police Department Contact with Older Adults: A Population-Based Exploratory Study," (Abstract) The Gerontologist 43 (2003): 159. (10) Supra note 9 (Lachs, Bachman, Williams, et al). (11) Supra note 9 (Lachs, Bachman, Williams, et al). (12) U.S. Fire Administration, Facts on Fire (2003); retrieved on May 6, 2004, from http://www.usfa.fema.gov/public/factsheets/facts.shtm; and U.S. Fire Administration, Let's Retire Fire: Fire Safety Tips for Older Americans (1992); retrieved on May 6, 2004, from http://www.usfa.fema.gov/downloads/pdf/publications/retire.pdf. (13) A.T. Elder, T. Squires, and A. Busuttil, "Fire Fatalities in Elderly People," Age and Ageing 25 (1996): 214-216; and G. McGwin, V. Chapman, J. Curtis, et al, "Fire Fatalities in Older People," Journal of the American Geriatrics Society The American Geriatrics Society (AGS): a professional society founded on June 11, 1942 for doctors practicing geriatric medicine. Among the founding physicians were Dr. Ignatz Leo Nascher, who coined the term "geriatrics," Dr. Malford W. 47 (1999): 1307-1311. (14) Supra notes 12 (Let's Retire Fire: Fire Safety Tips for Older Americans) and 13 (Elder, Squires, and Busuttil); C. DiGuiseppi, P. Edwards, C. Godward, et al, "Urban Residential Fire and Flame Injuries: A Population-Based Study," Injury Prevention 6 (2000): 250-254; and G.R. Istre, M.A. McCoy, L. Osborn, et al, "Deaths and Injuries from House Fires," New England Journal of Medicine The New England Journal of Medicine (New Engl J Med or NEJM) is an English-language peer-reviewed medical journal published by the Massachusetts Medical Society. It is one of the most popular and widely-read peer-reviewed general medical journals in the world. 344 (2001): 1011-1016. (15) Supra notes 12 (Facts on Fire) and 13 (Elder, Squires, and Busuttil). (16) Supra notes 12 (Facts on Fire) and 13 (Elder, Squires, and Busuttil); and U.S. Fire Administration, Fire Risks for Older Adults (1999); retrieved on May 6, 2004, from http://www.usfa.fema.gov/downloads/pdf/publications/older.pdf. (17) Supra notes 12 (Let's Retire Fire: Fire Safety Tips for Older Americans) and 14 (Istre, McCoy, Osborn, et al); and C.M. Ryan, W. Thorpe Thorpe , James Francis Known as "Jim." 1888-1953. American athlete. An outstanding collegiate football player, he later played professional football and baseball. , P. Mullin, et al, "A Persistent Fire Hazard for Older Adults: Cooking-Related Clothing Ignition," Journal of the American Geriatrics Society 45 (1997): 1283-1285. (18) Supra note 8 (Zevitz and Gurnack); and P. Frommer and K. Papouchado, "Police as Contributors to Healthy Communities: Aiken, South Carolina," Public Health Reports 11 (2000): 249-252; and S. Lachenmayr, K.D. Goldman, and F.S. Brand, "Safe Return: A Community-Based Initiative Between Police Officers and the Alzheimer's Association The Alzheimer's Association, incorportated on April 10, 1980 as the Alzheimer’s Disease and Related Disorders Association, Inc., is a non-profit American voluntary health organization which focuses on care, support and research for Alzheimer's disease. to Increase the Safety of People with Alzheimer's Disease," Health Promotion Practice 1 (2000): 268-278. (19) Supra note 1. (20) Supra note 1. (21) Supra note 6. (22) Supra notes 2 and 6. (23) Supra note 9 (Lachs, Bove, Wearing, et al). (24) Supra note 17. (25) Supra note 18 (Frommer and Papouchado). (26) Supra note 18 (Lachenmayr, Goldman, and Brand). (27) Supra note 8 (Zevitz and Gurnack). (28) L. Jordan, "Law Enforcement and the Elderly: A Concern for the 21st Century," FBI Law Enforcement Bulletin The FBI Law Enforcement Bulletin is published monthly by the FBI Law Enforcement Communication Unit[1], with articles of interest to state and local law enforcement personnel. , May 2002, 20-23. (29) Supra note 18 (Lachenmayr, Goldman, and Brand). (30) http://www.oag.state.ny.us/seniors/triad.html (31) Ibid. (32) Supra note 9. By SHARYN A. GESMOND, R.N., M.S.N., NADEREH TAFRESHI-DARABI, M.D., BARRY L. FARKAS, M.D., M.P.H., and ROBERT T. RUBIN, M.D., Ph.D. Ms. Gesmond is the primary nurse care coordinator, Physical Rehabilitation physical rehabilitation See Physical therapy. Unit, McKeesport Hospital, McKeesport, Pennsylvania. Dr. Tafreshi-Darabi was a research associate with the McKeesport Aging Program. Dr. Farkas is in private practice in McKeesport, Pennsylvania. Dr. Rubin chairs the Department of Psychiatry and Mental Health at the Veterans Affairs Veterans Affairs is a term of the business that deals with the relation between a government and its veteran communities, usually administered by the designated government agency. Greater Los Angeles Los Angeles (lôs ăn`jələs, lŏs, ăn`jəlēz'), city (1990 pop. 3,485,398), seat of Los Angeles co., S Calif.; inc. 1850. Healthcare System. |
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