In previous papers of this series we have shown how public policies of ‘planned shrinkage’ triggered contagious urban decay and massive destruction of low-income housing within poor minority communities of New York City. The resulting social disintegration exacerbated epidemics of infectious disease, including AIDS (acquired immunodeficiency syndrome) and TB (tuberculosis), and such behavioral pathologies as substance abuse and violence. We extend this work on the neighborhood-level ‘synergism of plagues’ to the metropolitan regional scale for eight US urban areas containing more than 54 million people. Several have central cities, which, like New York, suffer from what Skogan characterized as a relentless ‘hollowing out’ of poor communities. We find AIDS, TB, violent crime, and low birthweight near the worst affected cities to be markers of an accelerating regional synergism of plagues, a diffusing system of interacting and self-reinforcing pathology fueled by, but spreading far beyond, the worst affected inner-city areas. We uncover an apparent threshold condition for regional spread of this synergism, triggered through a stochastic resonance with public policies affecting the distribution of catastrophic events within central-city minority neighborhoods. Control of AIDS, violence, multiple-drug-resistant TB, and other pathologies in the United States will require regional reform and the sharing both of resources and of authority across presently ungovernable systems of fragmented administrative units: the urban centers of the late 19th-century USA, by the late 20th, are vast, tightly coupled urban and/or suburban complexes producing a regional ‘linear chain’ condition for both public health and public order in which the welfare of the whole is increasingly determined by the sickness of the least strong.

SummaryOngoing negotiations on the general practitioner contract raise the question of remunerating general practitioners for increased workload resulting from the shift from secondary to primary care. A review of the literature shows that there is little evidence on whether a shift of services from secondary to primary care is responsible for general practitioners' increased workload, and scope for making generalisations is limited. The implication is that general practitioners have little more than anecdotal evidence to support their claims of greatly increased workloads, and there is insufficient evidence to make informed decisions about remunerating general practitioners for the extra work resulting from the changes. Lack of evidence does not, however, mean that there is no problem with workload. It will be increasingly important to identify mechanisms for ensuring that resources follow workload.

ABSTRACT. Urban neighborhoods form the basic functional unit of municipalities. Socioeconomically, they consist of social networks and interlocking layers of social networks. Old, stable neighborhoods are blessed with large social networks and dense interlocking layers. Both social control and social support depend on these complex structures of tight and loose ties. Public health and public order depend on these structures. They are the basis of resilience of both the neighborhood itself and of the municipality that is composed of neighborhoods. In New York City in the 1970s and later, domain shift occurred because of the disruption of the socioeconomic structure by the massive destruction of low-rental housing. A combined epidemic of building fires and landlord abandonment of buildings leveled a huge percentage of housing in poor neighborhoods and forced mass migration between neighborhoods. Social relationships that had existed between families and individuals for decades were destroyed. Community efficacy also greatly diminished. Drug use, violent crime, tuberculosis, and low-weight births were among the many public health and public order problems that soared in incidence consequent to the unraveling of the communities. These problems spilled out into the metropolitan region of dependent suburban counties. The ability of a municipality and its dependent suburban counties to weather a disaster such as an avian flu pandemic depends on the size of social networks in its neighborhoods and on the interconnection between the social networks. Diversity such as gained by social and economic integration influences the strength of the loose ties between social networks. Poor neighborhoods with extreme resilience conferred by a dense fabric of social networks must also maintain connections with mainstream political structure or they will fail to react to both good and bad impacts and communications.

OBJECTIVES: In this study, data on violent deaths in the Bronx, New York City, from the 1970, 1980, and 1990 censuses were analyzed. METHODS: The incidence and areal density of intentional deaths were mapped by health area. Simple and stepwise regressions between violent death measures and other factors were performed. RESULTS: The incidence of deaths at levels of those in the highest 1970 quintile spread so that by 1990 only 2 areas saw incidences at levels of the lowest 1970 quintile. Overcrowding, socioeconomic status, population, population change, and drug deaths in simple regressions and overcrowding, socioeconomic status, and low-weight births in stepwise regressions correlated significantly with violent death incidence or density. CONCLUSIONS: Understanding the spatiotemporal development of violence can contribute to public policy on violence.

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