Staff Reporter

Los Angeles County has the state's largest number of doctors. But it also has some of the largest caseloads of AIDS, tuberculosis, syphilis and gonorrhea.

What gives?

One reason is that some of the more than 23,000 doctors in Los Angeles are busy lifting and tucking some of Hollywood's finest not fighting disease. And most of the others are a mixed bag of specialists and general practitioners treating everything from broken bones and common colds, to brain aneurysms and cancers.

But the larger reason is that disease is more a function of demographics than of doctors.

Los Angeles is a prime destination for people seeking to improve their standard of living. Many are from poorer countries that have not done a good job eradicating things like tuberculosis. In addition, many of L.A. County's immigrants and poorer, less-educated residents fear conventional medicine contributing to the spread of communicable diseases that can be prevented.

Moreover, there are signs that the county's arsenal against communicable disease the public health system is increasingly ill-equipped to wage war.

In the past 25 years the county's population has grown from 6 million to more than 9 million and diversified beyond expectations. But while public health needs have increased correspondingly, resources have not expanded to meet them. In fact, they have been cut dramatically, especially during the financial crisis that almost bankrupted the county government in 1995.

Since then, millions of dollars have been taken out of the county's public health system to make up for the ailing budget.

A jurisdiction that once boasted more than 50 public health doctors in 25 separate districts now has only 11. Forty public-health clinics were cut to 10 meaning one public health clinic for about every million people in Los Angeles.

Much of the patient load has been picked up by private clinics operating under contract with the county. But those private clinics are not geared toward arresting the spread of disease, according to Dr. Shirley Fannin, director of disease control for the county's Health Services Department.

"The health department has an intricate system of tracking more than 60 diseases that can be passed between human beings, or from animals to humans," Fannin said. "But the county's clinics are seeing an estimated one-third less patients a year, so it has become increasingly difficult to track the spread of disease."

Fannin said private clinics don't have the same tools or mission as the public clinics.

"They cannot do surveillance, investigation of outbreaks and intervention," she said. "They also don't always report to us. When you shrink the government arm that does that work, it has an impact. Private clinics do not do public health."

Los Angeles County Supervisor Zev Yaroslavsky said he believes the private clinics are working well and that if there is a problem with private clinics tracking disease, health officials have not brought it to the attention of the Board of Supervisors.

"We have expanded our partnerships so the public has a greater choice closer to their homes," Yaroslavsky said. "I don't know what (Fannin) is talking about."

Fannin and others, however, say difficulties in tracking patients is only part of the problem.

Health officials say many illegal immigrants are fearful of seeking medical attention, especially since the passage of 1994's Proposition 187, which barred most non-emergency public services to illegal aliens.

Dr. Brian Johnston, an emergency-room physician and immediate past president of the Los Angeles County Medical Association, said illegal immigrants typically take longer to report illnesses. And in the crowded conditions in which many immigrants live, diseases like tuberculosis are easily spread.

On top of that, more than one-third of L.A. County residents under 60 lack health insurance. Often, the mind-set is to avoid going to the doctor unless it's an absolute emergency, Johnston said. And by then, it's often too late.

In comparison to other counties in California, L.A. County is above average in AIDS, syphilis and gonorrhea and is No. 1 in syphilis.

L.A. County also has the largest per-capita incidence of AIDS after San Francisco. The disease is frequently spread by gay men and intravenous drug users, and the high incidence of AIDS here reflects the fact that Los Angeles, as a major urban center, has a comparatively high population of both.

"A lot of people take a cavalier attitude toward (sexually transmitted diseases)," Johnston said. "Risky sexual behavior is still a problem. Many people still ignore the warnings. I think that many people don't care. AIDS has not been cured. It's still a problem."

Still, Los Angeles is far behind San Francisco which has nearly triple the rate of AIDS as L.A., and more than quadruple the rate of hepatitis.

Fannin said that in general, most large cities have high instances of sexually transmitted diseases like AIDS, syphilis and gonorrhea.

"It is because large cities have a higher proportion of high-risk groups," said Fannin. "Those risk groups, like gay males, intravenous drug users and prostitutes live more in big cities vs. a small town."

So in reality, the fact that L.A. has lots of doctors and lots of disease is not so much a mystery. As a major urban center, Los Angeles has many hospitals big and small (including world-renowned institutions such as UCLA and City of Hope) and many doctors.

It also has a lot of sick genuinely sick people.

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