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Old pleas, new promises: Could aid finally be coming for public health?

After years of dreaming of an infusion of much-needed resources, help for the public health system could be on its way.

By Victoria Stagg Elliott, amednews staff. Jan. 21, 2002.

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Public Health: Renewed Attention
A six-part series exploring the role of the public health system in the context of our nation's newfound state of alert.

1. From the front lines
2. Recent history
3. Greater expectations
4. The risk-benefit ratio
5. New promises
6. Homeland security

Last month, the Thurston County (Wash.) Health Dept. finally moved to a new building. Its previous home, old when the agency moved in in 1974, had long outlived its usefulness. The wiring couldn't handle modern technology. The roof was collapsing. And the building looked like it was falling apart.

"The old building was symbolic of public health system neglect, and people were coming into that building getting a very negative message of the value of public health," said Pat Libbey, director of the Thurston County Health Dept.

Many public health officials around the country still work in buildings like the old one in Thurston County. Those buildings generally need so much work that, if an upgrade were ever approved by local government, it would be cheaper to start from scratch. Offices are cramped. Computers are out of date. Paint is chipping.

Even the venerable Centers for Disease Control and Prevention, a leader in public health for the world, is housed in a place that has run out of space. The CDC utilizes numerous rented offices all over Atlanta to make do. Some labs are state of the art while others struggle with outdated equipment and leaky ceilings.

"We have not adequately invested in maintaining the strength of our public health infrastructure," said Surgeon General David Satcher, MD, PhD.

For decades, America's public health system has worn its neglect in plain sight. But it now appears to be getting noticed. In October 2001, the United States, still reeling from disasters in September, woke up to a public health crisis -- anthrax.

In some ways, it was the public health system's shining moment. Only five died, and many more could have. People got the antibiotics they needed. Transmission routes were tracked. The source was found, although the perpetrator was not. Health information to calm people's fears was distributed.

"Anthrax wasn't wonderful," said James J. James, MD, DrPH, director of the Miami-Dade County Health Dept., which handled the sentinel cases in Florida. "But the fact that [people] noticed that we have a public health system is. In South Florida, [people] learned that it was important, and thank goodness it was working the way it should have."

But the cracks showed. Information provided the public was not always clear or consistent. Labs were pushed to capacity and struggled to process hundreds of samples. Personnel, already stretched thin, worked around the clock and tabled other projects. Experts concede that a larger event could have broken the system.

"It was a very limited outbreak," Dr. James said. "If we had many more cases, we'd have been overtaxed and wouldn't have been able to be that efficient."

Newfound momentum

For decades, public health officials have been calling for funding. In 1988, the Institute of Medicine produced the report "The Future of Public Health," which diagnosed the system as crumbling. Not much happened. Since then, numerous reports have been issued, most recently the CDC's own status report in March, again finding the system crumbling. But not much happened. That is, until now.

Public health officials may finally start getting what they have been wishing for. Legislation drafted in response to recent terrorist threats would authorize $1 billion in grants to state and local health departments and public and private health care facilities to improve planning and bioterrorism preparedness, enhance laboratory capacity, educate and train personnel, and develop drugs and vaccines. Another $450 million would be given to the CDC to upgrade facilities and improve security.

Most of the money is for bioterrorism response, but those are the same systems used to respond to any health crisis. This could be the start of rebuilding the nation's public health network.

"The infrastructure that we're talking about to be ready for bioterrorism is the same infrastructure that we would be able to better use for pandemic influenza, HIV, whatever it might happen to be," Dr. James said.

Thus, public health officials are now figuring out exactly what their infrastructure needs are.

They say they need laboratories with surge capacity. Their labs can be quiet for weeks and then have to be ready to handle hundreds of samples in a short period. And many of the laboratories desperately need to be updated.

"The laboratory we have is in an archaic building that should be condemned," Dr. James said. "If I had unlimited resources, the first thing I would do is build a freestanding laboratory."

Public health officials also want transport systems to move specimens around quickly and securely. In addition, they want the power of communication so labs can talk to each other. And they want the ability to quickly source information from physicians and first responders and disseminate the information to the public. Such systems would provide surveillance and earliest possible warnings of impending dangers or necessary changes in behaviors. Many public health departments don't even have the most basic ability to communicate.

When the first case of anthrax was found in Florida, the health department sent out a case definition to the hospitals in the county by fax and phone. But, according to a study by the CDC in 1999, only 45% of local public health offices have the ability to send broadcast faxes. Less than half had high-speed Internet access, and 20% lacked e-mail access. One department confessed to not reporting a disease outbreak because doing so would have involved a long-distance phone call that it could not afford.

"If I had more money, I would be spending a lot on blast faxes and setting up Web sites. Communication is vital," Dr. James said. "Not just to the medical community back and forth, although that's important. What we haven't really come to grips with is how you communicate with the public."

Their department, as well as many around the country that did not have cases of anthrax, were buried in phone calls from people reporting suspicious packages and powder. They called up afraid and seeking information. Dr. James said his department did not address it adequately, and this issue is a part of their planning process.

"It's important to ask what kind of people you have answering the phone," Dr. James said. "What you have is fear bordering on panic, and it's one thing to be able to give people facts. It's another thing to be able to deal with that fear."

Many health departments are looking at electronic means of transmitting information, but are running up against many barriers. In Mississippi, for example, only 20% of physicians have Internet access in their offices. When a new treatment regimen for anthrax was released in November 2001, the health department mailed the information to the state's 6,000 doctors.

"E-mail is probably as integral a part of the modern practice of medicine as a stethoscope," said Ed Thompson Jr., MD, MPH, health officer for the Mississippi State Dept. of Health. "You've got to have fast means of receiving the latest information on rapidly developing things in diagnosis and treatment of disease. Communication is the area we think we are the weakest."

His department has already purchased a faster fax machine, but he said one system is not enough, particularly in a crisis. Early in the anthrax crisis, he and his staff were supposed to participate in a conference call for state health officers with HHS Secretary Tommy Thompson and the CDC director. A bolt of lightning struck the transformer two minutes before the call was supposed to begin, rendering the conference phone useless. They had to attach a speaker to a smaller phone connected to emergency power.

"It reminded us that those things that work may not work at the time you most need them," Dr. Thompson said. "You need to have more than one system."

Work force investment is key

Those working in public health, however, say that the buildings -- whatever the condition -- are just a symbol of neglect. New offices, up-to-the-minute technology and fully equipped laboratories, while important, are not the most essential aspect of rebuilding public health infrastructure. Well-trained and appropriately compensated staff are.

"Getting a Palm Pilot or a cell phone isn't going to help the syphilis situation if I don't have people who can go out and work in the communities," said Michael Rein, MD, professor of medicine at the University of Virginia, Charlottesville, who also runs an STD clinic for the local health department. "People make the public health service."

A constant complaint has been about the limited funding for training and education. In Florida, the tuition reimbursement program was reduced for all state employees as a cost-cutting measure.

"Those kind of things hurt terribly," Dr. James said. "They hurt morale, and they hurt our ability to get people into required courses."

Salaries of public health officials also have been lower than for those requiring comparable education and skills in the private sector. Many who chose this field do so for intangible rewards.

"There's nobody working in public health today that couldn't be making more money working outside of public health," Dr. Thompson said. "They choose to work in public health because they believe in it. But there's a limit to how much you can sacrifice. You've got to pay people what their skills are worth."

Experts concede, though, that many local health departments are just too small. Some have only one part-time employee. In response, many experts suggest that the tiniest health departments merge into regional ones large enough to marshal the resources necessary to address any public health threat.

"Capabilities are expanded with a district approach," said Tom Milne, executive director of the National Assn. of County and City Health Officials. "When every single community regardless of size has a health department, it's a mess."

Many public health officials say now is the perfect opportunity to get some of the things they've been seeking for decades. But many are concerned that additional funding being considered will not be enough.

According to statements issued by the American Public Health Assn., $1 billion is what's needed now, in part to cover the costs of the anthrax crisis. But more than $10 billion, at least, will be needed in the next five years to rebuild the public health infrastructure.

Public Health: Renewed Attention is a six-part series exploring the role of the public health system in the context of our nation's heightened state of alert. Next: Standing sentry for homeland security.

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 ADDITIONAL INFORMATION: 

The wish list

What public health officials seem to long for:

• Education and training for staff.
• More personnel.
• Salaries comparable to the private sector.
• Legal power to operate in an emergency.
• National standards for public health departments similar to those for hospitals or physicians.
• Larger regional offices rather than tiny ones for each municipality.
• Office space to work.
• High-speed Internet access.
• Surveillance and early warning networks.
• Fast fax machines.
• Up-to-date laboratories with surge capacity.
• Transport systems to move specimens quickly and securely.
• Redundant systems in case of failures during emergency situations.
• Full funding.

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Weblink

IOM report, "The Future of Public Health" (http://www.nap.edu/catalog/1091.html)

CDC Public Health Practice Program Office, with "Public Health's Infrastructure: A Status Report" (http://www.phppo.cdc.gov/)

Chartbook, "Local Public Health Agency Infrastructure," October 2001 from the National Assn. of County and City Health Officials (http://www.naccho.org/general428.cfm)

Assn. of State and Territorial Health Officials (http://www.astho.org/)

American Public Health Assn. (http://www.apha.org/)

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