As Health Departments Expand Their Role, Can They Keep Up With Basic Services?

The conflicts playing out in one North Carolina county could be plaguing other places.
by | August 2017
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A scandal erupted in Mecklenburg County, N.C., earlier this year when it was reported that the Health Department had failed to notify 185 women of abnormal Pap smear results. For public health officials, that’s not the worst that could happen -- an epidemic that could have been prevented would top that list -- but it’s certainly a failing in what most would agree is a key duty in preventive medicine.

Mecklenburg County Health Department Director Marcus Plescia took responsibility for the fiasco, which was traced back to the mistakes of one nurse. But Plescia’s leadership continued to come under fire when he demoted a member of his executive team who had helped to blow the whistle on the mishandling of the results, adding to employee accusations that he had created a “culture of fear.”

Morale wasn’t the only leadership issue. The Charlotte Observer reported that some of the department’s employees were unhappy with the general direction the agency was taking, complaining that it was focusing too much on environmental and social factors that affect health across the community while neglecting basic patient care. The final straw came when it was discovered that the department had given operating permits to public swimming pools without performing the proper inspections. Plescia announced in June that he was resigning.

The conflicts playing out in Mecklenburg County are by no means unique. Public health officials everywhere are broadening their scope of practice. It’s become more apparent than ever, they argue, that a healthy community is one with plenty of affordable housing, green spaces and smoke-free environments. Yet ensuring access to care is unquestionably one of the foundations of public health work. Do health departments risk neglecting their core functions when they focus on such big-picture ideas?

“It does raise some pretty big questions, like who will provide direct care if the health department moves away from that,” says Jill Rosenthal, senior program director for the National Academy for State Health Policy. “Are there federally qualified health centers or Planned Parenthoods that can pick up the slack?”

For some health departments, she says, it might make sense to shift the focus to population health initiatives and pass off more routine primary care to community-based clinics, such as those operated by Planned Parenthood. That is, as long as those systems and partnerships are already in place.

It’s hard to say why things went wrong in Mecklenburg County. Some suggest that the Health Department was trying to do too much with too few resources, and without clear communication and trusted partners. Laudy Aron, a senior fellow at the Urban Institute, says the department is overwhelmed in part because North Carolina did not expand Medicaid under the Affordable Care Act. “So,” she says, “there’s already more care needed.”

Aron is among those in the public health community advocating for departments to take a broader focus on community health factors. “There are often tradeoffs when we start focusing on more things,” she says, “but at the end of the day we have to start addressing urgent health issues from a more holistic point of view.”

The debate about the proper role of health departments will likely continue, especially if we see more headlines around botched medical testing and disgruntled employees. But it’s important to remember that health departments are always going to be responsible for preventing disease and heading off epidemics. “It’s easy to see when someone doesn’t get care,” says Rosenthal. “It’s harder to see when a health department prevents an epidemic.”