The public health movement has become a victim of its own success. Each of its well-documented victories, in battles against diseases ranging from childhood maladies such as measles and mumps to scourges such as polio, tuberculosis and smallpox, has reduced the nation's sense of urgency. Since the 1970s, public health agency budgets have been in steady decline. "When TB was no longer ravaging communities, the government said it didn't need to fund the system anymore," says Mary Selecky, Washington State's health secretary and president of the Association of State and Territorial Health Officials. "But you don't stop funding a fire department if there are no fires."
With cash in short supply, many public health offices have been asked to focus on problems with a political constituency, particularly those that tend to resonate among the middle class. Breast cancer prevention and treatment, for example, has continued to receive generous funding- -and deservedly so. Meanwhile, however, public education about other equally deadly diseases has gone begging, as has money to support the public health workforce, facilities and technology.
Shelley Hearne, executive director of the Trust for America's Health, a nonprofit research organization, says this "disease du jour" funding pattern is a disservice to public health as a whole. "We keep dipping from the same pie," she says, "rather than making sure the pie has enough resources in the first place."
Now, bioterrorism has become the disease of the decade. The largest share of federal funding is dedicated to that cause and other needs are being ignored. "The real tragedy here is that the things that kill people every day--heart disease, lung disease--are still not getting the kind of attention they need," says Georges Benjamin, executive director of the American Public Health Association. "We're funding preparedness and cutting everything else."
The stories are the same almost everywhere. The portion of Oklahoma's public health budget derived from state general funds has been reduced 24 percent in the past two years; Indiana's state funds have declined 17 percent in the past three. In Massachusetts, lawmakers have cut the state appropriation by 28 percent in the last three fiscal years.
Underfunding public health is nearly always a short-sighted and ulti- mately expensive business. Vaccines save untold lives. Thousands of women can learn about proper prenatal care for less money than it takes to treat one extremely ill newborn child.
One need look no further than the current flu outbreak for a potent example. Despite repeated warnings, most states have no plan in effect for dealing with it. When the disease hits, their response is ad hoc.
CASE HISTORY
"Nothing can be more important to a state," Franklin Roosevelt said in 1934, "than its public health." By the time FDR uttered these words, state public health departments were already a major force in American life. Massachusetts formed the first one in 1869; by the turn of the century, 40 states had health departments, most of them designed to control and prevent infectious diseases.These state agencies--and by the 1920s, their local city and county counterparts--improved sanitation and purified drinking water to stop the spread of cholera and typhus. They inoculated millions against smallpox--eradicating that disease from the United States entirely-- encouraged the use of antibiotics to fight TB and administered the polio vaccine after its introduction in the 1950s. Once those activities were underway, the departments expanded the scope of their work to include fighting chronic diseases and more general prevention and education activities.
But "when public health does its job well, it's invisible," says Bud Nicola, medical officer at the Centers for Disease Control and Prevention. "It's hard to raise money for something when there's no visible problem." So, despite the admirable record of accomplishment, state public health budgets declined and the system steadily eroded. In 1988, a groundbreaking report by the Institute of Medicine condemned public health in America as a system "in disarray."
That study set out three core functions that public health systems should perform: assessment, policy development and assurance. "That gave us a common base," recalls Joan Brewster, director of public health systems and development in Washington State. "Health departments shifted their perspective to being part of a system with a broader framework." Officials from across the country came together in 1994 to elaborate on the IOM report and declared 10 essential services of public health (see box below). But funds to implement the agenda continued to be inadequate.
Then came the terrorist acts of September 11, 2001, followed closely by the anthrax scare, which turned bioterrorism preparedness into the overwhelming focus of many public health departments. Federal grant programs for this purpose expanded dramatically: States received $1.1 billion in 2002 and $1.5 billion in 2003 to enhance their capacity for dealing with public terror-related emergencies. State health agencies have used much of the grant funding for planning and orchestrating mock emergency exercises. Those plans have highlighted weaknesses in communication--particularly among the diverse roster of first responders at the local level.
Meanwhile, the impact of the terrorist attacks was amplified by the emergence of new diseases that captured public attention and became daily news stories: SARS, West Nile virus and monkey pox. "Now," says George Hardy, of the Association of State and Territorial Health Officials, "the public knows public health exists."
In 1999, 29 states had public health labs that met criteria for biosafety level 3. (Level 4 is the highest and indicates the facility can process the world's most dangerous matter; no state agencies currently operate at level 4.) By 2002, 43 states had built or enhanced their laboratories to BSL 3. The new labs don't come cheap: Virginia's new 195,000-square-foot lab, opened last June, carried a price tag of $63 million. Missouri expects its new lab will cost the state $30 million. Iowa will be spending $29 million to replace its current lab, built in 1917 as a tuberculosis sanitarium.
There is no question that these investments will improve the quality of services in the states that are making them. Unfortunately, however, the physical plant is only a small part of the public health package. More important in the long run are the funds and trained personnel needed to operate the facilities on a continuing basis.
COMPLICATIONS
Although public health departments have been accustomed to living on a frugal diet for decades, the more draconian budget cuts of the past few years have made it difficult for them to function. California was forced to reduce its newborn screening program dramatically and cut its media campaign to reduce teen pregnancies. Massachusetts cut its teen pregnancy program 82 percent in this year's budget, in addition to making drastic reductions to its environmental health, hepatitis and breast cancer programs. In the face of the lowest immunization rates for two-year-olds anywhere in the country, Colorado zeroed out its state general fund appropriation to support childhood vaccinations. Currently, Colorado public health agencies receive less than 5 percent of their funding from the state itself. "Not having funding does translate to difficulty in promoting immunizations," says Ned Calonge, the state's chief medical officer, in a model of understatement.Even the huge influx of cash from state settlements with tobacco companies, a large part of which was to be used for public health campaigns, has been diverted to other areas as a result of hard-hit budgets. Florida's anti-smoking program had cut the rate of tobacco use 35 percent among high school students and 50 percent among middle schoolers over five years. Nevertheless, the state reduced its anti- tobacco budget from $39 million to $1 million in the past year.
In Massachusetts, where adult smoking rates fell from 22.6 percent in 1993 to 18.3 percent in 2001, lawmakers slashed the anti-tobacco program from $48 million to $2.5 million over the course of two years.
Geoffrey Wilkinson, executive director of the Massachusetts Public Health Association, believes the anti-smoking initiatives worked with an increase in the cigarette tax to reduce tobacco use, and criticizes the dismantling of what he considered a successful program. He notes the resulting cutbacks local health departments have made in their efforts to stop shop owners from selling tobacco to minors. A study by the Massachusetts Association of Health Boards found that as local programs have shut down or been scaled back, the availability of tobacco products to teenagers has tripled. "A big advertising budget was not going to survive when they were looking to preserve direct services," Wilkinson says, "but there is no way to defend logically the kinds of public health cuts that have been made in the state."
The Brain Drain
In many states, one of the biggest obstacles to a functional public health department is the inadequacy of the workforce. About 500,000 people work in public health today. Some estimates are that the workforce needs between 10,000 and 30,000 more employees just to meet current needs.
"Since 1996," says Leah Devlin, North Carolina's state health officer, "we have lost 15 percent of our public health nursing workforce. That's as a direct result of funding." Many other states report public health layoffs and hiring freezes in recent years.
Early retirement packages have caused similar pain. Missouri lost 125 of its 2,000 health department employees this year and was allowed to fill 65 percent of the positions; 16 percent of the Illinois health department staff took the golden handshake last year. "People walked out the door with years of experience, and we had nothing to show for it," says state public health director Eric Whitaker.
The scenario darkens further. At least 25 percent of current public health employees are estimated to be eligible for retirement within the next five years, and the pipeline of workers to take their spots is depressingly dry. Most states report that they're expecting significant numbers of employees to leave in the near future--Alaska, Maine and Tennessee are prime examples--and they have no idea where they'll find replacements.
Young people are increasingly reluctant to enter the field. Low salaries are an obvious reason. That's theoretically fixable; information technology had the same problem a few years ago but addressed it with revised job descriptions and pay scales. But the current austerity in state budgets won't allow the same offers to health workers. "People who go into public health have a lot of dedication and are willing to receive less reimbursement in the long run," says Indiana Health Commissioner Greg Wilson, "but when there are large salary discrepancies, they can't afford to make that kind of sacrifice. We're beginning to approach that gap."
States were hesitant to use their new federal bioterrorism money to hire new public health workers. They feared that funding might dry up and leave them stuck with employees and no money to pay them. Instead, they made improvements in areas where funds could be used on one-time expenditures, such as building laboratories and buying communications systems. President George W. Bush has proposed additional future funding, easing those fears a bit.
The State-Local Connection
A good deal of the public health problem is local. States can't effectively manage efforts over a large geographic area without cooperation from localities. But a number of states lack essential pieces of local public health infrastructure. "The number one public health issue here is that we don't have a statewide public health system," says Saskia Bopp, executive director of the Maine Public Health Association. "There is no formal structure in place."
Even though states acknowledge the importance of having well- performing local health departments, some are cutting their funding. Massachusetts cut local aid by 7 percent across the board over the past two years, while Colorado and others cut the per capita funding that local departments receive. Minnesota consolidated its local public health grant program from eight programs to one. While the move was made to reduce administrative costs, the state health commissioner admits it resulted in cuts to program dollars as well.
Most localities are reluctant to pony up the cash themselves. Despite Louisiana's successful media campaign to inform residents about West Nile virus, the state health officer complains that efforts to persuade local parishes to run mosquito abatement programs have been a challenge. "There's been a resistance to raise taxes for that," says David Hood, secretary of health and hospitals. "We're hoping to overcome that mentality."
Influencing Lifestyle
Even as health officials face these obstacles, many are becoming convinced that they must confront a relatively new role in coming years: addressing the chronic diseases that are preventable by lifestyle changes. Chronic diseases cause 70 percent of American deaths, and cases of diabetes--one of the deadliest chronic killers-- have nearly doubled in the last decade.
But persuading people to change the behaviors that lead to chronic illness, primarily poor nutrition, lack of activity and tobacco use, takes more time for state health departments than other responsibilities. "How do you modify people's behavior," asks Les Beitsch, Oklahoma's former health commissioner, "without becoming the behavior police?"
The federal government has stepped in to help bankroll some chronic disease initiatives, particularly those that fight obesity. The federal Department of Health and Human Services recently announced a new program, Steps to a HealthierUS, designed to address diabetes, asthma and obesity--and their causes. That effort is just a drop in the bucket.
REMEDIES
Developing DataWith little hope for more funding in the near future, states need to spend every dollar they have as wisely as possible. Unfortunately, the data needed to make these judgments are in short supply. Many health departments produce reams of numbers and figures, but not the right ones. They need results-oriented information that shows, with little room for debate, the real cost benefits of public health efforts. With public health, as with any other program, people want to know how much it's going to cost and what they're going to get. And in public health, the outcomes can be expressed in very dramatic terms--lives saved or quality of life improved.
Terry Dwelle decided North Dakota needed to take a new direction in data management after being appointed as the state's health officer. The problem: the state lacked appropriate data to develop a health strategy.
Dwelle brought together 150 organizations and agencies to put together health objectives for the state; their 545 pieces were then boiled down into a strategic health plan organized around 10 main topics, such as nutrition, school health and tobacco. Now, the health agency is partnering with the University of North Dakota to develop a legislative strategy to match the health plan. Part of that strategy will include the presentation of useful data. "Health departments have been guilty of archiving data," Dwelle says. "That bothers me. If we collect it and don't use it, we're not going to collect it."
Efforts to move forward with measurement systems vary enormously. Some states, such as Washington, have struck out on their own, developing detailed strategic plans and performance reports. Others are benchmarking against Healthy People 2010, a set of objectives set by the U.S. Department of Health and Human Services, while another handful are working together through the Turning Point Initiative, funded by the Robert Wood Johnson Foundation.
More than a dozen states are participating in the National Public Health Performance Standards Program, developed by the CDC and other public health partners. The assessment tool sets optimum, not minimum, standards for state and local health agencies based on the 10 essential services outlined nearly a decade ago. Health departments and their stakeholders usually convene for one- to two-day retreats to run through the dozens of standards included in the assessment. Oklahoma used the assessment to set a baseline for its public health programs; it's now writing performance measures based in part on the information gathered during that process.
Unfortunately, developing the measures costs money and even legislatures hungry for useful information tend to be loath to spend enough to get the data. "From a legislative point of view," says Pat Nolan, Rhode Island's health director, "getting services done is more important than evaluating them."
The Local Network
A state's public health services are only as good as its local delivery system, and that's where Nebraska has made marked improvements. Three years ago, the state had only 16 local health departments, which provided services to 22 of its 93 counties. Using part of a $50 million appropriation from the state's tobacco settlement, and a Turning Point grant, the state built 14 new local departments and restructured two others in a remarkably short time.
Ninety percent of Nebraska's counties are now receiving public health services through the state appropriation; the rest are independently funded. The state awards each department, depending on its size, between $160,000 and $850,000 a year to develop annual plans, deliver the 10 essential services and enforce previously ignored public health laws.
In other states, where local health departments have operated autonomously for years, state health agencies are demanding more coordinated control. Michigan and Wisconsin are among the ones that have moved to set formal accreditation standards. In Wisconsin, employees of the state health department conduct site visits to certify each local health department as meeting the standards of level 1, 2 or 3. Level 1 certification indicates an ability to provide basic services; levels 2 and 3 assume the capacity to attain additional goals and objectives. The process is an incentive for localities to perform at a higher standard; a portion of their state funding depends on their certification level. The incentive seems to be working: 85 percent of the local departments are certified at level 2 or 3.
Finding Workers
Just about every state has begun examining the workforce issue, but they've yet to find a good answer. Some, such as Connecticut and Ohio, have convened task forces to look at options. Pennsylvania has concentrated on identifying the most immediate needs and developing depth in those areas before launching broader recruitment initiatives. Wyoming helps fund a Health Resources Network, whose primary focus is the recruitment and retention of health professionals.
On a national level, three groups--the CDC, the Council of State and Territorial Epidemiologists and the Association of Schools of Public Health--have partnered to promote a fellowship program, funded by CDC, to provide on-the-job training for recent graduates in state epidemiology departments. They placed 10 fellows in two-year positions last year; this year, they're shooting for 30. "Over the next 10 years, we could start meeting the demands of the states," says Patrick McConnon, CSTE's executive director.
More important, however, is the creation of new schools of public health to train the skilled professionals who will be needed. Right now, 33 such schools in 23 states are accredited nationwide--although there are many more public health programs within other institutions. Many state health officials consider this effort essential to meeting their future workforce needs. Arkansas, for example, set aside 5 percent of its tobacco settlement funds to create its college of public health, which opened in January 2002 and is on track to receive full accreditation this spring. Fay Boozman, the state's health officer, says the college has been instrumental in providing training in high-need areas, including epidemiology.
Boosting Technology
In the end, though, the most significant counter-balance to the lack of funds and staffing in public health will be technology. Departments around the country point to Louisiana's "Fight the Bite" media campaign as one good example of the way that technology can be used.
With its vast areas of swamp land, the state is prone to mosquito- borne West Nile virus. One early indicator that a region is at risk is the number of dead birds that have succumbed to the disease there. Louisiana officials worked with NASA and Oxford University in England to produce sophisticated climate data based on satellite pictures, tabulate numbers and locations of dead birds, and create "risk maps." These can be used to caution parishes that they are particularly vulnerable to the disease. This initiative was followed by a multimedia campaign in which the state's governor provided citizens with information about how to avoid West Nile, including the simple recommendation that they eliminate pockets of standing water that breed mosquitoes.
Technology is a key to advances in training for time-strapped employees. Tennessee's health department has installed satellite and video conferencing technology in its regional offices and some local health departments, enabling staff there to tune into CDC broadcasts and training classes based in Nashville.
Missouri has made the most of technology by posting on its Web site county-by-county health data, searchable by dozens of criteria. Legislators and citizens have found the database helpful in separating perceived community health problems and statistical realities, says Ron Cates, chief operating officer for the state's Department of Health and Senior Services. "We're trying to get people to look at what the real issue--not the perceived one--is," he says.
At the national level, a Health Alert Network spearheaded by CDC helps state health agencies communicate with local health offices, hospitals and physicians via e-mail and blast faxes during times of emergency. Minnesota's network had just been completed when 9-11 occurred. "We'd intended to test it," says Health Commissioner Diane Mandernach, "but the reality is that we used it."
Kansas, which experienced at least one case each of West Nile virus, monkey pox and hantavirus, as well as a suspected case of SARS during 2003, used its Health Alert Network to handle outbreak management and response. In Wisconsin, which experienced the most significant monkey pox outbreak with 18 confirmed cases, the state's former health officer attributes a quick response to the increased sophistication in bioterrorism resources. "I don't think there's any question that we're better prepared," says Kenneth Baldwin. But there's still a long way to go.
PROGNOSIS
Public health indicators move slowly. It can take years, even with an infusion of resources, to move disease incidence rates up and down. This is both good news and bad news. The good news for legislatures is that they have been able to cut public health dollars dramatically in the past couple of years without too many dire results showing up in the charts. The bad news is the data will catch up with them eventually.As a harbinger of what could eventually happen, states might consider what occurred when they defunded some immunization programs in the late 1980s. They had all but declared victory over measles by then. But there was a national outbreak of the disease in the early 1990s.
How much additional funding does the public health system need? Nobody really knows for sure. The Public Health Foundation, a nonprofit organization that works to build public health infrastructure, estimates the system needs an immediate infusion of $10 billion. But that figure isn't agreed upon in the public health community, and some think the figure is somewhat higher.
It's unclear for now as to what the real benefit of the bioterrorism efforts will be. Experts can pontificate, but until the dreadful day when they're tested, no one will be able to assert categorically how successful these efforts have been. It appears that quick responses to anthrax, West Nile virus and SARS have been moderately successful--but none of those have been the kind of society-wide threats that polio and TB once were--or that a deliberate effort to spread smallpox in the population could be.
What is beyond dispute is that the emphasis on preventing such terrors has created a new vulnerability when it comes to containing the spread of chronic diseases. Ed Thompson, CDC's deputy director for public health services, says the successful public health department of the future will have to be able to strike a balance, acknowledging the importance of "both chronic and acute public health problems and the ability to respond to both." At the moment, that balance is a long way from being achieved.
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