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Straight From the Source

I should have specialized in public health medicine. I am an intense advocate of efforts to keep our community healthy. I am a vigilant vaccinator; each year I have a flu shot contest with my entire staff competing on teams. When H1N1 announced its presence, I hounded our public health officials for information and vaccines. When the seasonal flu shots were impossible to obtain, I called multiple pharmacies and became a beggar on behalf of my patients and their families.

It was as if I was obtaining black market products – pharmacists literally told me “Don’t tell anyone I sold you these vaccines.” I talked to so many corporate Walgreen’s personnel, I lost count (no luck there), as well as a well-known local physician’s flu shot clinic (no luck there). I wrote thank you notes, sent flowers, and even gave a gift card to helpful pharmacists. I read the public health weekly email updates, and watched a lot of news to try to educate myself, my staff and patients. I found our public health officials to be forthcoming and tireless in their efforts to help me with this crisis. And yes, I had pre-ordered my vaccines a year in advance! After all of this, I’m proud of my staff for giving over 2000 vaccines for seasonal and H1N1 flu to our patients. It’s not enough, but it’s a great start.

Influenza is an important piece of the public health picture, but it is only one piece. This month I have requested Dr. Bob England, Director of the Maricopa County Department of Public Health, to give us an update. I hope you find this information useful and timely.

Sincerely,

Susan M. Whitely, MD
President


I am gratified by the community-oriented outlook that Dr. Whitely expresses above. The H1N1 flu pandemic is a good example of how public health is truly a collaborative effort between government, voluntary agencies, and you, the provider community. While nearly all of my correspondence with many of you over the last few months has been about H1N1, I’m happy to have this opportunity to begin to discuss how well the public health system is working here (it is, in some respects), how we are coping with the economic downturn, and how we hope to build for the future. But I have to be honest and tell you that we have dug ourselves a pretty deep hole in this community from which to start building.

First, let’s talk about how public health is supposed to work.

Public health isn’t about health care. That’s what you do. Public health is all those things that we do collectively to make a healthy life possible for each and every one of us.

Sometimes it’s regulatory. In our community, that’s mostly done by the Maricopa County Department of Environmental Services. They’re the ones who make sure that standards are met so that our water and food don’t put our lives at risk. Truth be told, most of the improvement in infectious disease mortality over the past century is due to that basic sanitation and enforcement.

Sometimes it’s behavioral education, motivation, and importantly, creating an environment where healthy choices are possible. It’s all well and good to tell parents their kids should be active, but if the only yard or “playground” is the street, or if there are not even sidewalks to walk to school, what can they do? It’s fine to tell people to eat healthy food, but if you can’t tell what the nutritional value is of much of the food you consume (as in eating out), it’s hard to choose wisely.

Sometimes it’s disease control. That core function of Public Health is actually a collaborative effort between you and us. You diagnose, treat and report certain infectious diseases to us – then it’s our responsibility to prevent its spread to others. We do that by:
1)making sure the index cases are treated (e.g., STDs, TB);
2)finding exposed persons and getting them treated
(e.g.,STDs, TB and various acute communicable
diseases);
3)education and support (e.g., HIV, various enterics,
and acute infectious diseases); and
4)immunization (assuring a “herd effect” to protect
us all).

You think in terms of individual patients. In public health, our patient is writ large – the entire community – so we think in terms of numbers and populations. Yet in all of our endeavors, the role of the individual health care provider is key. Changing behavior in the entire population may require a media strategy, but it won’t work without your support. For example, when we asked parents in focus groups what might convince them to immunize their children against the flu, the nearly unanimous response was, “if my doctor recommends it.” ‘Same thing with tobacco cessation, ‘same thing with nutrition and exercise, and on and on.

Having said that, there are lots of core public health activities that require the hand of government, or we all suffer. You can’t do your own disease control – your own outbreak investigations, contact tracing, and treatment of exposed persons. All of you put together can’t immunize enough persons to create the “herd immunity” upon which we all rely to keep vaccine preventable diseases at bay – not when so many people are uninsured or otherwise don’t have primary providers. And even though your health advice and education is necessary, it isn’t sufficient. Not without reinforcement of those messages in schools, in the community, and through the many media that people use today.

In addition, while not everything public health does will actually save society money in the long run, there are many researched and proven interventions that can. A report from Trust for America’s Health in 2008 projected that if we spent an extra $10 per person (beyond basic funding necessary for core public health activities), and we put it only toward those interventions with a demonstrated cost-benefit, we could save $4-5 for every dollar spent, and we’d start seeing some of those savings within 5 years.

Today, public health expenditures make up less than 2% of overall health spending. Honestly, that’s fine if that’s all it takes. But that’s based upon average national public health spending. And here, we’re anything but average.

All local health departments operate on a mixture of federal, state and local dollars. Local funding is most important, because that’s what’s flexible. Any time you accept a grant, you must do exactly what the grantor wants you to do, and having many grants doesn’t necessarily add up to what the community needs. We need that flexible, local funding.

Across the country, in 2008, the mean local health department funding for those that serve more than a million people was $55 per person served. For everything (not counting those departments in some communities that provide health care). That may not sound like much, but in Maricopa County, it stood at less than $12.

And then there’s the all-important local funding, the flexible funding that allows a local health department to perform its true, core functions. In the US in 2008, in large local health departments, it was ~$15 per person. Here, it was less than $3. That has very real implications.

And because of the economy, it’s getting even worse.

In future articles, I hope to tell you about how we try to deal with that. There are things that a community in such dire straits can still do to cope with such an enormous shortfall, and surprisingly, even opportunities that present themselves because of it.

As in all things to do with public health, I look forward to sharing them with you, those who provide the care.

Bob England, MD, MPH
Director
Maricopa County Department of Public Health

President