Cover Story -- June 2001
By Laurie Stoneham
Something was not quite right about the case. The Arlington elementary school student seemed well during school on Friday but was dead by Sunday. The provisional cause of death was chicken pox.
The school nurse was mystified. Children don't usually die from chicken pox. She contacted Alecia Hathaway, MD, MPH, the local public health authority for Tarrant County, with her concerns. Dr. Hathaway contacted the attending physician, who described the lesions. "They were less consistent with chicken pox vesicles and sounded suspicious for a skin reaction, more in line with a possible toxic shock condition," she recalled.
Because the child died before arriving to the emergency department and the cause of death was not firm, the parents had consented to autopsy. Dr. Hathaway then spoke to the medical examiner's office and upon learning of findings suggestive of toxic shock, she asked that blood samples be cultured for invasive group A streptococcus (GAS). The results confirmed this suspicion, and immediate action was taken to respond to what Dr. Hathaway called a "community health threat."
"Without creating a media scare, we sought to alert the medical community to contain a potential epidemic for our county," she said.
Such was the case for other localities of Texas. A "blast fax" went out to all members of the Tarrant County Medical Society and all medical directors in the area warning that a virulent strain of invasive group A strep was present in the community and had claimed a child's life. They were advised to look for specific presentations and to treat according to recommended regimens.
While other communities in Texas had several deaths during the GAS outbreak in 1998, Tarrant County had only the one. This is how public health, armed with the appropriate infrastructure, can work.
Unfortunately, the level of public health services throughout the entire state of Texas is spotty at best. The quality, intensity, and scope of services are as diverse as the state itself.
The numbers begin to tell the story. Of the 254 counties in Texas, only 64 have so-called "participating" local health departments that receive funds from the Texas Department of Health (TDH). Another 81 local health units provide far more limited services. Most communities in Texas have no formalized means of addressing public health issues, primarily due to lack of expertise and resources.
The gaps in public health infrastructure concern Fernando Treviño, PhD, MPH, professor and founding dean of the School of Public Health at the University of North Texas Health Science Center at Fort Worth. "In the large regions of the state that don't even have a health department, who's checking the water, who's checking the restaurants, who's educating the public, who's analyzing the data and providing disease surveillance to make sure there are no emerging diseases? The answer is, those things aren't getting done."
Gordon Green, MD, MPH, dean of allied health at The University of Texas Southwestern Medical Center at Dallas, believes past public health successes have lead to complacency. "We have allowed the public health infrastructure to relax and be less effective than it needs to be, given the potential for emerging diseases, bioterrorism, environmental exposures, and so forth."
Defining public health
Public health is far more than the direct delivery of health care services. Ciro Sumaya, MD, MPHTM, dean of the School of Rural Public Health at Texas A&M University, describes the discrepancy between perception and reality. "Public health has been viewed as an activity done by a few people who work primarily with the poor. Actually, public health involves the whole community -- the have and the have-nots, the rich and the poor, the educated and non-educated. The purpose of public health is to improve the health of the public. Public health not only requires the collaboration of public health agencies and health care professionals, but also must involve all community sectors including business, educational agencies, social agencies, political leadership, and the general public."
In 1995, the Texas Medical Association Council on Public Health adopted and the TMA House of Delegates approved a position paper that defined and categorized essential public health principles:
- Monitor health status to identify community health problems.
- Diagnose and investigate health problems and health hazards in the community.
- Inform, educate, and empower people about health issues.
- Mobilize community partnerships to identify and solve health problems.
- Develop policies and plans that support individual and community health efforts.
- Enforce laws and regulations that protect health and ensure safety.
- Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
- Assure a competent public health and personal health care workforce.
- Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
- Research for new insights and innovative solutions to health problems.
House Bill 1444, passed by the Texas Legislature in 1999, incorporated these principles.
The council has added another principle: Public health departments should provide accurate information about transmission of sexually transmitted diseases, including HIV, and should provide strategies and tools to the public for disease control.
No rhyme or reason
The organization of the public health system in Texas has no real logic or rationale. "It's a non-system," said Chip Riggins, MD, MPH, regional director for Public Health Region 8, headquartered in San Antonio. "Our system resembles a hodge-podge of available funding sources, not one to effectively complement the health care system as it should."
In Texas, there are state, regional, and local public health operations. TDH is at the top of the chain. Then the state is divided into 11 public health regions (see " Public Health Regions of Texas "), which are overseen by eight public health regional directors. Each region has a certain number of "participating local health departments." These facilities receive TDH funding based on historical precedence. The "nonparticipating local health departments" exist through local taxes and whatever other sources of funding they can scrounge up. All public health services within the state rely on a variety of grant programs to stay alive .
A local county or municipality also may appoint a local health authority to perform a variety of functions. These officials are always licensed physicians who serve on a full-time, part-time, or volunteer basis. Just as no two health departments in this state look alike, no two local health authorities perform exactly the same functions.
"While public health may be mandated at the state level for several states, functionally it has to happen at the local level. With few exceptions, public health is predominately delivered at the county or district level. In Texas, we can see a patchwork of smaller municipal health departments or units and overlapping jurisdictions, so that economies of scale and efficiencies are lost," said Dr. Hathaway. "But the way it is set up, the smaller localities have to try to do something for their residents."
Accountability is an issue. In those counties and cities that don't have a defined system, public health functions default to TDH. This creates time delays, which can impact the health of the community in an emergency.
"Most local health departments will tell me very candidly that public health is not a mandate of local counties. It is a mandate for the state to provide. And without resources, many counties simply don't deliver the services," said Charles Bell, MD, MPH, executive deputy commissioner of TDH, who is acting as commissioner while that position is vacant.
"If you look at the public health system as the continuum of local, state, and federal resources, the weakest link in that chain in Texas and certainly in my region is at the local level," said Dr. Riggins. "For example, the ability to collect, assimilate, analyze, and report back to the community on local public health indicators is virtually nonexistent, except in San Antonio, our largest local health department."
There is an attitude problem relating to public health. "I wish people would think about public heath as infrastructure for society, just like roads and bridges are infrastructures for a safe community," said Dr. Green.
"It's sort of like fire and police protection. It is a common good and it ought to be supported on an ongoing basis so that when and if a problem does arise, you have a well-trained cadre of professionals who are prepared to take action to protect the community," Dr. Green said.
Along with the variance in the roles and functions carried out at the local level, the systems that existing health operations have and use are all over the map, according to Mark Guidry, MD, MPH, regional director for Public Health Region 6 & 5 South, headquartered in Houston. "There is a great variance in the computer and communications systems used to report communicable diseases. This interferes with the capacity of the public health system as a whole to identify disease outbreaks early enough to implement timely interventions that may reduce morbidity and mortality."
Because the critical infrastructure elements of an early detection system and capacity to rapidly respond to a health threat were not in place, this shortfall was seen during the recent meningococcal meningitis outbreak in the Houston area. From October 2000 through March 2001, there were 65 confirmed cases and 8 deaths in a 10-county area, involving more than 10 local health departments and more than 10 local health authorities. Some 60,000 vaccinations were given to residents of New Caney-Porter, Conroe, and Humble.
While the outbreak was contained, resources from around the state were called in to provide assistance to investigate diseases, to logistically prepare for the clinics, and to respond to the volume of public concerns.
A large part of the problem is ill-defined funding for public health. Most local health departments spend an inordinate amount of time and energy chasing down grant monies to keep the lights on.
"How do you build appropriate infrastructure that doesn't fall under any categorical funding?" Dr. Hathaway asked. "Traditionally under the block grants, it's categorical -- for a specific disease or cluster of services -- and then we try to piggyback one grant onto another so there's some interrelated efficiency. So, say you get a grant for one category and you hire someone, but that work takes only 80 percent of that person's time. You put 20 percent of general fund with that person so he or she can be doing other duties."
Robert H. Emmick Jr., MD, immediate past chair of the Council on Public Health, said, "When we try to work on prevention for underage drinking, for example, there's no funding for the prevention aspect or for enforcing the rules that are made. When we look at monitoring the water or checking the food, each of these things is getting slighted. The individuals doing these kinds of jobs are spread out thinner and thinner so it's occurring less and less."
This intricate financial wrangling is a way of life in public health. According to Dr. Riggins, "The health of the health department, instead of the health of the community, becomes the focus for local boards of health. You'd like to see them working on such things as health improvement projects and community mobilization efforts. Instead, you see them concerned that this federal grant got cut or is running out, and this funding stream is changing the rules."
Eduardo Sanchez, MD, MPH, a family practitioner in Austin and chair of the Council on Public Health, says the situation is "not unlike your community-based physician who has to understand and comply with the rules and regulations of 15 HMOs to basically have a whole practice. A health department has to know the rules and regulations of a number of different grant and funding programs. That may not be the best way to use staff time and energy in a small local health department."
HB 1444 was designed to provide stable funding for public health infrastructure, but that hasn't happened. The language of the bill is littered with the phrase "subject to the availability of the funds." To date, some $8.6 million have been awarded in innovation grants exploring three issues -- improving health status, identifying health disparities in certain minority populations, and strengthening infrastructure to carry out essential public health functions.
The need for basic changes
"There's been a lot of talk this session about the budget crunch, but the budget crunch is really the symptom. The disease is the way taxes are assessed in this state," said State Rep. Patricia Gray (D-Galveston), chair of the House Public Health Committee. Companies organized as limited liability partnerships pay a different amount of taxes than do corporations that pay franchise taxes.
"Any time the budget starts to get tight, you see the money come out of health and human services first, then other things," Representative Gray said. "So, yes, it's going to get worse before it gets better, unless we fundamentally shift our attitude about what's important to us in the state and how we're going to pay for it."
She added, "This crisis isn't unique to public health. We've got to make some decisions on a number of fronts, and I don't see the political will out there to make those decisions."
Public health vulnerabilities
Dr. Emmick believes the state of public health in Texas is showing symptoms of widespread disease . "These are precarious times for public health in Texas. We are optimistic with Dr. Bell and what he has been able to achieve during his time at TDH. As a group, we are in agreement with the criteria and requirements set forth in the selection of the next commissioner. But the underpinnings of what makes up the infrastructure we call public health are lacking to the point that the hard-working, conscientious employees at TDH have been left possibly without the necessary tools if a public health emergency or disaster should befall the state of Texas."
Dr. Riggins thinks the recent meningitis outbreak in the Houston area pointed out the state's weaknesses. "Had we had multiple, simultaneous challenges going on in the state, we easily could have exceeded our system's ability to proactively respond and prevent disease."
What we don't know we don't know
"Our surveillance of disease is very, very limited," Dr. Green said. "I would cite as an example, food-borne illness. Most of these cases are never ever reported. So we really don't have a good reading on the incidence of food-borne illness in our community. It's an example that's easy to see, but it probably reflects the state of many other reportable conditions," he said.
"We probably have a large number of emerging diseases that we haven't even thought of yet," said Dr. Bell. "We are looking into mad cow disease [bovine spongiform encephalopathy, which causes Creutzfeldt-Jakob disease in humans]."
Dr. Green echoed that concern. "This represents a tremendous threat to the health of human beings. How these conditions are going to be dealt with over the next months and years as the problems unfold is going to be a very interesting challenge. And they may themselves point up some of the weaknesses in our public health infrastructure."
"Other things could be looming out there that, without a sensitive system, we're not going to be able to pick up until some damage has been done," Dr. Bell said.
Training the public health workforce
Dr. Treviño, the former executive director of the American Public Health Association, says education is critical. He quoted a study performed by The University of Texas-Houston Health Science Center School of Public Health that showed that only 7 percent of the people working in public health in Texas have formal training in the field.
Noting that many UNT-Fort Worth graduates enter rural practices, Dr. Treviño established a dual-degree program to give them greater understanding of individual and community heath. Students can earn a medical degree and master's degree in public health. "Being dually trained in medicine and public health, they're better prepared to recognize and respond to situations such as an outbreak of food-borne illness or an infectious disease emergency," he said.
The School of Rural Public Health at Texas A&M has enlarged its mission to work with communities in assessing their public health needs. Dr. Sumaya describes the process as "engaging the community" in identifying its health problems, looking at specific data, and pinpointing the resources both inside and outside the local area that are available for addressing the issues.
These assessments involve a wide range of community participants, including hospitals, private physician groups, business leaders, educators, and citizens. They work together to identify solutions and ways to measure their effectiveness, and to develop ongoing monitoring of the issues. Students plan, manage, and administer the projects, and the School of Rural Public Health provides needed services such as data processing. The first project involved the 13 counties around San Angelo. Plans are under way to extend these projects to the Coastal Bend area around Corpus Christi and to the Brazos Valley.
Keeping public health a priority
"We may not have done the best job in the past of articulating what our priorities are or we may have given mixed messages with regard to direct care services versus those essential public health services that effect populations as a whole," said Dr. Bell. "I think we need to get better at articulating what our priorities are so that we receive the necessary resources in areas where we can improve on those priorities."
He put the financial debate in perspective. "There are billions of dollars at stake when you're talking about Medicaid and millions when you're talking about public health. But good public health infrastructure will decrease the amount of money you pay on the Medicaid side. It's hard to put on a chart or graph so that it is seen as an investment," he said.
Dr. Green has a graver warning. "Health problems may seem to go away, but they are never entirely gone. What we see now as a reasonably healthy society is fairly thin veneer. We can not let down our guard, and to the extent that we do, it will be very costly, not just in dollars."
TMA Advantage: TMA's public health priorities
Public health regions of Texas
A strong public health system
Choosing a new Texas commissioner of health
June 2001 Texas Medicine Contents
Texas Medicine Back Issues