Medicine Rallies to Save Public Health System
Public Health Feature – January 2012
Tex Med. 2012;108(1):39-43.
By Crystal Conde
Associate Editor
Lubbock physicians and alliance members attending a Texas Medical Association Be Wise — ImmunizeSM event there in July were shocked when a Lubbock Health Department employee mentioned that six future Be Wise events would have to be canceled because the department was closing. Although that eventually proved not to be true, the comment mobilized the city's medical community in a successful effort to protect Lubbock's public health system.
Juanema Christensen, executive director of the Lubbock-Crosby-Garza County Medical Society, immediately called TMA for assistance in determining the department's future. The association's Division of Public Health and Medical Education put Ms. Christensen in contact with the Texas Department of State Health Services (DSHS). The TMA Media and Public Relations Department printed postcards promoting the health department and helped the medical society set up a meeting with the Lubbock Avalanche-Journal editorial board to garner the newspaper's support for preserving the health department.
James Morgan, MD, assistant commissioner of the DSHS Regional and Local Health Services Division, says he initially heard the health department was planning to shut its doors in August. But when he talked to city officials, "we learned they were actually looking at outsourcing a large percentage of health department services."
Indeed, DSHS and the medical society discovered the Lubbock City Council proposed outsourcing surveillance, sexually transmitted disease (STD), and immunization services.
City officials cited funding reductions as the reason for the proposal and told the Avalanche-Journal the city would save about $400,000 in fiscal year 2012 and $835,000 in fiscal year 2013 by outsourcing services.
Although relieved the health department was not closing, Lubbock physicians were still alarmed at the danger to public health and continued lobbying city officials.
"We felt like we had to get physicians and health professionals saying subcontracting these services would be to the detriment of the public health and safety of the people of Lubbock," Ms. Christensen said.
Many Lubbock physicians and other health professionals, Texas Tech University Health Sciences Center medical students, residents, and medical society alliance members rallied to advocate that public health services remain under one roof in the health department. Physicians gave radio interviews and testified at city council meetings.
Their efforts paid off when the Lubbock Board of Health, an advisory group to the city council, recommended the council delay the outsourcing for 90 days. During a packed meeting Sept. 18, the council granted the moratorium, giving a Board of Health subcommittee time to examine the most practical way for the health department to provide services for STDs, immunizations, and surveillance of infectious diseases and to develop a recommendation.
The subcommittee held three meetings and unanimously passed a resolution recommending the STD and immunization services remain under the health department's full control, said Donald R. May, MD, chair of the subcommittee.
"The subcommittee felt strongly that services should remain under the supervision of the health department, which can provide quality control," said subcommittee member Naidu Chekuru, MD, who drafted the resolution. "When you outsource services, you run the risk of weakening the infrastructure and losing the ability to provide services altogether."
The subcommittee presented the resolution to the Board of Health, which added three recommendations, including one that called for the health department to provide fully staffed surveillance services. The revised resolution passed Oct. 21.
On Oct. 27, the resolution went before the city council. Public health stakeholders, physicians, medical residents and students, alliance members, business leaders, and concerned community members jammed a meeting room to support the Board of Health's recommendation. After about an hour of discussion, the battle to prevent the fragmentation of public health services ended when the council voted unanimously to adopt the Board of Health's recommendations.
Eldon Stevens Robinson, MD, a family physician and president of the medical society, testified before city council to support the health department.
"Not all politicians have all the information they need to make better choices. They may just look at money and not understand the public health repercussions. The idea of saving money motivated council members, but fortunately, they saw the light politically," he said.
Dr. Robinson, who's a member of the TMA Committee on Rural Health, says outsourcing services would have been a mistake.
"Some of the nurses at the health department have been doing surveillance and STD services for decades," he said. "Outsourced services wouldn't be coordinated, and the level of care would suffer because you would be replacing experienced nurses with employees who don't have the same amount of training and qualifications."
More Work Ahead
For fiscal year 2012, which runs from September 2011 to August 2012, the Lubbock health department didn't experience any cuts to state funding for STD services or immunizations. According to DSHS, the City of Lubbock received $190,000 for clinical STD services and $232,000 for immunizations, with STD funds coming from general state revenue and $115,704 of the immunization funds provided by a federal grant.
There were reductions in three federal preparedness grants: Public Health Emergency Preparedness (PHEP), the PHEP Laboratory Response Network, and Hospital Preparedness. Budget cuts decreased total grant funding 14.6 percent, from $531,462 for fiscal year 2011 to $453,759 for fiscal year 2012.
Lubbock city officials cited the federal cuts as a reason the city needed to outsource surveillance, immunization, and STD services.
Although city officials kept vital public health services within Lubbock's public health department, Ms. Christensen says supporters can't rest for long.
"For now, health services won't stop, but the city council will likely have to address the same issue at budget time next summer. That gives us time to find more permanent solutions," she said.
Among the issues likely to surface as the city contemplates its next budget are finding a new space for the health department and establishing a joint city-county health department.
The Lubbock health department received the city council's blessing in early November to examine the possibility of the city and county joining forces to fund health services. Ms. Christensen says creating a joint entity would provide county funding, as currently only the city appropriates any local funds to the health department.
Lubbock Mayor Tom Martin told the Avalanche-Journal in November the 80-year-old building that houses the health department "probably needs a minimum of $1.5 million to keep it going." Ms. Christensen says an area hospital or other entity may be able to suggest a newer, less expensive space for the department.
What happened in Lubbock brings up an underlying concern regarding public health funding at the local level throughout Texas. Dr. Chekuru says public health officials and local governments need to examine ways to work with fewer resources while providing services more efficiently. He says in Lubbock that may involve moving the health department to a less costly building. Additionally, he suggests communities research other forms of funding.
"We need new sources of funding. Patients will get sick and end up in the ER if we don't have these services," Dr. Chekuru said.
Physicians Rely on Health Department
DSHS Commissioner David Lakey, MD, says local health departments are important partners in protecting the public's health in Texas.
"They are close to the people they serve, know what's going on at the local level, and can take quick action to improve health. We work with local health departments every day on issues as diverse as communicable disease investigations, chronic disease prevention, immunizations, public health training, and emergency preparedness," he said.
The potential fragmentation of services that would have occurred had the Lubbock city council's proposal passed worried physicians, Ms. Christensen says.
"All of the bus routes go to the health department. If a parent and child have to travel to multiple locations for health services, we'd likely have an access-to-care crisis, especially in preventive services like immunizations," she said.
She adds physicians rely on the health department to provide them with vaccines. The department allocates small volumes of vaccine to physicians, saving them money by preventing them from having to buy large lots. It also allows physicians to return expired vaccines and exchange them for fresher ones.
"That has been an invaluable service for local doctors. Small, independent providers may not be able to afford purchasing vaccines without the health department," Ms. Christensen said.
Dr. Robinson says he uses the health department's immunization services in his practice.
"The health department provides immunizations to us free of charge and helps us keep them accounted for with their computer system," he said. "It's a very valuable service that may have been lost to physicians who provide vaccinations in their offices."
The department's STD services are valuable, too, Dr. Robinson says, because Lubbock has high STD rates. The 2010 Texas STD Surveillance Report from DSHS shows Lubbock County made the top 10 among Texas counties with the highest case rates of chlamydia (684.7 per 100,000) and gonorrhea (230.7 per 100,000). Lubbock County ranked ninth and fifth, respectively. Garza County ranked fifth in total syphilis cases, with 57.3 per 100,000.
"It's [STD rate] not something to brag about," Dr. Robinson said. "When a patient in my practice tests positive for a reportable STD, the health department does a good job of tracking cases."
He says physicians work closely with the health department when disease outbreaks occur.
In the midst of the efforts to preserve crucial health services within Lubbock's health department, a restaurant in Lubbock reported a worker had tested positive for hepatitis A, potentially exposing thousands of people who ate there between Aug. 31 and Sept. 8. Ms. Christensen says the health department sprang into action, making surveillance calls and setting up a free immunization clinic at the Lubbock Memorial Civic Center. The city had a limited supply of hepatitis A vaccine.
University Medical Center Health System stepped in by ordering vaccines and paying for them up front. Mayor Pro Tem Floyd Price issued $275,000 in emergency appropriations to reimburse the institution for the vaccines.
"The hepatitis A scare drove home the need for the health department," Ms. Christensen said. "I think it emphasized that immunization and surveillance, as well as STD services, could best serve the public by remaining in one central location."
Dr. Robinson agrees and adds that cutting public health funding comes at a cost.
"If a community tries to save too much money, the people end up spending more money down the road. If there's an outbreak, people are going to wish they hadn't reduced funding," he said.
Surendra Varma, MD, a pediatric endocrinologist and chair of the Lubbock-Crosby-Garza County Medical Society Public Health Committee, testified in support of the health department at city council meetings and provided commentary on radio talk shows.
He says fragmenting health department services would have resulted in "a significant drop in immunization rates, more STDs, and no central place for reporting communicable diseases."
The positive outcome in Lubbock is a testament to the power of public health advocacy on behalf of many stakeholders, Dr. Robinson says.
"The county medical society received help from TMA, the CMS alliance, the medical school, and many other individuals and organizations. Our job is to advocate for the health of Texans, and it was very heartening for me to see this come to pass," he said.
Editor's Note: This is part one of a two-part look at public health funding. In the February issue of Texas Medicine, Associate Editor Crystal Conde will examine local and state funding challenges.
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.
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