Triage follows deep cuts

Public health authorities examining services following budget reductions
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A human walking down a long corridor

More than half of state and territorial health agencies in the U.S. have laid off workers since summer 2008.

About 90 percent have cut services such as clinics and immunization programs.

Paul E. Jarris, MD, executive director of the Association of State and Territorial Health Officials, which collected the data, noted that all federal pandemic preparedness money was cut before the 2009 H1N1 influenza outbreak.

He warned fellow public health experts that federal budget sequestration could further reduce the nation’s public health funding by $2.4 billion in fiscal year 2013, a cut “so awful nobody quite knows how to deal with it.” Sequestration, a provision of the Budget Control Act of 2011, will trigger cuts starting in 2013 if collective federal spending exceeds limits set by Congress. Dr. Jarris delivered the messages during the meeting “Sustaining Public Health Capacity in an Age of Austerity,” hosted in September by the Forum on Microbial Threats of the Institute of Medicine.

Mary C. Selecky, secretary of the Washington State Department of Health, said her budget has been reduced 10 times since February 2009. Since then, her department has dealt with a pertussis epidemic, H1N1 influenza, West Nile, and, in 2012, 10 times the typical number of whooping cough cases.

Dr. Lonnie J. King, dean of The Ohio State University College of Veterinary Medicine and one of the meeting moderators, said that, as U.S. public health officials were dealing with West Nile and Heartland virus disease outbreaks, record heat, Salmonella contamination of human food and pet food, and H3N2 influenza at county fairs, it was a good time to examine the effects of austerity measures on public health.

Many of the meeting’s presenters said the public does not understand how investments in public health improve their lives and reduce overall health costs. Dr. Jarris said even many private-practice physicians do not know why public health officials are brought into discussions on microbial threats, despite the existence of public health services related to tuberculosis and sexually transmitted diseases.

Zoonotic disease

About 3,150 veterinarians worked for the federal government in 2011, including about 3,050 in the departments of Agriculture, Health and Human Services, and Defense, according to results of an assessment conducted by the U.S. Office of Personnel Management’s Talent Management Advisory Council. The National Association of Federal Veterinarians was part of the study, and the OPM hired Dr. Michael Gilsdorf, NAFV executive vice president, as the director.

Dr. Gilsdorf also provided results of a 2011 survey of state-employed veterinarians conducted by a joint committee of the U.S. Animal Health Association and American Association of Veterinary Laboratory Diagnosticians, which he and Dr. David Zeman co-chaired. The survey revealed that about 90 public health veterinarians were employed by state governments, although respondents indicated hundreds more worked in regulatory and diagnostic positions.

One of your core public health missions is being compromised at the state level—routinely—in a number of states.

Dr. Cathleen Hanlon, director, Rabies Laboratory, Kansas State University

In 2009, the Government Accountability Office published a report that described chronic shortages of veterinarians at federal agencies and possible additional shortages in the future. Dr. Gilsdorf said in an interview that some agencies in the USDA, for example, have since offered bonuses to fill vacant positions, shifted some duties to nonveterinarians with veterinarian oversight, and eliminated positions that budget shortfalls would not let them fill.

But remaining shortages have left the nation with insufficient research to protect animal health and too few veterinarians able to respond to a disease outbreak, Dr. Gilsdorf said.

“We have less capacity now than we did five years or 10 years ago,” he said. Among more than 1,300 graduating veterinarians who accepted job offers in 2012, one accepted a state government job and eight accepted federal government jobs, according to survey results published in October (see JAVMA, Oct. 15, 2012).

State and local health departments also have primary roles in national food-borne disease surveillance, and job losses in those departments could harm outbreak detection and investigation programs such as PulseNet, according to John Besser, PhD, deputy chief of the Enteric Diseases Laboratory Branch at the Centers for Disease Control and Prevention. Moreover, local and state health agencies will become responsible for large-scale isolation of gastrointestinal pathogens needed by the federal pathogen surveillance program once hospitals and clinics shift to the use of new diagnostic tests that do not provide isolates, Dr. Besser said.

Arizona, Hawaii, and Nebraska are among the states that have eliminated their state public health veterinarian positions, and some states have lost federal grant money that would have helped them hire additional public health veterinarians, according to officials with the National Association of State Public Health Veterinarians.

Dr. Cathleen Hanlon, director of the Rabies Laboratory at Kansas State University, said in an interview that public health authorities from other states—such as Florida and Nevada—increasingly are asking for her laboratory’s help with rabies diagnostic tests because of budget cuts in their states.

”One of your core public health missions is being compromised at the state level—routinely—in a number of states,” she said.

Like highway bridges, disease prevention infrastructure needs to be maintained, she said.

“We’re letting it age and not investing in it, and at some point, it will fracture and we will be caught unprepared” for new or re-emerging diseases, Dr. Hanlon said.

Adjusting and focusing

In April, a separate IOM Committee on Public Health Strategies recommended in part that public health agencies become able to deliver a standardized service package that promotes and protects health, and, as the Affordable Care Act increases access to private clinical services, that public health agencies focus more on population health services.

The IOM report, “For the Public’s Health: Investing in a Healthier Future,” found in part that the United States has poor performance in health outcomes such as life expectancy in comparison with other developed nations. It states that the nation’s public health agencies need better alignment with population health needs and better funding.

Steven M. Teutsch, MD, chief science officer for the Los Angeles County Department of Public Health and vice chair of the committee, also said during the September meeting that state governments should routinely assess the public health effects of legislation and policies before and after implementation. The nation should have fewer but larger local health departments supported by flexible, evidence-based budgets.

We have less capacity now than we did five years or 10 years ago.

Dr. Michael Gilsdorf, executive vice president, National Association of Federal Veterinarians

Other recommendations given during the IOM conference included measuring the effects of public health programs, reducing the scope of services, pushing for reimbursement by insurance companies, and encouraging state and federal agencies to share data, such as air quality data collected by environmental regulators.

Patricia Quinlisk, MD, medical director and state epidemiologist for the Iowa Department of Public health, said her department has stopped performing full investigations into norovirus infections and, instead, has been conducting brief investigations that include identifying affected groups, collecting three to five samples, confirming infection, and implementing control measures. She also said that, if she had more resources, she would like to do more to help people with giardiasis or hepatitis C, although her department is providing population-based education on some chronic infectious diseases.

Murray Trostle, PhD, deputy director of the U.S. Agency for International Development’s Avian Influenza Preparedness and Response Unit, encouraged the meeting attendees to quantify the health effects of reduced budgets on, for example, immunization programs and prenatal services. He questioned whether departments absorbing cuts now will be cut again later and whether more efficiency and technology can help. He said the results could be dramatic, painful, and deadly.

Jay K. Varma, MD, deputy commissioner for disease control in the New York City Department of Health and Mental Hygiene, said public health departments need to align themselves with the public services they are uniquely qualified to handle and use the resources of budget-rich programs to prop up budget-poor ones.

About half of Dr. Varma’s departmental budget is protected by law, but the infectious disease programs are in the other half, he said. The department has increased its emphasis on chronic disease, but he said programs that target tuberculosis and other infectious diseases could be eliminated before the diseases are.

Public health’s funding woes are a symptom of a current debate over how we care for our society, said Jesse L. Goodman, MD, chief scientist and deputy commissioner for the Food and Drug Administration. He said it is important to study the effects of eroding public health funding.

In closing the conference, Eileen R. Choffnes, an IOM scholar and the staff director of the forum, noted the peril facing public health systems, which she said take a long time to build but just a signature to tear down.