Back in the Public Eye: The U.S. Health Service
An impossible responsibility has been placed on America’s public health agencies: to serve as stewards of the basic health needs of the entire population, but at the same time avert impending disasters and provide personal health care to those
rejected by the rest of the health system. The wonder is not that American public health has problems, but that so much has been done so well, and with so little.
—Institute of Medicine’s 1988 report
The Future of Public Health
Five dead of inhalation anthrax and a string of nonfatal cases caught the U.S. Public Health Service (PHS) off guard last year. Though small in scope compared to what could have happened, the anthrax attacks overloaded laboratory capacity at some of the most capable state and local health departments. Information intended to calm the public’s fears was at times inaccurate, inconsistent and not very reassuring. Unstandardized anthrax testing methods produced false alarms and a seemingly “Keystone Cops” climate of unnecessary expense, worry and inefficiency. Public health officials admit a larger bioterrorism attack could have broken the system entirely.
The system is already broken, says a chorus of experts who want the U.S. government to shore up the PHS infrastructure—the term used to describe the nation’s vast network of public health agencies. From big federal bureaucracies like the Centers for Disease Control and Prevention (CDC) to state health departments and 2,912 county and city health divisions—the whole system, many say, has been crumbling for at least 30 years. “We have not invested in maintaining the strength of our public health system,” says former Surgeon General David Satcher, who now directs the National Center for Primary Care at Morehouse School of Medicine.
“Anthrax was the wake-up call,” says Dr. Mohammad Akhter, the executive director of the American Public Health Association (APHA). “If the public health system is not working for bioterrorism, then it’s not working for radiation spills or West Nile encephalitis.”
After decades of ignoring the problems, federal officials may have finally heard the call. In a series of legislative moves, Congress authorized the largest infusion of cash in the PHS’ 200-year history. Most of it pays for bioterrorism preparedness, but many public health experts say initial and anticipated funding over the next several years will help the entire system better handle day-to-day activities like disease prevention and wellness promotion too.“NO RESPECT”
So why was the PHS forgotten for so long? Because it’s the Rodney Dangerfield of medicine. It gets no respect from politicians or the public. Only 5 percent of all health-care dollars get spent on public health, according to Dr. Michael McGinnis, the senior vice president and director of the Robert Wood Johnson Foundation’s health group. The rest of it goes to medical research and clinical medicine, which spends most of it on the costly job of treating illnesses instead of preventing them.
Some of that money might be better spent in public health, suggests McGinnis, who served under four presidents as assistant surgeon general. “Forty percent of premature death is caused by lifestyle behaviors that public health has been effective in changing. Even if clinical medicine had unlimited resources, it could still prevent only 10 [percent] to 15 percent of premature mortality in this country.”
Satcher agrees. “We don’t have a balanced health system. Most of the money goes to treat diseases like type II diabetes that wouldn’t [be so common] in the first place if we invested more in public health prevention.”
For years, public health wore its neglect in plain view, but nobody cared until anthrax arrived in the mail. In 1988, the Institute of Medicine’s (IOM) The Future of Public Health report diagnosed the PHS “in disarray” and falling apart—literally coming to pieces at the CDC in Atlanta, where paint flakes from walls and where duct tape is all that prevents leaky pipes from damaging lab equipment. Last fall, its antique power system blacked out during the climax of anthrax testing. “Some of [the labs] are not even safe for the people working in them,” says Satcher, who directed the CDC before he became surgeon general.
The CDC diagnosed itself unhealthy in a 1998 report on a survey of the nation’s largest county and city health departments, describing the entire PHS infrastructure “structurally weak in nearly every area,” especially in terms of telecommunications. The report’s findings were astonishing: One-third of county and city health departments lacked Internet access; 10 percent had no e-mail; 60 percent of the test e-mails the CDC sent to state and local departments came back undeliverable; fewer than half could broadcast disease-alert faxes; and one department admitted not reporting a disease outbreak because doing so would cost them a long-distance phone call they couldn’t afford. And if those weren’t enough problems, the survey also discovered that the average department could accomplish only two-thirds of its essential duties.
“Even before 9-11 and anthrax, it was clear to me just how undernourished the public health system is,” says Dr. Quentin Young, a Chicago internist and a former APHA president. He calls public health “the Cinderella of medicine.”
“A long time ago they took away the glass slipper and made public health medicine’s impoverished, neglected stepsister.”GLASS SLIPPER YEARS
Oh, for the years the PHS wore those glass slippers—when tuberculosis (TB), influenza, pneumonia and streptococcal infections were the major causes of death, and public health physicians were the rock stars of medicine. At the latter part of the 19th century, scientists had just discovered germs spread disease, but with no magic bullets like antibiotics, physicians in private practice could do little to fight infections.
So instead, public health took the lead by educating the nation how diseases are spread through sewage, dirty drinking water, mishandled food and poor personal hygiene. The PHS quarantined immigrants and anyone else carrying infectious diseases. It put toilets in tenements, taught families to build outhouses away from wells and established food inspection standards. PHS physicians stopped the bubonic plague in San Francisco and pellagra in the deep South. They also cleaned up hospitals and ordered physicians and nurses to scrub before and after touching patients. The PHS left big footprints across the land, while clinical medicine, still in its infancy, scurried for crumbs of respect in the underbrush.
Public health’s contribution to human life is enormous. It’s the main reason life expectancies have doubled since 1900, from 40 years to 80 years, according to Dr. William Roper, a former director of the CDC who’s now the dean of the School of Public Health at the University of North Carolina at Chapel Hill. “Five of those 40 more years of life can be explained by improvements in clinical medicine and the other 35 years to improvements in public health…. In no way do I diminish the important investments we’ve made in clinical medicine,” says Roper, a pediatrician, “but our investment in public health is a paltry pittance in comparison…. Public health and clinical medicine are not two separate worlds, but they are two very different ways of looking at health.”
Whereas clinical medicine diagnoses and treats individuals, public health protects the health of individuals by raising the level of health for an entire population—be it that of a city, county, state or the entire country, depending on which public health agency you’re referring to. It identifies the cause of disease, determines how it’s spread, stops the spread and researches prevention or cure.
The PHS remained a blossoming bureaucracy until after World War II. Through mass vaccinations, environmental cleanup and public education, it eliminated cholera, yellow fever, polio, smallpox and typhoid. It put an end to childhood scourges like whooping cough, diphtheria and typhoid fever. Americans were living healthier and longer.
PHS physicians were viewed as medical heroes by many middle-class Americans, who witnessed and respected the power of bacteriology-based public health action. The scales of medicine tipped toward community needs, rather than individuals’ rights, and the entire field of medicine was controlled and dominated by public health leaders.MAY THE FORCES BE AGAINST YOU
But after World War II, the scales began to tip the other way. Public health quickly lost power and prestige to clinical medicine. Local public health agencies became generally viewed as health-care providers of last resort, a safety net for the uninsured and underinsured—welfare’s cousin. Clinical medicine reigned, and it was public health’s turn to scurry for crumbs.
Several forces worked against the PHS. For starters, it was a victim of its own successes. It did such an outstanding job that by the 1960s, death rates from the worst infectious diseases were at historic lows. (Polio in the 1950s was the last epidemic in the United States.) “When the threat went away, the funding went away,” Akhter says. “Politicians cut public health budgets and spent tax dollars on more politically visible priorities.”
Then came medical advances. New technology, antibiotics, vaccines and other wonder drugs gave physicians in private practice more tools to effectively diagnose and treat patients. Today’s acute-care model of clinical medicine came of age. Diagnose it, then fix it, but don’t spend too much trying to prevent it.
Awe-inspiring medical devices and wonder drugs are still seen as medicine’s future. “The wizardry of high-tech medicine has drawn patients and talented professionals away from public health,” Roper says. Being a physician in the PHS Commissioned Corps used to be a position of prestige, but most newly minted physicians shun the field and instead pursue a career in clinical medicine, where pay and stature are higher, the technology more up-to-date and where patients prefer to go if they can afford it.
But that’s the American way, Akhter says. “That we spend most of our health-care dollars on curative medicine is part of the American mindset. If it breaks, fix it; then move on. We no longer pay as much attention to prevention as we should.”
Medicine shifted its focus away from infectious diseases to chronic diseases like cancer, diabetes and heart disease. “Public health was structured to fight communicable diseases, not chronic diseases,” says Robert Blendon, a professor at Harvard University’s School of Public Health.
That changed. By the late 1970s, public health had jumped on the chronic-disease-prevention-through-lifestyle-changes bandwagon, according to Dr. Julius Richmond, who served as surgeon general under President Carter and who is now professor emeritus of health policy at Harvard Medical School. Some public health historians credit Richmond with launching the second U.S. public health revolution, which advocated preventing chronic diseases by changing behaviors (see “Surgeons General: Defenders of Public Health,” in The New Physician’s January–February 2002 issue). “[Yet] when it comes to chronic diseases [now], clinical medicine dominates,” he says.
And with the creation of Medicare and Medicaid in the mid-1960s came another blow to public health, Richmond says. “Politicians wrongly believed that once they created Medicare and Medicaid, they’d successfully mainstreamed all the poor people into clinical medicine and solved the major public health problems that remained. Not true.”
The move further shifted power to private physicians, hospitals and insurance companies, according to Laurie Garrett, the Pulitzer Prize-winning author of Betrayal of Trust: The Collapse of Global Public Health. “Medicare emphasized spending health-care dollars treating patients in the final days of life,” Garrett writes.
The PHS took another hit when managed care took hold in the 1980s. Spending less on health care is managed care’s priority; spending more on public health is viewed as an extravagance.
Other forces shaping public health: modern anti-government rhetoric and right-wing conservatism, Garrett says. To some, public health is akin to socialism, because it addresses the health needs of the entire population and thereby treats everyone equally. But this view is really nothing new; government bashing has long been part of the American character. From 1840 to 1880, many Americans resisted public health initiatives. Coincidence or not, epidemics ran rampant. More recently, the notion that government can do nothing right reflects an American way of thinking dating back to the Barry Goldwater days of 1964, according to Garrett.
The conservatism re-emerged stronger than ever with the Rev. Jerry Falwell’s Moral Majority during President Reagan’s years in office and continued with Newt Gingrich’s Contract With America coalition in the 1990s. The result of this public opinion shift, according to Young, is that public health physicians and scientists are now disdained as paper-shuffling, busybody bureaucrats.
The PHS is accustomed to such suspicions. Even during the glass slipper years, its officers regularly battled local officials and the general public who believed quarantines were bad for business. They didn’t want “Big Government” coming to town with vaccines and telling them where to dig wells and put privies. Irrational resistance to vaccines has been an ongoing public health dilemma for 150 years, Garrett says in Betrayal of Trust. As each new vaccine was developed, she says, a nationwide pattern of opposition was repeated, despite their obvious disease-preventing benefits. “Big Business,” meanwhile, tolerated public health during disease outbreaks until the epidemics were stopped and the business of business took precedence.
Public health leaders threw gas on the anti-government fire during Richmond’s tenure as surgeon general in the late 1970s. That’s when they started telling people to stop smoking, wear condoms, don’t re-use drug needles, exercise and eat your vegetables. “Why is public health interfering in the private lives of individuals?” some politicians asked. “And why are they talking about sex and condoms in public?”
Politics—public health’s boon and bane. What once worked in the PHS’ favor now works against it, Young says. “Public health’s greatest strength—that it’s a public service guaranteed to everybody through public funding—proved to be its greatest vulnerability. Public health’s Achilles heel is that it has always been subordinated to the whims of politicians. All public health leaders serve at the pleasure of presidents, governors, county board chairs and mayors. What constitutes public health varies so much from state to state and county to county because local politicians decide what’s appropriate and feasible,” he says.
No group advocates for public health, Young argues. “Organized medicine is very effective at lobbying to improve conditions for doctors in private practice, but no one effectively lobbies for public health,” he says. The closest public health ever came to having an advocacy group was when the middle class supported it during the early 1900s. But then it dumped the PHS when younger, sexier clinical medicine came of age.
As president of the APHA from 1997 to 1998, Young says he attempted to rebuild a public health advocacy group. “I failed miserably. I just couldn’t penetrate public consciousness. There just isn’t a constituency out there that thinks public health is worth fighting for.” Until now.RESUSCITATING THE PATIENT
Receive anthrax in the mail and suddenly people think the PHS is valuable after all. Apathy toward public health is so-o-o Sept. 10. In many ways, experts say, it’s ironic that President Bush—who rejected previous attempts at boosting the PHS’ appropriations before Sept. 11—signed the legislation authorizing the biggest infusion of dollars in public health history. Supplemental appropriations signed in January increased the 2002 PHS budget by $2.9 billion. For fiscal year 2003, $3.74 billion has been appropriated through the Public Health Security and Bioterrorism and Preparedness and Response Act. The legislation also authorizes funding the PHS “such sums as may be necessary” through 2006; some have estimated the total infusion of funds could reach $10 billion. Most observers say that if the PHS receives that much money, we can remove the do-not-resuscitate order hanging from its toe.
The money is already being used to stockpile drugs and vaccines, expand hospital emergency capabilities, upgrade public health labs, and improve computer communications within and between all levels of the PHS. It also aims to attract, train and raise salaries for public health workers. “This legislation addresses all the pillars of public health,” Roper says.
Harvard’s Blendon agrees. “The money will create enormous improvement, not just for public health emergency response, but for the entire public health system, especially for infectious diseases. Labs will more quickly and effectively screen for lots of things not bioterrorist related. We’ll see an increase in reporting of all kinds of illnesses, like TB and food-borne illnesses. We’ll have better monitoring of food and water supplies. We’ll have much faster pick-up on things. As surveillance improves for known problems, we’ll find new things too.”
The CDC used some of its money to hire 16 more Epidemic Intelligence Service officers—the institution’s swat team of disease detectives deployed to infectious outbreaks (see “Tailing Disease” in The New Physician’s September 2002 issue). Meanwhile, the Department of Health and Human Services contracted with a British company to make enough smallpox vaccine to protect the entire U.S. population, though it has no plans to vaccinate everybody yet. It has already increased its emergency supplies of other vaccines and antibiotics.
The CDC is establishing the Health Alert Network, a $90 million two-way computer link between itself and every state and local health department in the country. The high-speed Internet connection will be used to distribute advisories, lab findings, prevention guidelines and educational materials, as well as to gather information from local departments about possible disease outbreaks.
“The CDC is also identifying regional hospitals and large public health departments prepared to deal with outbreaks of strange and scary stuff,” Blendon says. The bioterrorism act also beefs up the centers’ National Lab Response Network, a coast-to-coast coordination of diagnostic facilities that receive and analyze public health data.
The projected funding is enough to rebuild the public health system, as long as most of the rebuilding is done at the local level, Akhter says. “Ultimately, all public health responses are local.” To make grass-roots disease tracking more effective than it is now, the legislation allocated $1.6 billion in fiscal year 2003 for upgrading state and local health departments. In a nutshell, here’s what it’ll attempt to do:
- Increase local lab capacity—County and city labs will expand their capabilities to trace infectious diseases, no matter what the causes. As it is now, exposed individuals are often never found for treatment. Labs will also increase their surge capacities—their abilities to process large volumes of potentially infectious samples.
- Improve communications—Only 20 percent of local health departments have infectious disease early warning systems in place, according to Akhter. Physicians, who are supposed to report instances of several medical conditions to local health departments, do so only about 50 percent of the time, according to the CDC. Often when they do, nothing gets done with the information. The bioterrorism legislation provides money for computers and fast Internet connections so that physicians in private practice have direct and immediate contact with their local health departments, hospitals and paramedics.
- Beef up the ranks—County and city health departments will have money to hire more staff, Blendon says, so “if the phone rings, someone’s there to answer it.” By providing more money for salaries, Akhter and others hope more physicians and nurses will choose public health careers. Right now, only 20 percent of Master of Public Health (M.P.H.) graduates go to work at state and local agencies, according to the Robert Wood Johnson Foundation. The remainder teaches, does research or works at federal agencies. “Well-trained, adequately compensated staff is the most essential part of rebuilding public health,” Akhter says. And it’s not as if students aren’t interested in the field. “Ten years ago, there were 17 schools of public health. Today, there are 34. More than two-thirds of medical schools now offer programs for medical students to earn their M.P.H. along with their M.D.”
- Create better training—The legislation also pays for physician bioterrorism continuing medical education courses. “You have to be able to recognize a disease before you can report it, but many doctors and nurses have never seen a case of smallpox or plague,” Akhter says. Ideally, the process works this way: A physician who spots a suspicious infection consults with her local or state health department, which confirms the diagnosis, which is then validated by the CDC, which then alerts all health departments nationwide. It takes an informed physician to get this ball rolling.
- Update state emergency plans—With the new funding, states can use the CDC’s Model State Emergency Health Powers Act as a template to design their own emergency procedures. It ensures each state will have established: adequate emergency powers statutes; measures to detect and track potential and existing public health emergencies; provisions to define and declare a public health emergency; and powers to control people and property during states of emergency.
Most public health officials are elated about the public health windfall. According to a National Health Policy Forum background paper, “the cash and resource infusion could potentially transform the nation’s public health system. Not only is there unprecedented federal support [for local public health departments], there is unprecedented oversight, all of which could lead to a more uniform and robust public health preparedness.”
But will enough money trickle down to the state and local health levels to make a difference? “That’s the big unanswered question,” McGinnis says.
Blendon believes it will, but he and Akhter do worry that enough won’t make it to the county and city levels. “States spent most of their tobacco windfalls on tax rebates, highways and on just about everything but what it was supposed to be spent on—anti-smoking initiatives,” Akhter says. “Forty-six states are running deficits, and 32 of those have serious deficits—so how they spend the money will have to be closely monitored.”
Then there’s another nagging question: Will the legislation really improve the entire PHS or just bioterrorism preparedness? “I see no sign that the bioterrorism bill will benefit the entire public health system,” Young says. Historically, PHS funding has been driven by crisis and the disease of the moment. There’s support for public health because the middle class now feels vulnerable to diseases like anthrax and smallpox. So Young doubts that the new funding will benefit public health beyond bioterrorism preparedness.
Satcher agrees public health has been shaped by crisis-oriented, shortsighted thinking, but he thinks the bioterrorism legislation will benefit public health overall, “though not as much as I wish,” he adds. “It will help if some of the money actually reaches state and local public health labs, but I wish more of it was going toward public health prevention.” Tens of thousands of Americans die every year from preventable chronic diseases. “Doctors aren’t paid to prevent disease. They’re paid to treat it.” That leaves public health to address prevention, but the system is not adequately funded to do so effectively. “If the public health system had adequate funding, we could prevent 50 percent of type II diabetes cases.”
He ticks off a list of startling statistics: Less than one-third of Americans get the recommended amount of exercise, and 40 percent get none; less than 10 percent follow the dietary pyramid guidelines; only 25 percent of public schools offer their students physical education classes; and obesity in children has doubled in 10 years, and among adults, it has tripled. “We’re doing ourselves in,” he says, “and we’re never going to catch up if all we do is treat diseases that could be prevented in the first place.”
Young, meanwhile, worries that the legislation will militarize the PHS by putting anti-terrorism officials in charge, leaders who will divert resources away from traditional, non-emergency public health tasks such as chronic disease prevention and wellness promotion—ho-hum duties that don’t have the political pizzazz or the public’s attention. He points to President Bush’s new surgeon general, Dr. Richard Carmona, who is a former Army Green Beret, county sheriff and SWAT team member with little public health experience. Consider, too, he says, that much of the CDC’s responsibility for protecting the public against bioterrorist attacks may be shifted to the proposed Department of Homeland Security. And President Bush has granted HHS Secretary Tommy Thompson the power to classify information as secret—another step, Young says, showing how the fight against bioterrorism is drawing domestic agencies into the national security apparatus.
Young is old enough to have witnessed what happened to public health in the 1950s. “Biological warfare was fashionable,” he says. “We were obsessed with preparing to defend ourselves from biological attack and to accumulate our own stockpile of dreadful biological weapons. The public health budget went down as the defense budget went up. I abhor and deplore this subordination of the public health system to the garrison state, and I’m concerned it might happen again.”
Resuscitating the PHS should, of course, include bioterrorism preparedness, but not at the expense of traditional, nonemergency public health missions, he says. “I do not diminish the tragedy of 3,000 people dying at the World Trade Center, but every day 3,000 kids start smoking. One thousand of them will eventually die from smoking. So the Trade Center tragedy represents three days of smoking in this country.”
Still, most observers remain optimistic that the current and anticipated funding will jump-start the entire PHS, not just bioterrorism preparedness. “There will be double, triple, even quadruple uses for that money,” Roper says. New computers, new hires and improved labs will work on non-bioterrorism matters too, he argues.
Akhter agrees. “Public health was always the stepchild. This time we’re not being left behind.”
So, most experts say, to prepare for the future, the PHS will have to return to its past by once again making communicable diseases a priority. “What’s needed is not so much new bureaucracies or new public health techniques, but the same public health system that’s been needed all along,” Akhter says.
Based in Onalaska, Wisconsin, Howard Bell is a contributing editor with The New Physician.