Playing politics with public health

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HEALTH & SCIENCE

Playing politics with public health

Controversy in New Jersey offers an object lesson in the fragility of public

health in the face of political pressure -- and of its resilience when it

has a constituency to speak for it.

By Mark Moran, AMNews staff. Oct. 4, 1999.

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Englewood, N.J. -- When pediatrician Hyatt, MD, came to this

bedroom suburb of New York City seven years ago, he expected to find a

different medical practice than what he knew as an infectious disease

specialist in Harlem and inner-city Baltimore.

What he encountered, instead, were some of the same problems, on a smaller

scale, that characterized the urban settings he left behind: teenage

pregnancy, substance abuse, isolated poverty and a lack of social support

for patients that critically affected his ability to care for them.

From the sprawling estates to the housing projects " across the tracks " that

segment this town of 25,000, Englewood is a remarkable composite.

Complementing an already racially mixed population is an influx of

immigrants from Colombia, now believed to make up 15% of the town's

population. In demographics and public health needs, Englewood defies

conventional stereotypes of suburban America.

But here Dr. Hyatt also found an unusually active local health department

and an energetic officer in Violet Padayachi Cherry. Arriving in Englewood

25 years ago, having been raised in apartheid South Africa, Cherry began

building a health department on the principles of " community-oriented

primary care " taught by her mentor, internationally recognized South African

physician Sydney Kark.

That tradition, which grew out of the hardships of bringing health services

to poor, disenfranchised South Africans, emphasizes active engagement of

local leaders to empower citizens and incorporation of social and

psychological dimensions in addressing the health needs of a population. An

expansive vision of public health sometimes known as " social medicine, " this

approach has penetrated, to varying degrees, American public health

activities everywhere. In Englewood it has formed the basis for a department

that supporters argue is a national example.

For instance, meet Guy Romain. The 25-year-old Haitian is everywhere -- in

parks, school cafeterias, health fairs -- talking about the dangers of

smoking, drugs and unsafe sex. He can sometimes be found in the local

barbershop teaching men about testicular cancer with a model of testicles.

In dreadlocks and a T-shirt, the part-time DJ at a local radio station has a

cachet with kids in town, and his omnipresence has earned him the moniker,

" Mr. Health Guy. "

Romaine is the outreach worker for the department's Reach and Teach Program.

A spin-off of Reach and Teach is a project to prevent teenage pregnancy

using a computerized doll, programmed to cry sporadically, that teenage

girls are charged with tending night and day for 24 hours. " That doll is

cute, and every girl wants one, " Romain explained, " but after 24 hours they

want to throw it away. "

Integral also to the department's efforts is the Friends of the Englewood

Health Dept., an advocacy group chaired by Englewood resident

Pierson, MD, a clinical professor of medicine at Columbia University School

of Medicine. The Friends have served as defenders of the department and a

constituency for its activities.

In recent months the Friends have been kept busy, as the health department

and Violet Cherry have come under scrutiny by politicians on the city

council. The department's detractors have focused on Cherry's salary,

unusual for a municipal employee, of more than $90,000. And they allege that

Cherry, who has long been active in the city's Democratic party, has unduly

influenced city politics.

Her supporters counter that her salary is not unusual for someone who has

served 25 years, receiving normal salary increases every year while raising

the city's health department to national prominence. Cherry has stepped down

from her position in the Democratic party, denying any conflict of interest

in her activities.

But clearly she has opponents, some of whom are on the city council and the

board of health. Chouake, MD, a member of the board, said he

believes some of the department's programs can be run on a slimmer budget or

consolidated with those in neighboring towns. " It's an expensive health

department, and some people feel it should be run more efficiently. "

Supporter Earl Marsan, DDS, vice president of the board of health, said

Cherry's salary and political activity are red herrings used by her

opponents; what they really seek, he said, is " control of the agenda and

programs of the health department. "

Dr. Pierson agreed that whatever the source of her detractors' enmity, the

price is liable to be paid by cuts in the department's programs, which is

only 4% of the city's total budget. " A council with limited awareness about

the health department's mission and eager to save money in the short term

could install a new board with a lower budget and diminished staff that

could threaten its current mission, " he said. " This challenge comes at a

time when health departments across the country are under pressure to reduce

budgets, services and missions. "

Dangerous climate

Beyond the parochial intrigues of the city's politics, the story of

Englewood's health department is an object lesson in the fragility of public

health, and of its resilience when it has a constituency to speak for it. A

creature of -- and sometimes captive to -- the local political structure,

public health perennially faces an uphill battle against budgetary

strictures, the whims of local politicians and the fickleness of a public

that distrusts government and taxes and has little understanding of what

local health departments do.

" It's a classic case of the pressure public health is under in the current

American frenzy to avoid government and taxes, " said Quentin Young, MD, past

president of the American Public Health Assn., who attended a public hearing

last year in Englewood about the controversies surrounding the health

department. " This is an extremely dangerous climate for public health, which

is by definition public and supported with tax monies. "

McNutt, MD, who had been one of only two physician executives of local

health departments in Illinois, said the politicalization of public health

bodes ill for medical leadership of local health agencies. Recently, he

resigned as executive director of the DuPage County (Ill.) Health Dept.

because of what he called " inappropriate politicalization " of the health

department's activities.

" As public health becomes politicized, we have experienced a decline in the

number of physician health directors, " Dr. McNutt said. " In turn, the

specialty of preventive medicine is being undermined. "

And smaller towns and suburbs like Englewood may be at an additional

disadvantage when it comes to acquiring funds from the state to meet public

health needs. Dr. Hyatt, chief of pediatrics at Englewood Hospital and

Medical Center, found that in the competition for state dollars to meet

needs in the community, wealthy suburban Englewood often loses out to cities

like neighboring Newark with its long-standing social and health problems.

" Communities like ours that are mixed, with a wealthy population and a

smaller urban-like population, are in a competitive disadvantage, " he said.

" After all, how could you blame anyone for funding Newark? "

It is a phenomenon that's not unique to Englewood. A recent report from the

National Public Health and Hospital Institute on " The Social and Health

Landscape of Urban and Suburban America " documents a phenomenon with

far-reaching consequences for public health policymakers: The demographic

changes visible in Englewood have been transforming suburban America

everywhere, and the health and disease conditions once unique to urban areas

are increasingly common in outlying suburbs.

" The findings raise questions about the wisdom of policy initiatives that

are based on outdated assumptions: that cities are dangerous enclaves with

intractable social problems, while suburbs and exurbs are America's

'Pleasantvilles,' " said Dennis Andrulis, PhD, author of the report and

former president of NPHHI.

Difficult sell

Leaders cite a host of factors that make public health a " difficult sell "

and render it vulnerable to the vagaries of politics.

Principal among these is the instability of leadership at the state level.

The average tenure of a state health administrator has been estimated at 18

months, a turnover rate that renders progressive efforts difficult to

sustain. " A commissioner of public health serves at the pleasure of the

mayor or the governor, " Dr. Young said. " At the end of the day he or she

must reflect the policies the chief executive wants. Those policies may be

broad and ambitious or pinch-penny and harsh. "

And among public health professionals there is disagreement about what

constitutes the proper definition of public health. Should health

departments provide direct medical care to poor people or return to the

traditional core functions of disease-tracking, epidemiology, food and water

safety, air quality and immunizations?

" Because public health has taken on the responsibility of provider of last

resort, our more traditional role may have been blurred, " said Donna Crane,

director of congressional affairs at the American Public Health Assn. " To

the extent that they're even aware of public health, many lawmakers

automatically think of us as 'health care for the poor.' But that is only

one role we play, with the other important one being protection of the

entire population from health threats. "

Yet even those functions that serve the entire population as guarantors

against disease are often not appreciated or understood by the public.

In a 1997 nationwide Poll, fewer than 4% of respondents could give a

knowledgeable answer when asked " What do the words 'public health' mean to

you? " In contrast, advances in biomedical research of the last 50 years draw

on a vast store of public enthusiasm for curative medicine and the profits

inherent in high-tech innovations. " It's a lot easier to sell CT scans and

PET scans than it is to sell immunizations, " Dr. Pierson said.

Even among clinicians the connection between gaps in public health

infrastructure and the conditions that bring patients to their office is not

always appreciated. " With the exception of pediatricians, infectious disease

and cancer specialists, the visibility of public health to physicians has

traditionally been minimal, " Dr. Pierson said.

Whether serving the poor, ensuring the safety of food in restaurants where

the wealthy dine or monitoring the diseases that threaten whole populations,

public health agencies are stuck with a service that has low visibility and

minimal return. " You can summarize what has been given to public health as

health care that does not turn a profit, " Dr. Young said. " This society is

increasingly sloughing off huge health care responsibilities vital to the

public health. "

But in Englewood, there appears to be a wellspring of popular support,

embodied in the Friends, for the achievements of an activist local health

department. " I feel my greatest achievement is building this partnership

with the community, " Cherry said.

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New Jersey hospitals put money into public health

Finding additional sources of funding for public health is always difficult,

especially when public health programs are hampered or even hamstrung by

politics and strict budgets.

Why not look to hospitals for funding?

That was the idea behind the creation in 1992 of seven maternal/child health

consortia to respond to high infant mortality in New Jersey. Under the plan,

all facilities providing obstetrical services in the state are required to

join a consortia and pay a fee to support public health activities aimed at

improving maternal and child health.

The Northern New Jersey Maternal/Child Health Consortium serves the counties

of Bergen, Essex, Passaic and , which includes Newark, the state's

largest city. NNJM/CHC has identified a host of service gaps and problems:

barriers to primary care, teenage pregnancy, domestic violence, child abuse,

lack of routine gynecological services to teens, perinatal substance abuse,

and racial and ethnic disparities in accessing prenatal care.

Hyatt, MD, chief of pediatrics at Englewood Hospital and Medical

Center and NNJM/CHC president, called the consortia an innovative experiment

in funding that reaps benefits to the community.

But with hospitals facing fierce budgetary constraints, the long-term future

of the consortia may be precarious, begging the question: Who will pay for

public health?

" One could argue that 10 years ago, this was a very good idea -- taxing the

rich to support public health, " Dr. Hyatt said. " But the rich aren't rich

any more. Why not regulate the HMOs and force them to fund the consortia? "

Whether the consortia survive remains to be seen. " Many CEOs of hospitals in

the state -- because of their tight financial budgets -- are reviewing the

regulations requiring them to support this, " he said.