A vaccine clinic closed. One mosquito spraying program eliminated. A mother-child health program outsourced. The public health department in Harris County, Texas, has been hit hard by state, federal and local budget cuts and there’s no end in sight.
And now everyone’s talking about a new strain of bird flu in China that may or may not threaten the United States.
Dr. Herminia Palacio isn’t happy.
“I do worry about if it comes here, how long are we going to be able to sustain a response,” says Palacio, who is executive director of Harris County Public Health and Environmental services. “What resources are going to be available at the federal level in the current environment? These things are very troubling.”
Local health departments have been forced to cut 39,600 jobs since 2008, according to the National Association of County and City Health Officials (NACCHO).
“Preparedness programs have been among the hardest hit,” says Alisa Blum, a spokeswoman for the organization. Its 2012 survey of public health departments found about 24 percent of local health departments cut emergency preparedness programs in 2011.
“More than half of local health department in 17 states lost staff, including Idaho, Florida, Mississippi, and Maryland, where more than three-fourths of local health departments experienced work force reductions,” the report reads.
Harris County, which surrounds and includes Houston, was one of them.
“We have gone from a staff of 700 in 2009 to a current staff of just over 500. We have lost about 230 people total,” Palacio said in a telephone interview. “It was kind of a perfect storm – we had local, state and federal (budget) cuts all simultaneously coming down on us.”
So the agency, which provides childhood vaccines, family planning services, inspects restaurants, responds to hurricanes and floods, watches out for people when it gets too hot or too cold, helps warn people of food poisoning outbreaks, tests bats for rabies, works to control outbreaks of West Nile virus, and plans for terrorist attacks, chemical disasters and epidemics, had to decide what to cut.
“Should food be 30 percent less safe?” Palacio asked. Food inspectors were kept on, but anything that could be outsourced was.
“We had to dramatically reduce the number of family planning patients that we see because of budget cuts at the state level. We had to transition maternity care. We don’t see prenatal patients any more due to combined budget cuts at the state level,” Palacio said. It was all outsourced to the county’s indigent care services at county hospitals.
“As much as we could, the department took a very hard strategic look and tried to reduce our work force and cut back to our very core public health mission. That being said, even at baseline we felt like there was much more we could be doing from a public health perspective. More important – this really erodes our emergency response capability.”
The department cut back from five vaccine clinics to four, and now none operates five days a week. In 2009 the department administered 111,742 shots; in 2012 this was cut by more than 80 percent to 19,823. In 2009, county public health clinics saw more than 45,000 patients; this dropped to 7,400 in 2012.
Harris County staffers worked full-tilt for 18 months straight when H1N1 swine flu broke out in 2009, the first new influenza pandemic since 1968. “We had been preparing for an avian influenza pandemic since as early as 2004,” Palacio says.
“So we were in response mode when H1N1 actually hit.” And the department was fully staffed. “At the end of March 2010, we got hit with the first wave of layoffs. I laid off 56 people,” Palacio says.
“Unfortunately, preparedness is usually one of the first places to get cut,” says Andrew Roszak, who directs pandemic preparedness for NACCHO.
Preparedness always scores more funding after a big national event, such as the 9/11 attacks, he said. Then the cuts start as the years pass. “Especially in this fiscal backdrop,” Roszak says.
“We have fewer epidemiologists to track these outbreaks and track the spread of disease,” he said. That means fewer feet on the ground to test patients for new diseases. It was local public health officials who first detected H1N1 swine flu in patients in California in 2009, and who caught the first cases of a new kind of H3N2 swine flu that eventually sickened more than 300 people who caught it from pigs at state fairs last summer.
“Maybe we need to buy big red trucks and ride around in them like the fire department does,” Roszak said, only half-joking. Public health, Roszak says, is largely invisible.
If and when a new pandemic of disease hits, county health officials will be at ground zero for delivering vaccines, for handing out drugs and for helping to distribute face masks and other protective equipment.
Emergency funding and staffing is likely to come in case of a true medical emergency, but Palacio says it’s not always enough to just throw money and people at a problem. Her department lost years of training. “If you lose 50 people and you get back 50 people, it’s different,” she said. “You don’t get back the same wealth of experience and expertise.”
And, she says, staff are worn out. “People are weary,” Palacio said. “People have been doing their own jobs and trying to pick up the jobs of the colleagues that we have had to let go.”
It’s a lot to ask, she says. “Eventually, you can only do less with less,” she said.