Science & Technology
PUBLIC HEALTH IS IN A BAD WAY
Julio Bellber doesn't need anyone to tell him that there's a crisis in public health. It's 10:45 a.m. at the William F. Ryan Health Center in upper Manhattan, and Bellber, the executive director, has just closed the doors to the walk-in clinic. The reason: Nineteen patients with complaints ranging from asthma attacks to fevers have jammed into the waiting room to see the one doctor who staffs that facility. It's like this most days, says Bellber, whose federally funded center provides primary care for 35,000 to 40,000 urban poor, including 300 who are HIV-positive. It averages 170,000 visits a year, and 45% of clients have no insurance. "We have a capacity issue here," he says. "We book appointments three months in advance."
Bellber's overcrowded clinic is just one result of what many experts believe is a crisis in public health in this country. Decades after defeating the scourges of polio and smallpox, the U.S. now finds itself battling such infectious diseases as AIDS, tuberculosis, measles, and syphilis. And according to the U.S. Public Health Service, one out of eight Americans has inadequate access to primary care, a key factor in preventing disease. In 1988, the National Academy of Sciences' Institute of Medicine charged that the public-health system was in "disarray." The situation is no better now. "We're dramatically underinvesting in prevention," says Dr. William L. Roper, director of the Centers for Disease Control.
While politicians debate funding and argue over strategies, several epidemics are racing out of control. As many as 1.5 million people are infected with the virus that causes AIDS, and by 1993 the CDC estimates that some 480,000 cases will have occurred. Old diseases, believed defeated just five years ago, are back with a vengeance. Tuberculosis cases are up, and in New York City 40% of strains tested are of a variety that is resistant to most drugs and kills 70% of its victims in just a few months. And the CDC estimates that nearly half the country's two-year-olds are not adequately immunized against childhood diseases. "There's been a complete erosion of the public-health system," says Bailus Walker Jr., dean of public health at University of Oklahoma Health Sciences Center. "We're going to see a major resurgence of many infectious diseases, and we don't have resources to deal with it."
COMPLACENCY. The costs of this crisis are huge. Preventable diseases add billions to the groaning $700 billion national health care burden. Caring for AIDS patients alone will require $10.3 billion this year and will hit $15.2 billion in 1995, estimates Fred J. Hellinger, director of the cost and financing division of the Agency for Health Care Policy & Research. As the health care bill escalates, business feels the crunch as it shoulders the rising costs of insurance. "It's a moral and business concern," says Dr. Allan G. Rosenfield, dean of the School of Public Health at Columbia University.
For many decades, an intricate web of federal and local agencies have protected public health through such efforts as keeping water supplies safe, immunizing children, and tracking new epidemics. The current crisis is the result of a confluence of factors. For one, the 1980s were a time when medicine focused on the individual, with expensive treatments such as organ transplants and other high-tech procedures taking the limelight. And as vaccination and prevention programs began succeeding, the country got complacent about public health, says Roper. The CDC--which tracks disease and disperses funds to state and local agencies--saw its budget limp along until 1988, when it jumped from $539 million to $778 million after a major infusion of funding for AIDS. Such programs as childhood vaccinations and prevention of tuberculosis and sexually transmitted diseases suffered. At the same time, the country was experiencing a growing drug crisis, AIDS, and a rise in the number of people with no access to health care.
Economic pressures at the state and local level didn't help. "Health services once deemed vital were now being seen as nonessential," says Walker. Federal grants to state public-health agencies essentially remained flat from 1979 to 1989. So states struggling with their own diminished budgets began nipping and tucking public-health dollars--affecting everything from antismoking campaigns to immunization programs. "The states are deciding between restaurant inspectors and prenatal care," says George K. Degnon, executive vice-president of the Association of State & Territorial Health Officials (ASTHO), an organization of public-health officers.
The clash between local officials and federal authorities is starkly clear. In a 1990 report called Healthy People 2000: National Health Promotion and Disease Prevention Objectives, Health & Human Services Secretary Dr. Louis W. Sullivan set out a series of goals for improving public health. In response, ASTHO members took Sullivan's list and figured how much money they would need to implement the screening, immunization, education, and inherent administrative costs called for by his plan. They came up with a figure of $1.7 billion on top of the $3.5 billion they received in 1989 from the feds.
WAITING LINES. Strategies for attacking public-health problems are well-known--and can bring dramatic results. Take sexually transmitted diseases, or STDs. Including AIDS, there are 12 million cases per year in the U.S. The medical costs associated with these diseases are upwards of $7 billion a year, and two-thirds of all cases occur in people under 25. Yet except for viral infections such as AIDS or herpes, most are easily treatable with antibiotics--if detected early enough. That's a problem, says Dr. King K. Holmes, professor of medicine and director of the University of Washington's Center for AIDS and STDs. Many public clinics are swamped with people wanting testing and counseling for HIV. They haven't expanded clinical services and, like the Ryan center, they can fill up at 9:30 or 10 in morning. Patients have to wait an average of four hours to be seen. "We have the federal government thinking of innovative ways of finding people with STDs," such as partner-notification programs, says Holmes, "but we're turning these people away when they do show up at clinics."
Chlamydia, a bacterial infection that often produces no symptoms in men or women, has surpassed both syphilis and gonorrhea in number of cases and racks up $2.2 billion in medical costs each year. It is a major cause of pelvic inflammatory disease, infertility, and other reproductive problems. But, says Holmes, even though there is a test for chlamydia, at $3.50 it is too expensive to be used routinely in public clinics. "Here's the most common, curable STD, and yet if you go to an STD clinic in New York City, they don't test for it," he says.
A similar situation exists for hepatitis B, a potentially deadly virus that infects the liver. More than 50% of all cases result from sexual intercourse, and the disease is spreading rapidly among heterosexual youth. The chance that an urban youth will get hepatitis B after puberty is 25% to 30%, says Holmes. A vaccine has been available since 1981 for the disease but is considered too expensive to be used in adolescent programs.
Holmes believes simple, cheap diagnostic tests could be part of the answer for sexually transmitted diseases. He cites a successful program to prevent chlamydia in the Pacific Northwest. For five years, 170 family-planning clinics routinely screened women for chlamydia, reducing the cost of the test through bulk purchasing. The result was a reduction in the prevalence of this disease from 10% to 5% in clinic patients.
`TRAGICALLY SHORT.' Another effective tool is education--although it's a political mine field. As AIDS and other sexually transmitted diseases continue to spread among teens, officials are arguing over how explicit educational material should be. And even as research shows that needle-exchange programs help prevent the spread of HIV among drug users--the main link to the heterosexual world--officials try to block these efforts as blows to the nation's war on drugs. "We've fallen tragically short," says Dr. David E. Rogers, vice-chairman of the National Commission on AIDS. "Issues of morality prevent us from tough, explicit educational programs for teenagers and drug users."
In the end, though, access to primary care is probably the best way to fight public-health problems. Facilities that focus on health education and prevention of disease, such as the Ryan Center in Manhattan, are a good way of achieving that. There are 640 of these community centers across the U.S., funded by direct grants from the Public Health Service that also serve migrant and homeless populations. State and local governments fund an additional 3,000 public-health clinics. But a 16% increase in patient load last year has made these centers unable to meet demand, says Alice M. Jackson, assistant director for policy research and analysis at the National Association of Community Health Centers. A recent survey found that 8% of rural children and 18% of urban children must wait at least three weeks for a visit. And some 2% of all centers must turn away all new children. The top problem, says Jackson: "We don't have enough doctors to take care of patients."
Citing low pay and low prestige, 75% of medical school graduates are choosing specialties over primary care. In rural areas, one-third of the population has no access to primary care. And in major cities, there has been a 45% drop over the past few decades in the number of family physicians. Some medical schools, such as the University of Minnesota and the University of Tennesee offer tuition breaks or other perks for students who agree to practice primary-care medicine in underserved areas. Dr. David Baer, a family practitioner in rural Bedford, Pa.--a town of 4,000--took advantage of a program at Jefferson Medical College in Philadelphia that sets aside 10% of admissions for urban and rural applicants. Baer, who grew up on a farm in Bedford, agreed to return to his town to practice.
Still, experts believe there must be a fundamental shift in health care. That means changing the focus from what Roper calls "very high-tech curative medicine," which may add a few weeks to a dying person's life, to medicine that concentrates on maintaining the health of the population. The economic benefits of this shift are clear. The CDC estimates that in the case of measles, for example, $1 spent on vaccination saves $14 in medical costs. The same is true for tuberculosis. The cost of a typical six-month course of drugs to treat a latent TB infection is $850, while hospitalization and treatment of a victim of the new, multidrug-resistant variety can climb upwards of $100,000.
PET PROJECT. After years of stagnating budgets, the Administration has decided to act against some of the most pressing problems. HHS's Sullivan has made prevention his pet project. And at Bush's request, Congress upped the CDC's funding for next year from $1.3 billion to $1.5 billion--a real feat in tough budget times, says Roper. Bush requested a 128% increase in the CDC's $15.3 million tuberculosis program, and a 17.7% increase in its $297 million immunization program.
But this is just a start, says Columbia's Rosenfield, adding that funding was cut so much that "it will be very difficult to solve these problems." The overwhelming human and economic cost of communicable diseases is such that he and others recommend enlisting the kind of organized government response to public health that is mobilized to maintain national security. The result is the same: "If we do preventive medicine and public health right, then nothing happens, and it's very boring," says Dr. June E. Osborn, dean of the School of Public Health at the University of Michigan and chairman of the National Commission on AIDS. And, she adds: "We should all be praying for boredom."Naomi Freundlich, with Gwendolyn Kelly, in New York and John Carey in Washington