Advocates: Public Health Slashed Too Far, Risk 'Not Acceptable'

Accused former state chemist Annie Dookhan
Accused former state chemist Annie Dookhan (Josh Reynolds/AP)

Normally, just the words "public health infrastructure" are enough to make people's eyes glaze over and roll upwards. But not this year in Massachusetts. Not when the state has seen a huge scandal in the state crime lab that called into questions thousands of convictions. And then a horrifying national outbreak of meningitis that killed three dozen people and raised serious questions about oversight of the local compounding pharmacy where the tainted steroids were made.

Dr. Alan Meyers connected the dots of the two scandals in a guest post here, pointing out the dangers of cutting public health funding too far. Now the latest state emergency budget cuts have been proposed. Rachel reported last week here that health care in its various forms takes the hardest hit of all. And today, the Massachusetts Public Health Association is sending over a letter to the Patrick administration imploring it to stop cutting the basic public health measures that keep us all safer.

We are writing with an urgent message that funding for basic elements of our public health infrastructure – protections that we all rely on every day – is not sufficient to meet basic needs, and we implore you to reverse the trend of disinvestment from these essential services.

That infrastructure includes food inspections, licensing of medical machines like X-rays, emergency preparedness, monitoring of the system to report on infectious diseases, and more. "This type of infrastructure is not sexy and it is not free," the letter says. "It does not have a constituency that will hold rallies on the State House steps. But we all benefit from it each and every day – and mostly, we take it for granted."

Read on for the association's warning that the level of public health risk is not acceptable, and a sweeping summing-up of the drastic cuts to the state's public health structure over the last few years.

We understand that all areas of government have needed to tighten their belts during these difficult economic times. We do not fault your Administration or the Legislature for looking for budget savings from all state agencies in order to meet your responsibility to pass a balanced budget.

However, if we accept that the pre-recession resources are no longer available to fund our public health infrastructure, we must be prepared to accept a lower level of services, oversight, and monitoring. We at the Massachusetts Public Health Association do not find this increased level of risk to be acceptable.

As we speak, Department of Public Health staff, and others inside and outside of government are working day and night in response to the mishandling of evidence at the state drug lab and the national meningitis outbreak. Individuals – inside or outside of government – who committed criminal acts must be held accountable for their actions and the harm they have caused. At the same time, Department of Public Health must put in place new systems of accountability to ensure proper oversight is in place to safeguard the public health and safety.

Both of these activities are essential, and all signs indicate that they are being addressed aggressively. However, addressing criminal activity and gaps in oversight alone will not solve our problems.

Adequate financial resources to carry out public health programs, provide oversight of those programs, and monitor compliance with public health regulations are not currently available due to several years of dramatic cuts in state funding.

Consider the recent history of state funding for DPH:
• Since the pre-recession budget of fiscal year 2009, more than $70 million has been slashed from the DPH budget for community-based programs.

• That amounts to more than 17% of state funding in just four years, and it has resulted in the loss of 117 FTEs from the Department’s community-based programs. An additional 106 DPH hospital staff have been lost due to state funding cuts; and 110 federally-funded staff have been lost during this same time due to federal budget cuts.

• The reality of these cuts for public health infrastructure is worse than it appears on the surface. Removing the six major DPH direct service programs from the equation provides a better snapshot of funding for inspections, regulatory activities, monitoring, and oversight activities that comprise the public health infrastructure. Under this scenario, cuts since FY09 amount to a full 25% of state funding. This represents a nearly $50 million budget gap.

• Further, keep in mind that numerous unfunded mandates from the legislature and Congress have added to the responsibilities of Department staff without additional resources, and that the cost of providing services increases every year, so even “level funding” results in cuts in service levels.

Numerous Programs are Funded at Dangerously Low Levels

Programs across the Department are funded inadequately. Here are just a few examples:
• State funding for Environmental Health has been cut by 18% (or $747,000) since FY09. This has led to:

o The elimination of more than 50% of the food inspectors who conduct inspections of food manufactures and wholesale establishments, a staffing level that is below federal performance standards. There has also been a significant reduction in monitoring and support for local board of health inspections of restaurants. The number of local boards of health who currently meet statutory food safety responsibilities has decreased and now stands at less than half of all municipalities. A report by the State Auditor in 2007 found severe deficiencies in food protection activities within the Commonwealth, primarily due to resource constraints. Current funding levels are below those at the time of the report’s release.

o A significant backlog of requests for indoor air quality assessments at elementary and middle schools, as well as other public facilities with potentially-dangerous air quality due to mold and other contaminants. There is typically a backlog of several dozen requests from across the state in facilities where children, teachers, police officers, and other public servants work every day.

o Decreased capacity for environmental testing for water and air contamination around the Pilgrim nuclear power plant in Plymouth, MA and in Massachusetts communities within emergency planning zones of Vermont Yankee nuclear power plant and Seabrook nuclear power plant in New Hampshire.

• State funding for the Bureau of Health Care Safety and Quality has been cut by 17% (or $2.8m) since FY09. The Bureau is central to the state’s goal of promoting health care cost containment and high quality care, goals which are threatened by limited resources. Cuts have led to:

o Loss of personnel to conduct inspections at more than 2,300 health care facilities licensed by the Department, including hospitals, long term care facilities, clinics, hospice providers, and dialysis units.

o Strained ability to respond to significant new regulatory responsibilities under Chapter 224 of the Acts of 2012, including new responsibilities related to the determination of need process and health facility planning, limited service clinics, expanded roles for physician assistants and nurse practitioners, medical checklists, and others.

• State support for the Hinton State Laboratory and the Bureau of Lab Sciences has been cut 22% (or $3.9m) since FY09.

Amidst the fallout from the mishandling of evidence at the state drug lab (currently run by the State Police), it is important to remember that the Hinton Laboratory contains 17 other public health labs which continue to operate and play a vital role in protecting the public health. The labs conduct testing and surveillance of many diseases that can compromise health, including EEE, flu (including H1N1), food-borne illnesses, STDs, TB and others. Lab personnel also provide guidance to health care workers on emergency preparedness in the case of suspected chemical terrorism. Since revelations about misconduct at the drug lab have surfaced, the independent Association of Public Health Laboratories, as well as federal agencies, have conducted inspections and assessed the procedures and quality assurance protocols at the 17 remaining labs. All have been found to be operating at high level of quality and fully up to professional standards.

As a result of state cuts affecting these 17 public health labs:

o Personnel shortages that have resulted in a growing backlog of tests, including on suspected cases of TB. These backlogs delay treatment and follow up and increase the possibility of disease outbreaks.

o Purchases of new testing equipment and supplies have been delayed, resulting in the use of older equipment that is less accurate and slower, leading to further testing backlogs, delayed response, and associated health risks.

Readers? I'm feeling decidedly less safe than I felt before I read this letter...

This program aired on December 10, 2012. The audio for this program is not available.

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Carey Goldberg Editor, CommonHealth
Carey Goldberg is the editor of WBUR's CommonHealth section.



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