Flaws Cited in Public Health Effort

Los Angeles County’s public health program is a hamstrung bureaucracy, underfunded and understaffed, suffering “considerable tension . . . with diminished morale” and poor communication with the communities it is set up to serve, according to a county-initiated review of the system by UCLA experts.

The $90,000 review, ordered by county health services Director Mark Finucane and distributed to county supervisors this week, calls for another reorganization--”Yes,” the report states, “yet another time!”--favoring a more “coherent approach” to health problems.

One key move, the review stresses, is the appointment of a health officer, a “recognized professional leader,” to expand the mission of public health. (The position is now being filled by an interim appointee.) The report also advocates moving the focus of activity away from the department’s downtown headquarters into the communities where diseases, chronic and communicable, take hold.

“Corrective action is urgently needed,” according to the report, which calls for revamping health department leadership within six months.

Finucane said he was not surprised by the findings and will support many of the recommendations.

“There’s no question there is criticism in the report,” he said. “It may surprise people that we would air our laundry, but that really is the only way to spur a community like Los Angeles back into the leadership position it belongs in.”

The report lands on supervisors’ desks amid a massive reorganization of the county Department of Health Services, which includes the public health program, after a 1995 fiscal crisis that resulted in widespread layoffs and a $364-million federal bailout. Federal officials since have pledged $600 million over three years for top-to-bottom reform of the health system. Though that is proceeding apace, with some successes recently noted by federal officials, the public health program still is widely perceived to be in disarray.

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Public health programs deal with the overall health of the population, as opposed to individuals, and are geared more toward creating healthful living conditions and controlling or preventing disease through such measures as inoculations and education. In the past, especially in Los Angeles County, such programs have suffered as more dollars have been directed toward more costly acute care and inpatient treatment.

The UCLA report notes that the Los Angeles County public health program, subject to declining appropriations in the last 25 years, was particularly hard hit in the health department’s recent fiscal crisis. Reviewers say Los Angeles County’s funding for public health dropped from $10.08 per capita in fiscal year 1992 to $7.68 in 1996.

In a 1995 reorganization, the number of sites offering public health services was cut from 45 to 10. The result in the next year: a 26% reduction in visits to venereal disease clinics, a 50% drop in tuberculosis screening and prevention, and a 16% decrease in immunizations.

To support the recommended improvements, UCLA reviewers call for a $20-million boost to the public health program’s $303-million budget.

Finucane’s department is facing an $80-million deficit in the next fiscal year and is still very much in a cost-cutting mode. But the UCLA panel’s recommendation is consistent with the federal government’s expectation that the department will shift $100 million from hospital-based care to outpatient clinics and community-based care.

“I agree with [the monetary recommendation], and I will argue for it,” Finucane said. “I know I will have to generate it out of existing resources, and I will only use it in increments that get the recommended changes [done].”

When he took over as health director 1 1/2 years ago, Finucane resolved not to pull any more money out of public health. And he said Thursday that he ordered an objective review of the program as part of his commitment to preserving its vital functions.

Dr. Lester Breslow, a professor emeritus in public health at UCLA and director of the review project, said the UCLA team of more than a dozen faculty members and students was told to take a “no-holds-barred” approach to the study. The team was overseen by a task force appointed by Finucane.

“We really wanted to make it . . . utterly candid,” Breslow said. “But I’d like to emphasize . . . that [though] things are quite a bit worse here budget-wise, the same kinds of problems are facing local public health programs across the country.”

The report, moreover, states that “the current situation actually offers tremendous opportunity.” It emphasizes that even department detractors acknowledge “staff expertise, dedication and justifiable pride in their work” as building blocks.

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Reviewers also repeatedly single out Finucane for his openness and commitment to public health, saying he has been warmly received in the county. They also say the public health program’s troubles are largely historical, dating back to the department’s inception in 1972.

Among the critiques and recommendations:

* The mission of public health has been too narrowly defined in Los Angeles County, and needs to be expanded beyond finding and treating disease victims and assuring safe food in restaurants.

They recommend a community-based focus, forming public-private partnerships that accommodate diverse needs in various neighborhoods and ethnic groups.

“Public health interest is expanding to include heart disease, cancer, diabetes, water and air pollution, violence, teen pregnancy, tobacco use and other issues,” according to the report.

There is “a clash between what the public increasingly regards as major community health problems and what [public health employees] regard as their responsibility,” the report states.

Los Angeles County, with relatively high death rates compared to neighboring counties and a diverse and changing population, faces a “major public health challenge,” reviewers say.

* A systematic training program is needed for public health employees, including sensitivity instruction, because community-based organizations have complained of employees’ “arrogant, abrasive” styles.

At the same time, employees, beset with budget cuts, poor communication in the ranks and increased demand for services, are suffering from low morale.

* Public health programs often operate “grossly inadequate” data collection systems that do not give a coherent view of community health problems. A modern system should be developed that is compatible “across the whole of [the department]” so that meaningful information is assembled and communicated promptly, reviewers say.

* The bureaucracy needs to be streamlined so it can respond to urgent needs. Reviewers note that during a recent outbreak of drug-resistant tuberculosis, a county hiring freeze--plus a hiring process that required approval from six offices--thwarted effective action.

Reviewers also say that strictly earmarked federal and state funding left the public health program rigid and fragmented.

“It has become extremely difficult to maintain comprehensive rational effort,” the report says.

* District health officers, who are responsible for control of communicable diseases in their communities, have been rendered ineffectual and left out of the power and information loop. They should be given more authority over money, staff and services, and made accountable to the health officer.

“A decentralized, more flexible organization is needed to meet community priorities,” the report says.