The Public-Health Crisis


October 28, 1992|By RONALD BIALEK

Maryland's support of local public-health services is rapidly dropping toward zero. Only two years ago, the state provided more than $50 million to local health departments; this fiscal year it was $40 million. The most recent budget cuts reduced this support to $14 million, subject to further reduction if the state budget must be cut once again.

Have public-health needs of Maryland's residents subsided? Do we no longer need to provide immunizations to children and the elderly; prevent the spread of communicable diseases such as tuberculosis, syphilis and AIDS; reduce teen pregnancy and infant mortality; inspect our restaurants; safeguard our drinking water; provide pest control to reduce transmission of rabies and Lyme disease; reduce mortality from cancer, heart disease and other controllable chronic diseases, and minimize our exposure to toxic chemicals in the environment?

What are we doing to ourselves? Maryland has served as a national model for the structure and funding of its county and city health departments. Not only do these departments provide services directly, they also work with the private hospitals, medical societies, voluntary organizations and others in their communities. In the absence of local health departments, it is unclear how the needs of communities will be met and how the continued involvement of the private sector will be preserved.

Somerset County has a large population of migrant farm workers. As you might imagine, there are unique needs in this community, such as adequate sanitary conditions in temporary housing, immunization of children, and the provision of preventive health-care services to a population with little access to health care. Because Somerset is less able to raise revenue itself (per-capita income is low, as are revenues from real-estate taxes), the state has traditionally provided approximately 80 percent of the funds for Somerset's local health-department services. Reducing the state share to zero will not only reduce services to a population in need, but may very well destory the essential structure for providing public health services in that county.

Somerset County is not alone in facing the real possibility of having to close up its public-health facilities. Eighteen of Maryland's 24 political subdivisions receive over 50 percent of their local health-department funds from the state. How will they continue to provide services to their communities?

The remaining six counties provide the majority of their own public-health funds. They are likely to weather the storm, reducing vital services, but not totally eliminating all. However, the basic structure for providing comprehensive public health services in this state will have been destroyed.

So what? Isn't government inefficient and ineffective anyway? Not when it comes to public health. Maryland's structure of local health departments subsidized by the state according to the actual needs and wealth of communities serves as a model for other states.

For example, in Pennsylvania there are 20, 30, or more local health departments within single counties. Not only are services less comprehensive, but the state does not differentiate between its funding of wealthier or poorer jurisdictions. Funding is based solely on the ability of a jurisdiction to match what the state is willing to provide. As a result, poorer jurisdictions receive fewer public health services.

There are more than 3,000 local health departments nationally, with some states having none and others having as many as 200. Maryland's 24 local health departments are large enough to provide comprehensive services, but small enough to tailor services to community needs, as well as to enlist private-sector support.

The recent state budget cuts will have a direct and debilitating impact on the delivery of public health services in Maryland. Last year nearly 62,000 immunizations were provided to children through local health departments. Influenza vaccinations were delivered to more than 60,000 adults. Pregnant women made more than 67,000 prenatal-care visits. There were more than 60,000 visits for sexually transmitted diseases and 48,000 for tuberculosis treatment. If each of our localities follows the lead of the state, we may see these vital public health services reduced by 60 percent or more.

The state can ease today's budget crisis by eliminating funding of local health departments. But what will the cost be tomorrow? Will you be exposed to tuberculosis because a local health department was unable to provide effective treatment to an infected person? Will you drink tainted water because no one was available to monitor its purity? How many unimmunized children will suffer crippling or deadly childhood diseases?

Ronald Bialek is director of the Health Program Alliance of the Johns Hopkins University School of Hygiene and Public Health.

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