Public Health, '90s Style

SARA ENGRAM

September 05, 1993|By SARA ENGRAM

During meetings of the Continental Congress in 1776 and 1777, conditions in Baltimore were so primitive that a Connecticut delegate called the city "the most dirty Place I was ever in."

A colleague from New Hampshire noted that in this city "the man with the Boots has very great Advantage over a man with shoes, the Carriages are Stoped by the Depth of the mire in the middle of the Street . . ."

So the city's appointment of two health officers 200 years ago was long overdue. The city health department marked the anniversary this week with a series of seminars at the Convention Center.

Unsanitary conditions give rise to all kinds of ills, but it was the fear of yellow fever that finally prompted the appointment of two "quarantine physicians." They were charged with patrolling the roads coming from Philadelphia and other northern points as well as preventing entry of the disease through the port. As it turned out, yellow fever was not contagious but was spread by a species of mosquito.

However pesky, that mosquito was at least an identifiable threat, an enemy at which the city's health officials could take aim with relative ease. These days, the threats to public health are less clear, and the challenges to public health officials are as political as they are medical.

Dr. Peter Beilenson, the city's health commissioner, has targeted five priorities for his department -- violence, AIDS, drugs, adolescent pregnancy and basic preventive services for children.

The list may strike some people as a bit removed from traditional public health concerns, but it reflects the realities of life in American cities. The list also illustrates how the role of public health officer has changed from the days when the challenges were more easily identified and measured. Today, the major threats to public health are tied into broader social forces, and combating them is not as tidy a challenge as cholera or yellow fever.

Why does a 13-year-old get pregnant? What can we do to stop deaths by gunfire, whether random or deliberate? How do we convince young people that dealing drugs is a dead end street? Where can we point to give them alternatives?

Looked at this way, jobs, housing, gun control and -- especially, perhaps -- the challenge of restoring hope to people mired in urban ills are all public health concerns.

Nothing better illustrates how medical problems become political issues -- and how the work of a public health officer has changed over the years -- as the debate about the city's desire to institute a needle exchange program for intravenous drug users, a proposal that puts a health officer like Dr. Beilenson squarely in the middle of a sensitive political debate.

Despite a well-documented need in the city for a needle exchange program -- four to five more IV drug users contract the AIDS virus each day -- political sensitivities won out over medical realities in the General Assembly this past session. The legislature turned down the city's request for permission to undertake a pilot needle exchange program.

Now, however, Gov. William Donald Schaefer, a former opponent, has become a convert. His birthday gift to the city health department was a promise to support emergency legislation in January that would allow the city to proceed with a ++ program. The health department's proposal includes drug treatment referral and other medical services, including screening for sexually transmitted diseases and tuberculosis.

These are important efforts. Unless the health department finds ways to reach this population, AIDS will be compounded by other problems. Left untreated, sexually transmitted diseases can increase the chances that a person will contract the AIDS virus. Tuberculosis, which is far more easily transmitted than AIDS, poses an especially sinister threat with the appearance in other cities of drug-resistant strains of the disease.

In fact, the control of tuberculosis in Baltimore is one of the great triumphs of the city health department. Because of a thorough program of identifying cases of the disease and careful monitoring to make sure people with the disease take the cumbersome doses of medication needed to overcome it, the city has so far seen only one case of drug-resistant TB. Given the fact that New York City is facing thousands of such cases -- and the resulting fear it causes -- that is a remarkable record.

For a former aspirant to elective office -- he ran for City Council in 1991 -- Dr. Beilenson may well have landed in a post where he can have an even greater impact on the public agenda. Certainly the goals he has set for his department leave no room for complacency.

Sara Engram is editorial page director of The Evening Sun. Her column appears here each week.

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