Health Affairs, 22, no. 4 (2003): 241-248 doi: 10.1377/hlthaff.22.4.241 © 2003 by Project HOPE	New Online   Obama's Success & Next Steps   3 Health Policy Options for President Obama   A Hybrid Proposal   Bipartisan Compromise

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Update

STATE REPORT

A Prescription For Change: The Need For Qualified Physician Leadership In Public Health

Abstract

 
A key element missing in the federal bioterrorism preparedness plan is qualified physician leadership at the local level. Physicians now lead fewer than one-fourth of local health departments. When appointed leaders are not physicians, leadership falls on elected officials or non–medical administrators who become managers of outbreaks. As illustrated in recent case examples, these leaders may find themselves in medical emergencies that they are not qualified to handle. In serious disease outbreaks, unprepared leadership could contribute to unnecessary illness and death. Here I propose strategies to increase qualified physician leadership in state and local public health infrastructures.

The CDC has listed critical capacities that state and local public health agencies must create in order to receive 80 percent of the funding available to them.² None of the CDC’s requirements, however, specify personnel qualifications for leadership of the state and local public health agencies.³ Although physicians are the only people who are licensed and fully technically qualified to diagnose illness and prescribe medical interventions without oversight from higher-level professional staff, the CDC plan fails to specify a role for qualified public health physicians during a bioterrorist attack.

Few public health physicians work in state and local public health agencies. A 1988 Institute of Medicine (IOM) report found a 22.5 percent decline in state health agency physicians from 1977 to 1982; there was a concomitant increase in planners and program analysts of almost 50 percent.⁴ Kristine Gebbie and colleagues found that physicians make up only 3 percent of the practicing public health work-force; of these, 67 percent (4,055 out of 6,008) work in federal agencies.⁵

Moreover, in state and local public health agencies, qualified physicians are rarely appointed leaders. Current public health laws in many states do not even specify who has legal authority to make decisions to vaccinate or quarantine populations, and civil libertarians are fighting legislative changes to improve this situation.⁶ Steven Boedigheimer and Gebbie found that public health leaders are expected to have critical skills such as communications, management, strategic thinking and planning, knowledge of epidemiology, and decision-making ability during a public health emergency.⁷ Although many of these skills are taught in preventive medicine and public health residency programs, federal and state financial support for such programs is weak.

One explanation for the current situation may be the past successes of public health. Since there are no longer major foodborne, waterborne, and other infectious disease outbreaks, elected officials do not see a need to train and hire costly public health physicians. Moreover, many elected officials do not recognize the difference between physicians who practice traditional medicine and those who are public health specialists. Thus, some of the physicians appointed as public health leaders in the past did not have public health training; they proved to be unsuitable for the positions both politically and administratively.⁸

Three levels of physician leadership exist in the current public health infrastructure: complete, partial, and absent. Complete leadership occurs when a physician is appointed director or commissioner of the government agency. Partial leadership occurs when physicians serve as advisers, not the actual leaders. This arrangement leads to quasi-leadership positions in which physicians provide medical advice as "chief medical officers." The third level is the absence of an officially appointed physician. In this situation, the people practicing medicine during a crisis would most likely be elected officials, non–medical managers, or other health professionals. Local physicians might be consulted informally. As the following examples show, each of these levels of physician leadership has been tested by infectious disease outbreaks. Their differing results highlight the degree to which physician leadership is essential in managing public health crises.

Example 1 (complete physician leadership): 1947 smallpox outbreak in New York City. In 1947 Israel Weinstein, a physician and commissioner of New York City’s Department of Health, faced an outbreak of smallpox. Potentially hundreds of people were exposed. Weinstein quickly ordered all doctors, nurses, nonclinical employees, and patients at the hospital in which the smallpox patients were located to get vaccinated.⁹ He mobilized public health teams of hundreds of physicians, nurses, and volunteers and sent teams of physicians to investigate the outbreak’s source and to track down, vaccinate, and observe every person known to have had possible contact with the first- and second-generation smallpox patients. The physicians were instrumental in convincing reluctant and recalcitrant people to get vaccinated.¹⁰

As additional smallpox victims appeared and vaccine supplies dwindled, Weinstein decided that a mass vaccination campaign was needed. He requested and received from Mayor William O’Dwyer an additional $500,000 for vaccine and other expenses.¹¹ He communicated directly with the public and the media on the need to get smallpox vaccinations. The media and public response was overwhelming. In less than a month more than 6,350,000 people had been vaccinated. The smallpox outbreak was limited to just twelve victims, with only two fatalities.¹²

Example 2 (partial physician leadership): 1993 Cryptosporidium outbreak in Milwaukee. In contrast to the earlier New York City experience, for several weeks no one at the Milwaukee Health Department suspected that the largest waterborne disease outbreak in U.S. history was taking place. Disparate bits of information were accumulating: The city’s water treatment plants had been receiving complaints about turbid, foul-tasting water for several weeks, and the health department’s telephone hotline was receiving many calls about stomach ailments. However, the hotline personnel never contacted the communicable disease division. Only after the city’s water plants began receiving calls about "stomach flu" was the health department called in.¹³

Because the health department itself had no surveillance system in place, staff began investigating the problem by calling physicians’ offices, laboratories, pharmacies, and nursing homes. They found further signs of an outbreak: Pharmacies reported selling all of their antidiarrheal drugs, and businesses reported high absentee rates. Yet the health department did not suspect a waterborne disease outbreak until after an infectious disease specialist identified Cryptosporidium in an immuno-compromised patient. Because the health department lacked trained personnel, staff called the CDC for help.¹⁴

Even after the outbreak was recognized, effective response was delayed. The city’s health commissioner, Paul Nannis, and the water works director, Jesse Cooks, could not agree on a plan. Nannis, an administrator, relied on his medical director, Thomas Schlenker, to provide him with medical advice. In the end, the mayor made the medical decision to recommend that the public boil all water until the Milwaukee Water Works department could ensure a safe water supply.¹⁵ The outbreak sickened more than 400,000 people; 100 died.¹⁶

Example 3 (absent physician leadership): 2001 anthrax attacks in Mercer County, New Jersey. Mercer County includes the state capital and is densely populated, with more than 350,000 people.¹⁷ When anthrax contaminated the Hamilton Township postal facility in Mercer County, no locally appointed physician leader was available to decide whether the 1,000 postal workers should be treated with antibiotics as a preventive measure. The Hamilton Township mayor, Glen Gilmore, sought help from the state health department.

Officials from that department recommended that postal workers get the appropriate antibiotics. However, since the public health infrastructure was lacking, the state health commissioner could only recommend that postal workers obtain antibiotic prescriptions from their individual private physicians, a particularly impractical solution since the recommendation was issued on a Friday night.¹⁸ The situation quickly deteriorated; even postal workers who obtained prescriptions panicked when local pharmacies ran out of the antibiotics they sought. Eventually, Gilmore contacted the local private hospital’s chief administrator, Christy Stephenson; the hospital ordered 18,000 antibiotic pills itself, even before federal or state officials recommended it. Gilmore personally sent a police car to South Jersey to pick up the supply and deliver it safely to the hospital. Over the next three days the local hospital treated the postal workers. The New Jersey area had seven anthrax cases, including two inhalational victims; fortunately, no one died.¹⁹

The Necessary Capabilities

Top The Necessary Capabilities Macro And Micro Medicine The Magnitude Of The... Discussion Editor's Notes NOTES

 
The differing responses to these three outbreaks illustrate the leadership and management capabilities needed to rapidly and effectively respond to an outbreak: legal authority, credibility, staff, and resources.

In the New York smallpox example, Weinstein was the sole leader who made the final medical decisions. His success depended upon his legal authority, the mayor’s full support, and a staff qualified to implement his orders; his credibility helped to win public compliance. These key elements allowed him to make swift and decisive actions that contained the outbreak.

In the Milwaukee Cryptosporidium example, Schlenker was not the sole authority but instead served as a consultant to the health commissioner. This scenario produced four leaders: a politician, two administrators, and a physician. The politician made the final medical decisions. The response to this outbreak was neither swift nor decisive.

Complicating the outbreak were the limitations of the public health infrastructure. The health commissioner, Nannas, was hindered by his lack of legal authority and possibly by a lack of credibility since he was not a physician. He had no oversight of reporting or monitoring for signs of an outbreak. Telephone hotline personnel ignored early warning signals, which led to a delay in the recognition of the outbreak. Nannas was further disadvantaged by not having the personnel needed to respond to the outbreak. In 1993 the Milwaukee Health Department had very few physicians.²⁰ Only after the outbreak was well under way were CDC physicians called in to help.

In the New Jersey anthrax example, the chaotic response reflected public health leadership failure at all levels. Some might argue that the state health commissioner, a physician, should have made the decision to treat the workers directly. However, expecting a state health commissioner to make all county-level treatment decisions is inefficient, impractical, and unsafe. It is analogous to expecting a hospital’s chairman of medicine to make treatment decisions for each hospitalized patient.

Furthermore, the commissioner had no local public health troops to rally. New Jersey has 115 local health departments distributed across twenty-one counties, but most are too small to justify hiring full-time public health physicians.²¹ These local health departments typically focus on inspecting restaurants and septic systems, removing dead animals, and dealing with lead abatement. While important functions, they are not preparatory for handling serious infectious disease outbreaks. To manage the outbreak, the mayor and hospital administrator had to improvise a public health response by dragooning the police and a local private hospital.

Macro And Micro Medicine

Top The Necessary Capabilities Macro And Micro Medicine The Magnitude Of The... Discussion Editor's Notes NOTES

 
Government confusion about the role of public health physicians may explain why so few people seem to recognize the need for practitioners in this specialty. One problem is that terms such as "population-based" and "preventive" medicine that are used to describe public health medicine are unclear. Virtually all physicians work with populations and do "preventive medicine" at some level. To reduce this confusion, I borrow from the field of economics and use the terms "macro" and "micro" medicine to describe community and individual units of focus in these two areas of medicine.

Understanding and integrating these two realms of physician action are vital if we are to combat future outbreaks, terrorist or otherwise. There are many similarities between macro and micro medicine, although the differences that exist are important (Exhibit 1). Macro medicine relies much more heavily on the explicit use of statistics in the process of data collection and analysis. Practitioners of this form of medicine need to be comfortable with the use of statistical computer software. In addition, they should be knowledgeable and skilled in designing, conducting, and administering epidemiological studies to investigate outbreaks and other unexplained disease trends in populations.

The Magnitude Of The Problem

Top The Necessary Capabilities Macro And Micro Medicine The Magnitude Of The... Discussion Editor's Notes NOTES

 
In 1997 the National Association of County and City Health Officials (NACCHO) conducted a "census" survey of all 3,000 local health departments to determine the current status of public health in America.²³ Only 23 percent of the 2,491 local health agencies responding reported being directed by physicians (osteopathic or allopathic). Of these, 196 (8 percent) reportedly had master of public health (MPH) degrees or were fellows in the American College of Preventive Medicine (FACPM). Other doctorally trained clinicians included sixteen veterinarians and twelve dentists; six had additional MPH degrees. Approximately one-fifth of local health department directors reported nursing credentials. The remaining respondents reported a variety of degrees; one-fifth listed no academic credentials (Exhibit 2).

Top The Necessary Capabilities Macro And Micro Medicine The Magnitude Of The... Discussion Editor's Notes NOTES

Recognizing the lack of qualified public health professionals, the IOM has recommended that Congress designate funds to meet the nation’s needs.²⁹ In response, the CDC has created the Office of Workforce Policy and Planning to implement and oversee the IOM’s recommendations.³⁰ However, much more needs to be done.

Physicians need training in macro medicine. The nation’s schools of medicine should collaborate with schools of public health to provide high-quality courses relevant to macro medicine practice, so that all medical school graduates can be effective members of public-private efforts. For graduate physicians, the CDC and schools of public health should offer Internet-based courses on epidemiology, outbreak investigation, infectious diseases, bioterrorist threats, statistics, and public health management and law to physicians interested in learning macro medicine. Some schools of public health already offer this educational option.

Preventive medicine/public health residency programs, which are two years in length, provide one year in course work toward an MPH degree and one year of on-the-job training in a variety of public health settings. These residents are required to have at least one year of micro medicine training before entering the macro medicine program.³¹

HRSA Title VII funds represent the most comprehensive source of federal funding for these programs; however, funding is often unpredictable.³² To meet the nation’s needs, funding must be increased from federal agencies such as HRSA and the broader Department of Health and Human Services (HHS).³³ The Department of Veterans Affairs (VA) and the military should help by increasing macro medicine funding and training opportunities in their medical programs.³⁴

The number of physicians in the CDC’s Epidemic Intelligence Service (EIS) program should be expanded. Federal bioterrorism funds could be used for this purpose. Physicians would be able to receive practical surveillance and outbreak investigation training within their home communities; this would help ensure that physicians with these skills remain where they are needed—at the local level. Physicians who successfully complete the courses and EIS training program would secure credit and become board-eligible in preventive medicine.

Federal requirements are needed for qualified physician leadership. The CDC should require in its Cooperative Agreement Awards for bioterrorism funding that physicians direct local public health departments in densely populated jurisdictions. For example, the New York State Code of Rules and Regulations requires that counties of 250,000 or more have qualified physicians directing the county health departments.³⁵ Suburban jurisdictions with populations too small to justify full-time physician leadership should consider consolidation or collaboration. Sparsely populated rural areas should be given the needed leadership and technical assistance from the state public health agency. These physicians would be the ones to practice macro medicine and make the crucial medical decisions at the local level in the event of a public health emergency such as a bioterrorist attack.

State and local governments should require that public health agencies be directed by macro medicine physicians with these or comparable qualifications, and they should be competitively compensated for these skills. These physicians would have the legal authority to make macro medicine decisions.

Public health law needs reform. The IOM recommends that state public health laws be reformed to ensure optimal performance.³⁶ Larry Gostin and colleagues drafted a Model State Emergency Health Powers Act, which would ensure that basic public health functions be facilitated by law. This model act would empower public health leaders to compel vaccination, treatment, isolation, and quarantine when clearly necessary during a disease outbreak.³⁷ The 1993 Cryptosporidium outbreak in Milwaukee illustrated the health commissioner’s lack of legal authority. Leadership confusion should not occur when rapid decision making is required during a crisis.

The threat of future bioterrorist attacks, increasing antimicrobial-resistant organisms, and newly emerging infectious diseases will persist in the foreseeable future. As this paper illustrates, competent leadership is vital for effective public health responses to outbreaks, natural or human-made. Attracting and retaining qualified professionals requires that salaries at the state and local levels be competitive.

The anthrax attacks in fall 2001 demonstrated an overreliance at the local level on CDC physician expertise. While the CDC provides important services, it should not serve as a substitute for local physician leadership. Professional public health physician organizations can improve this situation by educating the public and elected officials such as county executives, legislators, and governors on the importance of having qualified macro physicians in practice at the state and local levels. The first step in accomplishing this goal is the widespread recognition of the importance of this long-neglected medical specialty.

Editor's Notes

Top The Necessary Capabilities Macro And Micro Medicine The Magnitude Of The... Discussion Editor's Notes NOTES

 
Laura Kahn is a member of the research staff of the Program on Science and Global Security, Woodrow Wilson School of Public and International Affairs, at Princeton University in Princeton, New Jersey.

The author thanks Ruth Berkelman, Joseph C. d’Oronzio, Joel Nitzkin, and Frank von Hippel for their useful comments and suggestions. Special thanks to Judith A. Swan for invaluable editorial suggestions. The National Association of County and City Health Officials (NACCHO) data were obtained from the 1997 National Profile of Local Health Departments, a project supported through a cooperative agreement between NACCHO and the U.S. Centers for Disease Control and Prevention.

NOTES

Top The Necessary Capabilities Macro And Micro Medicine The Magnitude Of The... Discussion Editor's Notes NOTES

 

1. U.S. Department of Health and Human Services, "HHS Announces $1.1 Billion in Funding to States for Bioterrorism Preparedness," Press Release, 31 January 2002, www.hhs.gov/news/press/2002pres/20020131b.html (15 April 2003).
2. U.S. Centers for Disease Control and Prevention, "Cooperative Agreement Award Notice and Grant Guidance," 9 December 2002, www.bt.cdc.gov/Planning/CoopAgreementAward/index.asp (15 April 2003).
3. CDC, "Notice of Cooperative Agreement Award, Attachment A, Focus Area A: Preparedness Planning and Readiness Assessment," 22 February 2002, www.bt.cdc.gov/Planning/CoopAgreementAward/CDC3BTATTACHMENTA-MASTER-2-14-2002-317pm.asp (15 April 2003).
4. Institute of Medicine, The Future of Public Health (Washington: National Academies Press, 1988).
5. K.Gebbie, J. Merrill, and H.H. Tilson, "The Public Health Workforce," Health Affairs (Nov/Dec 2002): 57–67.
6. T.B.Cole, "When a Bioweapon Strikes, Who Will Be in Charge?" Journal of the American Medical Association 284, no. 8 (2000): 944, 947–948[Free Full Text]; and M.Chase, "Civil-Liberties Issues Check Plans to Counter Bioterrorism," Wall Street Journal, 17 May 2002.
7. S.F.Boedigheimer and K.M. Gebbie, "Currently Employed Public Health Administrators: Are They Prepared?" Journal of Public Health Management and Practice (January 2001): 30–36.
8. JoelNitzkin, past president, American Association of Public Health Physicians, personal communication, 29 January 2003.
9. B.Roueche, "Annals of Medicine: The Case of the Man from Mexico," New Yorker (11 June 1949): 70–83.
10. Ibid.
11. Ibid.
12. I.Weinstein, "An Outbreak of Smallpox in New York City," American Journal of Public Health 37, no. 11 (1947): 1376–1384.
13. PaulBiedrzycki, manager, disease control and prevention, City of Milwaukee Health Department, personal communication, 5 February 2003.
14. Ibid.
15. Ibid.
16. W.MacKenzie et al., "A Massive Outbreak in Milwaukee of Cryptosporidium Infection Transmitted through the Public Water Supply," New England Journal of Medicine 331, no. 15 (1994): 161–167; [Abstract/Free Full Text]CDC, "Surveillance for Waterborne-Disease Outbreaks—United States, 1993–1994," Morbidity and Mortality Weekly Report (12 April 1996): 1–33; and D.Rutz, "Milwaukee Learned Its Water Lesson, but Many Other Cities Haven’t," Cable News Network, 2 September 1996, www.cnn.com/HEALTH/9609/02/nfm/water.quality (15 April 2003).
17. U.S. Bureau of the Census, "Mercer County QuickFacts," 24 September 2002, quickfacts. census.gov/qfd/states/34/34021.html (15 April 2003).
18. M.Winerip, "Our Towns; Hail the Mayor (Whose Name Isn’t Giuliani)," New York Times. 14 November 2001.
19. Ibid.
20. Biedrzycki, personal communication.
21. New Jersey Department of Health and Senior Services, "Search the Directory of Local Health Departments in New Jersey," www.state.nj.us/health/lh/directory/lhdselectcounty.htm (15 April 2003).
22. CDC, "Notice of Cooperative Agreement Award, Attachment B, Focus Area B: Surveillance and Epidemiology Capacity," 22 February 2002, www.bt.cdc.gov/Planning/CoopAgreementAward/CDC4BTATTACHMENT-B-MASTER-2-14-2002-442pm.asp (15 April 2003).
23. National Association of County and City Health Officials, "1997 Profile of Local Health Departments Questionnaire," www.naccho.org/GENERAL148.cfm (15 April 2003).
24. A listing of these Web sites is available from the author. Send e-mail to lkahn{at}princeton.edu.
25. American College of Preventive Medicine, "A Public Health Crisis: The Shortage of Physicians Trained in Preventive Medicine," www.acpm.org/finalproof_90.pdf (15 April 2003).
26. U.S. Department of Health and Human Services, "Preventive Medicine Training Grant," bhpr. hrsa.gov/publichealth/preventive/index.htm. (15 April 2003).
27. ACPM, "A Public Health Crisis."
28. American Medical Association, Physician Characteristics and Distribution in the U.S., 2002 (Chicago: AMA, 2002).
29. IOM, The Future of the Public’s Health in the Twenty-first Century (Washington: National Academies Press, 2002).
30. CDC, "Office of Workforce Policy and Planning," 10 April 2003, www.phppo.cdc.gov/owpp/index.asp (15 April 2003).
31. MaryApplegate, director, New York State Preventive Medicine Residency Program, and chair, National Association of Residency Directors, personal communication, 7 February 2003.
32. D.S.Lane, "A Threat to the Public Health Workforce: Evidence from Trends in Preventive Medicine Certification and Training," American Journal of Preventive Medicine 18, no. 1 (2000): 87–96.[Medline]
33. ACPM Task Force, "Rebuilding Our Nation’s Preventive Medicine Workforce" (Unpublished paper, 12 November 2000).
34. Ibid.
35. New York State Code of Rules and Regulations (10NYCRR11.11).
36. IOM, The Future of the Public’s Health in the Twenty-first Century.
37. L.O.Gostin et al., "The Model State Emergency Health Powers Act: Planning for and Response to Bioterrorism and Naturally Occurring Infectious Diseases," Journal of the American Medical Association 288, no. 5 (2002): 622–628.[Abstract/Free Full Text]

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