President's Page January 2003

Robert W. Haley, MD

Public Health
A good investment for all of us

A year ago a friend of mine called me for advice about her 29-year-old son who had developed an unusual, progressive neurodegenerative disease. An honor student through high school and college, he was a dynamic, up-and-coming young executive when, shortly after his wedding, he developed headaches and neurologic deficits. Six months later, after a rapid downhill course, he died. The diagnosis was subacute sclerosing panencephalitis (SSPE).

SSPE is a much-feared, late complication of measles. Despite having completed all his immunizations in infancy and childhood, the young man had developed a severe case of measles in high school during the 1990 measles epidemic. Several years earlier, childhood immunization rates in Dallas and elsewhere had fallen far below the 80 percent threshold where “herd immunity” keeps contagious diseases away and measles spread like wildfire.

This tragic case, like the tuberculosis skin test conversions and the occasional meningitis deaths in our schools, emphasizes the crucial role of our local health department in protecting all of us who live in Dallas County. Many people, however, mistakenly believe that the health department provides health care only to poor people; they confuse “public health” with “public health care.” The job of public health is to mount programs that prevent or control diseases that could spread and affect any of us. Of course this often means directing preventive care to certain groups of the indigent, but the focus of the health department is on conditions that must be controlled for the safety of the public at large. The job of treating all other conditions in people unable to pay, ie, public health care, is the mission of our public hospital—Parkland Health & Hospital System—assisted by our private hospitals and practicing physicians.

The responsibilities of a local health department are divided into four categories: clinical preventive services, health protection, health promotion, and health assessment.

Clinical preventive services comprise those treatment services that health department personnel must provide directly to individuals to protect the community. Examples include the Tuberculosis Control Program, which ensures that TB patients complete their course of anti-TB medications; the Sexually Transmitted Diseases Program, which identifies and treats the unsuspecting sexual contacts of people diagnosed with STDs; and the Childhood Immunization Program, which delivers vaccinations to the many toddlers who otherwise would not be immunized. These services are delivered in clinics or by outreach workers who find those who must be treated. They may require that TB patients take their medications in their presence (directly observed therapy, DOT), and if the patients do not show up for DOT, the health department is directed by state law to get a court order to have them incarcerated for the duration of therapy.

Health protection are the actions that directly reduce disease risks. These include prompt investigation and control of epidemics, regulatory actions such as restaurant inspections, clean water and air, and participation in local ordinance formulation, such as requiring smoke alarms. Have you ever wondered why you expect to get tourista when eating in restaurants in Mexico, but not in Dallas County? The difference is the health protection programs of our local health department. In a bioterrorist attack, an immediate, skillful epidemic investigation could avert thousands of casualties.

Health promotion includes efforts to influence the public to adopt lifestyles that will avoid illness. Relatively modest expenditures in scientifically based health promotion programs can bring about far larger reductions in medical care expenditures. Aggressive local health departments have programs to reduce risky sexual behaviors, drug abuse, cigarette smoking, and drunken driving, and increase seat belt and smoke alarm use. With recognition of the catastrophic increase in type II diabetes from the epidemic of obesity, forward-thinking health departments are starting programs to change population eating and exercise habits to reduce obesity.

Health assessment involves analyzing disease and behavioral data to evaluate current disease control programs and identify the critical situations where public health interventions could be most effective.

My friend’s son might be alive today if Dallas County had kept its immunization rate above the critical level that bars measles epidemics. We wouldn’t now be embarking on a massive escalation of liver transplants from hepatitis C infection if we had curtailed the epidemics of intravenous drug abuse and unregulated tattooing. Think how many diabetics we would not now be dialyzing, amputating, and resuscitating if we had curtailed the obesity epidemic.

Dallas County must revitalize and expand its public health department. It’s a good investment for all of us.

Copyright 1997-2003, Dallas County Medical Society.
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