When he first volunteered to serve as health officer in the town of Sedgwick (population 1,090), Belfast cardiologist Dennis DeSilvey was put off because town officials weren’t sure such a position even existed.
“We’re looking into it,” explained Selectman Nelson Grindal, who admits to having been caught flat-footed by DeSilvey’s offer this spring. It turns out no job description exists, and no money is budgeted for a health officer. “It probably would not even be on our radar” had Desilvey not approached the town, Grindal said. “We’re looking into it to see if it’s required.”
Maine cities and towns have been required to appoint a local health officer since at least the late 1800s, but it’s a function that has practically disappeared from municipal government. Until recently, few people seemed to care much about the situation, even though Maine is one of the few states without a public health system, and even though Maine’s has a high death rate from chronic diseases such as cancer, diabetes, heart disease.
The moribund status quo would probably continue, but for one pressing concern: the possibility of a deadly avian flu pandemic. Such a crisis would demand the utmost of local health officers: educating the public, reporting conditions from the field, and coordinating a response with state and county officials. But hardly any local health officers currently possess the education and training that such a role requires. A mobilization has begun to change that.
“We don’t have a public health infrastructure and we did have one 100 years ago,” explained Dr. Dora Anne Mills, director of Maine Center for Disease Control and Prevention. Today, the state employs 50 public health nurses and six nurse epidemiologists, but they are spread woefully thin. “We definitely need a more coordinated presence than we have. We do not have a cadre of trained public health professionals we can call on in a public health emergency. We need to have people on the scene who know the area pretty well and can act pretty quickly.”
The disrepair of Maine’s public health system leaves the state less prepared than others to combat bird flu, however the state’s rural settlement pattern makes it less vulnerable to the disease than urbanized states where it would spread much quicker, according to a consensus opinion of experts. In any case, a sense of urgency prevails.
Two legislatively appointed groups are working on different tracks to quickly develop a public health system. The Public Health Work Group was appointed by the Health and Human Services Committee to identify resources and make recommendations on establishing a system. The group is planning to produce a final report and give it to the Legislature by January 1, 2007. The Task Force on Homeland Security, appointed by a different committee to work on preparedness, has begun working toward the same goal. It is expected the separate groups will eventually mesh their efforts, although it hasn’t happened yet. The leading plan — pushed by Mills — calls for hiring trained public health professionals in each county at a cost upwards of $2.5 million. In the meantime, a website – www.MaineFlu.gov – is up and running. [Various state agencies and public health providers have taken steps to address the particular threat of a pandemic].
“We are much more ready than we were six years ago, six months ago, or six weeks ago. We have developed statewide exercise plans for both avian and pandemic flu,” Maine Gov. John Baldacci was quoted by the Maine Sunday Telegram on May 21 in response to a question about Maine’s preparedness for a bird flu pandemic.
Yes, but Maine is starting from way back in the pack. That may come as a surprise to people accustomed to thinking of Maine as a leader in health policy. After all, Maine has been one of the few states to dedicate significant sums of tobacco settlement money for health improvement programs. And, Gov. Baldacci’s Dirigo health program, despite its well-publicized problems, is an ambitious attempt to extend health coverage to all. Furthermore, Maine’s top public health officer — Harvard-educated Mills — enjoys wide respect as a progressive leader.
History of Local Health Officers
The origin of Maine’s system of local health officers coincided with the advent of Maine’s Board of Health in 1885, the precursor to today’s CDC. Local health officers may have been working long before that but it was the reporting requirement to the state board that made it a system. At the outset, health officers were invariably doctors and nurses and they had the authority to order quarantines and clean-ups. Back then, open sewers and farm animals posed serious public health threats. Reports from that era recount the incidence of such common 19th century diseases as smallpox, cholera, and typhoid fever. Though those conditions may sound downright backward today, the original system – trained professionals in every community reporting to the state about infectious disease threats – is more advanced than what exists today.
Maine’s public health system became a casualty of a certain kind of progress.
Piped public water, more sophisticated sewage systems and eventually vaccines improved overall health and reduced the need for local health officers. The regulation of public drinking supplies and eating establishments saw a migration of authority to the state. At the same time, the medical profession changed. Doctors became clinicians and specialists and stopped thinking of themselves as public health practitioners.
In most towns today, “health officer” is little more than a title. Typically, it’s an unpaid position with no job description assigned to whoever in town government is willing or can be compelled to take the job: the town manager in Woodstock, a paramedic in Madawaska, the code enforcement officer in Harrison, a retired public health nurse in West Bath. To the extent they are designated to do the job, health officers typically deal with health nuisances, such as malfunctioning septic systems that endanger groundwater and squalid living conditions. The classic case of a health officer's job would be figuring out what to do with an impaired elderly person living alone with a houseful of cats.
While local health officers have a significant degree of authority to inspect premises and order the abatement of health nuisances, that authority is often not used due to a lack of training and funding and confusion over roles and responsibilities.
Town of Harrison
Confusion reigns about the role of health officers and what they do.
“Good luck with that,” quipped John Wentworth, the assessors’ agent, plumbing inspector, code enforcement officer and health officer in Harrison. Wentworth has been on the job less than a year and is still learning what his health duties are.
“Do I know exactly? No. Am I aware of some of the things? Yes. What are they? Good question. I would have to go to a book,” he said. Wentworth said he’s so busy he’s not particularly eager to learn the full extent of his health duties. “I’m flat out straight,” he said. “If I know more of what I’m supposed to be doing, that’s more that I will be doing. I’ve got more than I can handle right now. There’s just so many hours in the day. I try to do as much as I possibly can.”
Town of Sedgwick
DeSilvey said he volunteered for the Sedgwick position because he has experience and wants to contribute to town affairs. He said he enjoyed serving as health officer in Vermont, where they are routinely called to deal with failed septic systems and children living in squalor. “They ( Vermont) really use their health officers,” he said. “ Maine (health officers) are kind of an untapped resource,” he said.
DeSilvey said he views the role of health officer as “proactive” and “almost entirely educational.” As a medically-trained person, he said he feels responsibility to help his community deal with bird flu. Mainers should take some comfort in the state’s dispersed settlement pattern, he said. “The Great Flu of 1918 was largely a disease of urban areas because of their density of population. [Bird flu] definitely will eventually get here but I do think Maine, being rural, we’re somewhat protected,” he said.
DeSilva likened the current climate – in which the disease is poorly understood – to the early AIDS epidemic. “There’s the same sort of panic – how does it get transmitted, who gets it? ... It will get here and will take a large number of lives,” he said. “I have a sense of responsibility to allay the paranoia, but allow legitimate fears and help people understand.”
For now, DeSilva said he is awaiting direction from town officials.
“I have no idea [about a job description],” he said. “They were kind of surprised someone wanted to volunteer. They’re still figuring out what to do with me.”
Town of Madawaska
Percy Thibeault, a full-time paramedic and part-time police officer, has been health officer in Madawaska for more than three decades. He said he considers himself fortunate because of his medical training. “I definitely think more training would be good,” he said. “I got my training through my paramedic (training).” He’s trained to give vaccinations “if I had to,” he said.
Town of Woodstock
Health officer duties in the western Maine town of Woodstock fall to Town Manager Vern Maxwell. He concedes that he lacks a public health background and thinks additional training is advisable and probably inevitable. “Why more? I don’t know, it’s just a sense,” he said. “Part of it is preparedness, pandemic.” He said he thinks most people in town would consider a paid position to be an “unnecessary expense,” but “maybe down the road, a few dollars for training.”
Municipal Health Departments
Portland and Bangor are the lone communities in Maine with professional health departments.
Bangor’s Department of Health and Welfare is organized on the lines of a human services department with a sexually transmitted disease clinic, a nutrition program for young children and mothers, general assistance program, immunization progam, emergency and transitional housing program, dental clinic, and home visitation program for young mothers. The department has just completed a rigorous survey of community needs and is planning to expand at least two programs. The immunization program – which concentrated on seasonal flu shots and shots for oversees travel – will begin offering regular immunization for common childhood diseases, according to director Shawn Yardley. The need has grown as family doctors and pediatricians spend less time on immunization, he said. Maine’s ranking has fallen from top five to middle of the pack in the rate at which children are immunized, he said. The dental clinic will expand into early oral health education. Sugar-loaded fruit juices are a particular danger, he said.
Portland is the only community in Maine with a true public health department (under the administrative wing of the Health and Human Services Department.) It employs 60 people. The city contributes less than 20 percent of the $5 million budget, with the rest coming from more than three dozen grants. Services include epidemiology, family health, health promotion, indigent health care, and infectious diseases.
HHS Director Doug Gardner said he thinks the public health services are the legacy of the city having once owned and staffed a city hospital, which evolved into the Barron Center elderly housing project. Health services “have a pretty strong foothold,” he said. His department has conducted “table top drills” in preparation for pandemic flu and says preparedness is improving “but we’re not there yet.”
County Health Services
Away from Portland and Bangor, there is another bright spot in the overall disrepair of Maine’s public health system . . . Sagadahoc County.
Beginning in 2005, the Sagadahoc County Emergency Management Agency began beefing up public heath services throughout the region. With funding from a grant from the Bingham Foundation, it began gathering and compiling data on health conditions. Since then it has teamed up with the state’s network of epidemiologists and public health nurses, and holds regular meetings with municipal health officers. Training in two areas has been conducted – one on procedures for testing water quality and for closing public beaches to swimming, and another on preparedness training for small public water system operators. Officials are also partnering with the state for more effective sanitation procedures at restaurants and convenience stores.
One of the driving forces in Sagadahoc County is Dr. Hugh Tilson, a part-time resident of Maine and a public health professor at the University of North Carolina. He’s a proponent of a strong, county-based, public health system as exists in North Carolina. “Organizing sub-state regions makes sense because of the prohibitive expense of hiring professional public health officers in nearly 500 separate towns,” Tilson said. Sagadahoc County’s voluntary leadership can be a model for others to follow, he said.
“My meager role at the county level is to consolidate our strengths and provide some local coordination and accountability ... a strategy which can fit very nicely into a multi-county regional “agency” if that’s the way we end up going,” said Tilson.
One of Tilson’s key allies has just quit, however. County EMA Director Rusty Robertson stepped down this month in a dispute over funding a part-time public health staff position.
“Lack of understanding and support was part of the reason,” said Robertson. State EMA Director Art Cleaves had pushed for a full-time position, but mindful of county finances, Robertson said he sought funding for just a part-time position. Proposed half-time funding was cut to a quarter time by county commissioners and eliminated entirely by the county budget advisory committee, he said.
Robertson said he hopes commissioners will hire someone with a public health background to fill his position, but says his departure won’t derail progress. “We have a very dedicated group of volunteers assembled. I was just a player like everyone else,” he said.
The lack of “surge capacity” at hospitals and an inadequate communication network remain vulnerabilities, he said. “We have a very limited way to get the message out on what actions people should be taking,” he said. “If the flu strikes, people are going to have to be taught how to take care of people at home because the hospitals will be filled.” That kind of education is best done in small meetings held throughout the state, rather than through the broadcast media, he said. “A five to six minute blurb (on TV) isn’t going to do it,” he said. Still, Robertson expressed optimism that a public health system can be pulled together statewide.
“We are a small state with not a lot of population. This is not something real complex,” he said.
Mandates Without Money
Maine law is quite specific about the authority of a local health officer. Chapter 153 of Title 22 says “every municipality in the state shall employ” a health officer. Furthermore, officers “shall assist in the reporting, prevention and suppression of diseases and conditions dangerous to health.” It says officers “shall receive and evaluate complaints” concerning nuisances, and can order the “suppression and removal of nuisances and conditions posing a public health threat...” It says they are also authorized to provide free vaccines.
“It’s quite explicit,” said Tilson. The authority to report, conduct investigations and enforce rules: “It’s all there,” says Tilson. He and others acknowledge that Maine statutes need “updating” because nearly all health officers lack the training to report disease conditions.
The statutes, as applied, also lead to frequent confusion because of a lack of clarity as to whether a particular issue should be addressed by the LHO, code enforcement officer, or other town officials. LHO roles also vary from town to town based on the existence of ordinances conferring authority upon them in a particular area, such as food service. All of these factors make it extremely difficult for a LHO to define his or her duties.
The bigger problem, says Tilson, is that “mandates without money are doomed to failure.”
Those who work with local health officers are well aware of the obstacles posed by lack of funding and adequate training. Using Homeland Security funding, a working group led by the Muskie School and comprised of representatives from state health agencies, local health departments and MMA are working towards development of a health officer training program. The group will soon be sending a survey to all Maine municipalities which is intended to help determine the strengths and weaknesses among local health programs and identify needed training areas. The end result will hopefully be the formation of a training program for LHOs, much like the opportunities that are already available for other town officials.
Maine’s tradition of local control has stymied the development of a public health infrastructure, according to authors of an article on “Turning Point” a six-year experiment to develop public health capacity in Maine. The article in the March/April 2005 article of the Journal of Public Health Management & Practice was written by Paul Campbell, a lecturer at Harvard School of Public Health and president of Maine Center for Public Health and by Ann Conway, education and training coordinator at the Maine Center for Public Health.
While countering arguments for local control in the public health infrastructure, the authors concede that Mainers are not likely to either “give up their municipal governments” or “strengthen their regional or county governments very quickly.” General distrust of government, tight budgets, an eroding tax base, and a history of unfunded state mandates are all obstacles, according to the authors. The biggest challenge, however, may be “selling infrastructure development,” which the authors concede is an “abstract” goal.
The bird flu – which has yet to reach the United States and cannot routinely affect humans in its current form – has at least taken debate about Maine’s public health infrastructure out of the abstract category.
Maine has elements of a public health infrastructure to build upon. Federal bioterrorism money has funded epidemiologists, nurses and planners at the state level. Tobacco settlement money has funded a statewide network of Healthy Maine Partnerships focused on chronic disease prevention. County EMA officials are already engaged in preparedness drills.
Local communities still desperately need doctors and nurses to step back into their old roles as local public health leaders, says Tilson.
SIDEBAR
Essential Public Health Services
1. Monitor health status to identify community health problems.
2. Diagnose and investigate health problems and health hazards in the community.
3. Inform, educate and empower people about health issues.
4. Mobilize community partnerships to identify and solve health problems.
5. Develop policies and plans that support individual and community health efforts.
6. Enforce laws and regulations that protect health and ensure safety.
7. (a) Link people to needed personal health services, and
(b) Assure the provision of health care when otherwise unavailable.
8. Assure a competent public health and personal health care workforce.
9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
10. Research for new insights and innovative solutions to health problems.
Source: Essential Public Health Services Work Group of the Public Health Functions Steering Committee