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Public Health is capable of excellence when funded adequately

Public Health – Seattle & King County is regarded across the state and country as a high quality, innovative health department with extraordinary expertise among our highly professional workforce. Where funds permit, our people are capable of great things. In addition, we are effective because of key partnerships with the University of Washington and other local partners. This biennium, we have been working with the UW on formalizing our relationship as an Academic Health Department, which is an arrangement encouraged nationally between Metro or state health departments and the state research institution to benefit to public health programming, workforce development, and our data work in particular.

  • HIV/AIDS: A recent study showed that King County has among the best HIV viral suppression rate in the country, which is the gold star measure of program effectiveness. Viral suppression increased by 89% between 2006 and 2013, and in 2013 an estimated 74% of all persons with diagnosed HIV infection were virologically suppressed. These remarkable improvements in viral suppression were seen in all ethnic groups. AIDS diagnoses and mortality among people living with AIDS declined over the same period, and eliminating HIV in King County is a goal within sight. The study authors attribute our success, in part, to a well-developed public health system and long term investment in HIV/AIDS programming by local and state sources that leverage federal dollars.

  • Nutrition & Physical Activity: Our work in chronic disease prevention has shown tremendous success. For example, obesity prevention is an important focus, because obesity is tied to many diseases from heart disease to diabetes. King County partnered with schools and community organizations to implement a $25 million multi-year obesity prevention initiative funded by a federal grant. Among many achievements, we were able to reduce youth obesity by 17% in low-income school districts. While youth obesity rates fell significantly in school districts with initiative projects (Auburn, Highline, Kent, Northshore, Renton, Seattle and Tukwila), rates remained the same in districts not involved in the initiative and were also unchanged in the rest of the state. Public Health has shown that with appropriate funding, we can make a difference in preventing and responding to today's leading causes of illness and death.

  • Physical and Behavioral Health Integration: We have shown we can move the needle on managing the constellation of medical and behavioral health needs among our community's most needy. The public health primary care services pilot in the Navos center in Burien serves severely and persistently mentally ill and/or substance abusing patients with integrated behavioral health and medical care. This program results in excellent patient outcomes, but the payment model isn't yet keeping up with high costs of integrated services. More will be known when the state comes out with their payment model for integrated care. However, we know that these highly targeted services help to keep these residents out of the criminal justice system and emergency rooms.

    • The experience of a recent Navos client with developmental delays, depression, diabetes and morbidly obesity demonstrates the success of the program: She had bounced in and out of homelessness and used the ER for shelter and socialization. Her Navos case manager, the Public Health nurse care manager and the Healthcare for the Homeless-funded outreach worker worked together to help the client find stable housing and to set up a care plan to help her maintain her housing and work on her health. During the first five months of the year, the client had 14 emergency room visits. Since then she has had only one - and her diabetes is under control.

  • School Based Health: Our School Based Health Centers, funded in past years from the Seattle Families and Education levy, deliver results including decreases in absenteeism and improvements in grade point averages and higher rates of immunizations (typically around 15% improvement), improved asthma outcomes (typically a 70% decrease in hospitalizations) and increased use of contraception (typically around 8% increase).

  • Emergency Medical Services: Our EMS system, funded through the EMS levy, is highly regarded nationally and internationally. A key to our success is adequate funding levels that provide the capacity to develop innovative, successful interventions that save lives and prevent illness. For example, we have the best cardiac arrest survival rate in the country, due in no small part to community support and funding that allows evidence-based treatment.

  • Our Communicable Disease Epidemiology & Immunization Section has a national reputation for excellence. During the 2009 H1N1 influenza pandemic, we rapidly put in place a novel system to ensure vaccination pregnant women who were at high risk for severe infection and achieved a 77% vaccination rate in this population. In 2013, we investigated and reported on a hospital outbreak of multidrug-resistant infections associated with endoscopy that contributed to major changes in how these procedures are done nationwide.

There are many other examples of the excellence that Public Health delivers when it is adequately and sustainably funded.

Inadequate and unpredictable funding in many of Public Health's programs means we are not always able to perform to the high standards that both the community and our professional staff expect and aspire to. In just the last two years, we have responded to major events that have required staff from across the department to stop performing their regular duties to focus on supporting the community-wide public health response. Examples include:

  • Zika: While the mosquito that spreads Zika does not live in Washington, the impact of this dangerous emerging infection is being felt in King County. We need to provide guidance to healthcare providers and residents on risks and mitigation, as well as coordinate testing and respond to resident concerns.

  • Ebola: Our response took hundreds of hours from staff across the department, including Communicable Disease and Epidemiology, Communications, and others. A total of $400,000 of staff time was spent on our response. Our involvement included intensive coordination and training at hospitals and other health care settings such as identifying and treating patients, training front line clinics and EMS providers on appropriate protocols, coordinating purchasing of protective equipment, supporting law enforcement around transporting potential persons with Ebola, interpreting CDC guidance, and fielding a heavy load of local and national media and other stakeholders daily.

  • Tuberculosis in public settings: Two cases of active TB at an area high school led to a large response, including testing and reading the tests of over 1200 people. Over a dozen TB staff members were pulled from regular investigations for the duration of the event. We even needed to call on mutual aid from a neighboring county.

  • Mercer Island water contamination: Required full activation of our Health and Medical Area Command staff, as well as Environmental Health and Communications staff. EH staff provided over 450 hours of response.

Public Health is primarily a prevention-oriented profession. We work to anticipate, prevent, mitigate and assure treatment of illness and disease along a continuum from upstream causes and social determinants of health and health equity to downstream health impacts on individuals and communities from unhealthy environments and interactions.

Over the past 100 years, the public health profession has made tremendous gains for our people – measured by indicators such as infant mortality and life expectancy. Yet these gains have not been evenly distributed across our communities, and here in King County, there are enormous health inequities between the healthiest and the least healthy of our residents. Our programs and services aim to promote prevention across all groups, and we are determined to begin to get at the root causes of health inequity, which are underlying injustices of racism and sexism.

  • Chronic disease: Apart from grants, described above, our health department has very little capacity to prevent and respond to the leading causes of death. For example, tobacco use continues to be a leading cause of death. While traditional tobacco use is down among many groups, it continues to impact communities of color in an inequitable way. In addition, with the emergence of vaping, we're seeing a disturbing trend towards adolescent use of tobacco, which could undo decades of public health success in lowering rates of tobacco use. In past years, we had funding to provide to local community based agencies to lower tobacco use among priority populations. For example, we worked with churches, colleges and housing providers to implement smoke free policies and school grounds policies to be enforced with alternatives to suspension. We also were able to conduct media campaigns and counter tobacco advertising. We also used to be able to more comprehensively support cessation by providing training and even nicotine patches to healthcare providers that work with low income populations.

  • Adult immunizations: The return on investment from evidence based methods of disease prevention through adult immunization is not in dispute. Currently, Public Health does not have ability to meaningfully promote adult immunization or work to assure that healthcare providers promote adult immunizations to their patients, except in limited circumstances. Key adult immunizations that we are not able to advance include:

    • Influenza: Our current seasonal influenza immunization rates are less than 50%; yet millions of people die in the U.S. each year from this largely preventable cause of death.

    • Herpes zoster: Herpes zoster vaccine prevents shingles, and is recommended for healthy adults 60 and older. It is believed to be one of the most cost effective vaccines available because of the impact shingles can have on a person's quality of life.

    • Pneumococcal disease is an infection that causes pneumonia, meningitis, and sepsis (bloodstream infection). It kills tens of thousands of adults in the U.S. each year, and those who survive it can have lifelong complications, including blindness and paralysis.

  • Human papilloma virus: This very common virus is a leading cause of cervical cancer. A vaccine provided in three doses to pre-sexual boys and girls prevents this cancer, but apart from a small, temporary grant to promote its use in Seattle school based clinics, Public Health does not have a program to promote it to families and providers. Led by the Public Health – Seattle & King County Immunization Program and funded by a grant from the Group Health Foundation, a coalition of both internal (Community and School-Based Partnerships and Family Planning Programs) and external (Neighborcare, Group Health, Odessa Brown, Swedish, Planned Parenthood, and Seattle-based primary care VFC-enrolled practices) partners is collaborating on a two-year project to increase adolescent immunizations in Seattle School-based Health Centers (SBHCs) by 1) increasing awareness of the benefits of adolescent vaccines and simplifying access to vaccination services at SBHCs, and 2) enhancing collaboration between primary care providers and SBHCs to support Tdap, MCV and HPV vaccination, with special emphasis on completion of the HPV vaccines series. Project activities include the development of student-led promotional campaigns, facilitating immunization-related events in participating schools, piloting a streamlined, digital vaccine consent process, and conducting outreach activities to private primary care providers that serve adolescents.

  • Perinatal Hepatitis B Prevention Program (PHBPP): The PHBPP is a case management program to assure preventive medications are given on time to prevent hepatitis B infection in babies born to women with hepatitis B. We know that up to 85% of babies born to mothers with hepatitis B who do not get preventive medications will themselves develop hepatitis B, most of whom will have hepatitis B for their lifetime. And, 25% of infected babies will die of liver complications later in life, often prematurely. One component of the PHBPP is to follow up with household and sexual contacts of the infected women, not just the infant. However, in King County, we have not had the resources to follow-up with the household and sexual contacts of these women to assure that they get the recommended testing and vaccination for hepatitis B.

  • Pertussis (Whooping cough). Comprehensive outreach is no longer possible. For example, while schools with pertussis cases used to receive direct outreach by phone, now district nurses receive a generic faxed notification. Whereas in the past, we ensured infection control guidance is received in clinics where people had presented with pertussis; now, we can no longer assure that healthcare providers will follow up with their patients and staff accordingly. Lastly, whereas a course of antibiotics may help prevent illness for all people who have had close contact with a pertussis case, Public Health only directly communicates with those at highest risk of infection, such as pregnant women or infants. We rely on the patients to distribute pertussis information to their close contacts, which is a suboptimal strategy.

  • Latent tuberculosis (TB): Currently, our TB program works to investigate cases of and prevent the spread of active TB. We have about 100 cases per year in King County. Investigating and treating active TB is an extremely time-intensive, expensive endeavor, requiring patients to interact with Public Health staff on a daily basis for months at a time. However, 100,000 people in King County have latent tuberculosis infection, an inactive form of the disease. About 1 in 10 people with latent TB will develop the active, infectious tuberculosis some time in their lives. To turn the corner on TB would mean working with health care providers across the county to identify and treat persons with TB, which is something for which we have no current resources.

  • Medical Examiner's Office: To provide adequate 24/7 service, KCME needs more than the current 11 Death Investigators it employs. Over the past 10 years, KCME's death investigators have decreased as population and caseload have increased from 140 to over 200 cases per year. Impacts are significant for staff and the people we serve. Investigators used to be able to respond to deaths for scene investigations in pairs. Now, in order to cover King County, KCMEO investigators are spread thinly over 24 hours and respond to nearly all scenes alone. Furthermore, the current staffing shortage leaves a single investigator covering all of King County from 10PM-6AM. The current investigator staffing model endangers employee safety, increases the risk of liability for King County, and underserves the community. The current staffing levels are barely adequate to meet the operational needs during the day. When a single Investigator is on vacation, sick, or injured, there is insufficient coverage to maintain adequate operations. Among other impacts, this staff shortage means investigators are at risk for injury and residents have to wait, occasionally for an unacceptable period of time, for KCME to respond to the deaths of their loved ones.

  • Gonorrhea and syphilis: Syphilis cases nearly doubled from 2010 to 2015; we received 289 case reports in 2010 and 444 case reports in 2015. Both gonorrhea and syphilis infections can increase HIV transmission. Furthermore, gonorrhea represents a significant risk to women's health, because, in part, of its impact on ectopic pregnancy and infertility. The increase in these sexually transmitted disease (STD) cases impacts our ability to deliver partner notification services, a key way of controlling STDs. Part of STD work involves contacting the sex partners of persons with STDs to notify them of their partner's infection and convince them of the need to seek evaluation and treatment. This notification method is labor intensive, but the alternative, which is leaving notification up to the infected person, is less effective. Between 2010 and 2015 the proportion of persons with syphilis and gonorrhea interviewed by Public Health for purposes of partner services decreased from 92% to 77%, and from 68% to 49%, respectively.

  • Environmental Health services are severely constrained when those services are not funded by permit fees. For example, lead poisoning has life-long impacts on children, lowering IQ and causing organ damage, among other impacts. Public health's role is to provide home environmental assessment and follow up when a health care provider identifies a child with elevated blood lead levels. Current levels of funding enables minimal but often delayed, case management services to families with lead poisoned children. All other primary and secondary prevention services recommended by the Centers for Disease Control and Prevention and Washington State Department of Health are not provided.

  • Public Health Informatics: Our assessment, policy development and evaluation (APDE) unit provides the core work to provide information about the health status of King County residents. For example, APDE data allows King County to know rates of infant mortality, smoking, cancer, and many other health indicators that aggregated state or federal data does not provide. This information allows Public Health and community partners to target and evaluate the success of programs and interventions. The more granular the data, the more we can pinpoint where and how to target programmatic resources. Without adequate funding, the unit cannot routinely track community health indicators (CHI) and qualitative information about the health and well-being of "small" populations who often bear the burden of ill-health, but for whom we don't have timely (if any) data to use (e.g. African immigrant subgroups, American Indian/Alaska Native, Native Hawaiian and Pacific Islander, Asian sub-groups, etc.). The data we do receive cannot be processed and analyzed in as timely a manner as our communities might expect.

  • Adequate resources for data collection and analysis are needed to identify areas for policy improvement and measure the effectiveness of policies, as well as "democratize data" by providing data trainings, workshops, and increasing overall data capacity among potential grantees. Incorporating new datasets from other non-health sectors, e.g. housing, encouraging new partnerships, and increasing our ability to provide evaluation support to other departments and the community, among other activities, is essential to help King County maintain effective and efficient programming for the health of the community.

  • Our infectious disease program lacks needed interoperable data systems between Public Health and healthcare institutions to allow for the most timely recognition and investigation of communicable diseases.

  • In the Medical Examiner's Office, the abundance of data on each death under its jurisdiction are not able to be adequately stored and analyze to show valuable information such as death trends in relation to drug abuse, firearm violence, suicide, homelessness, domestic violence, and traffic injuries. Across programs, better data systems and more up-to-date ability to analyze it would enable the department to better identify and describe health problems and target prevention programming to improve the health and well-being of our entire community.

When time permits to prepare and submit proposals, Public Health staff are extremely successful in obtaining a wide variety of competitive grants, but relying on grants to fund core work is neither sustainable nor healthy from the perspective of organizational stability. Overreliance on grants can be highly inefficient, requiring a cycle of hiring and then losing experienced staff. We are at the mercy of the program priorities of the funding agencies and lack the ability to create sustainable programs and solutions to local health priorities, particularly in our most vulnerable communities. Even so, in an effort to retain valuable personnel during budget downturns, we've avoided laying them off by shifting some of them to grants. This means that these experienced staff members are not available to improve our capacity when we need to surge our staffing, nor are they available to lend their expertise to work outside their funded area, or develop and submit new grants. Furthermore, while Public Health is renowned for having a mission-driven, highly skilled workforce, this hiring and laying off cycle undercuts our efforts to be an employer of choice and worsens our ability to hire the best possible employees

The preferable approach is to use grants as "seed money" to pilot promising practices or demonstrate effectiveness of program strategies, and then identify permanent funding for the most effective programs. However, as key public health priorities are not funded with ongoing dollars, we use grants as a stop-gap measure to fill funding gaps.

Examples of core work funded through grants include:

  • Asthma: Asthma affects 1 in 20 children and almost 1 in 10 adults in King County. Public Health houses a national award winning asthma program. Multiple regions follow and replicate our programming based on the solid evidence base that was built here. The program began in 1997 with support from 9 consecutive research and program grants. The current $3.4 million Patient-Centered Outcomes Research Institute (PCORI) grant began in July 2014 and will end July 2017. The project seeks to expand the evidence base on strategies and interventions aimed at improving asthma outcomes among low-income patients with uncontrolled asthma. This includes strategies such as home visits by community health workers (CHWs); clinical quality improvement to include guideline practices and routine asthma follow-up; and the use of novel communication pathways that reach across care teams and assures that the managed care plans, providers, and CHWs are working from the same asthma care plan. The service model overcome standard barrier with participation by the hardest to reach populations and those not easily engaged in the healthcare system. We will lose the entire asthma program if we do not have other new sources of funding. Asthma is a key health issue for families in many communities.

  • The Partnerships to Improve Community Health (PICH) grant: Tobacco use, obesity and poor nutrition are leading causes of preventable, premature death. The bulk of our work to address these health risks relies on an $8 million three year (expiring in 2017) Centers for Disease Control and Prevention (CDC) year grant that funds collaboration among Public Health, Seattle Children's Hospital, the Healthy King County Coalition, and over 25 community partner organizations to address these leading causes of preventable, premature death. It's the third competitive CDC grant awarded in King County on these topic areas in six years. While the funding has led to improved outcomes in these foundational public health services, each grant requires significant investment in grant writing, start-up time including hiring of new staff and development of community contracts. Funds are unpredictable from year to year, as CDC's budget swings with the tide of the federal budget.

  • Hepatitis C: (HCV) is the main cause of chronic liver disease, liver failure and liver transplant. Public Health received a four year, $6 million CDC "Hepatitis C Test & Cure Project" grant for Hepatitis C (HCV), a liver infection that kills more people than HIV/AIDS. Yet currently as few as 50% of HCV-infected people are aware of their diagnosis, and once diagnosed, only about one-third of patients are referred to care where a fraction of these are treated. Only five to six percent of infected people are cured. The grant is improving testing, treatment and cure of baby boomer aged people with chronic HCV infection, training for clinicians on the diagnosis, evaluation, and treatment of HCV, and enhancing the ability to track patients through better integration of clinical and public health data systems. In King County, an estimated 17,600 people are infected with HCV, with over 9,600 chronically infected. Once this grant for testing and curing expires, so will the program.

These are just a few examples of grants that fund core public health work. Through work at the state level and with partners, we are seeking state funding that will provide adequate, predictable and long term funding for these basic public health priorities.