RAND Report Raises Concerns About Parts of California Public Health System

For Release

June 2, 2004

California’s public health system is not adequately prepared to deal with a major disease outbreak and other significant challenges, and the level of preparedness varies widely across the state, according to a RAND Corporation report issued today.

The report, which concluded that there is poor coordination among public health agencies at both the state and local levels, raises concerns that parts of the public health system can’t adequately protect the public in the event of an emergency.

Overall, California’s public health agencies have made progress planning for infectious disease emergencies such as smallpox, the study found. However, the public health system is not uniformly capable of taking care of infectious disease outbreaks and other important challenges, such as chronic disease prevention and control, according to the report.

In some communities, the attention given to bioterrorism preparedness efforts and budget cuts that have reduced the number of public health personnel or eliminated programs, have diverted attention from other public health priorities, the RAND Health study found.

As a result, some communities have reduced or eliminated important public health programs and services. Examples of this include contact tracing for sexually transmitted diseases and programs designed to prevent teen pregnancies. The unintended consequences of these changes could lead to future public health emergencies, the report warns.

Researchers urged California lawmakers to appoint a high-ranking commission to examine the organization and appropriate roles of the state’s public health system. The purpose of the commission would be to identify concrete steps that could strengthen statewide public health leadership and the public health workforce, and to improve state-local relationships.

“The level of protection you have depends on where you live and not whether you choose an urban or rural lifestyle,” said Dr. Nicole Lurie, lead author of the report and the Paul O’Neill Alcoa Professor in Policy Analysis at RAND. “More engaged leadership from the state Department of Health Services is critical to improving the system.”

Researchers urged state leaders to create an objective set of standards for public health preparedness, and to measure and test the standards regularly.

California’s public health system is charged with protecting the state’s population from current and future threats such as communicable diseases, as well as promoting practices that can improve the health of the state’s residents.

Researchers estimated that an additional $96 million annually is needed to bolster the ability of local public health systems to respond to bioterrorist attacks and to other naturally occurring infectious disease outbreaks.

However, centralizing some functions—such as training public health department staff and providing epidemiological and laboratory services at either the regional or state levels—could speed improvement and lower the cost of the effort, according to the report.

The RAND study did not estimate the amount of additional money that would be required for local health departments to combat chronic diseases, or to provide health promotion and disease prevention services.

The findings were published in two related reports—one as a web exclusive of the journal Health Affairs and the other on the RAND website. Lurie and her colleagues also will present their findings today at a hearing of the state Senate Health Committee in Sacramento.

Researchers from RAND Health examined California’s public health system at the urging of the state’s Little Hoover Commission, formally known as the Commission on California State Government Organization and Economy.

Funding for the work was provided by the California Endowment, with additional support from Kaiser Permanente.

Researchers closely examined preparedness efforts made in seven of the state’s 61 local health jurisdictions, visiting each department and conducting “table-top” simulations of a smallpox outbreak for those jurisdictions during the fall of 2003. The jurisdictions examined included both urban and rural areas, and account for 39 percent of the state’s population.

In addition to providing information about preparedness, the study examined other aspects of California’s public health infrastructure, researchers said.

There was substantial difference of opinion among local public health officials about what they should do when faced with a specific bioterrorism-related public health emergency, including what other agencies should become involved when such a crisis develops.

While better-prepared jurisdictions tended to be larger, researchers said those that were best prepared seemed to make more flexible use of their staffs. Those jurisdictions also carried out more planning, and tested their plans with police and other first responders. In addition, such jurisdictions were clearer about their legal authority and had stronger relationships with the fire, emergency medical services, and law enforcement communities.

“The jurisdictions that were best prepared benefited from a health officer who demonstrated leadership and had fostered leadership skills among the staff,” said Robert Valdez, a co-author of the report and a RAND senior analyst. “This underscores the need to train and nurture public health leaders across the state. While we have some great public health leaders, the state faces impending retirements of experienced key individuals and a lack of public health leadership and succession planning.”

Health departments said one of their top needs is a robust information system that would automate regular disease reporting from laboratories and hospitals, as well as aid many other critical operations, according to the report. Officials in most jurisdictions also said the state Department of Health Services could not be counted on in an emergency, other than for the services offered by the state’s public health laboratory.

Although not a primary focus of the study, the researchers also explored issues related to diabetes prevention and control for insight into how health jurisdictions address chronic health issues. Researchers found significant variation not only in the level of chronic disease prevention activity, but in views about the extent to which chronic disease prevention was part of what health departments should be doing.

The Trust for America’s Health recently ranked California as one of the four best-prepared states in a nationwide survey of state public health infrastructure and preparedness to respond to a bioterrorism attack.

“The fact that one of the nation’s best-prepared public health systems has so many shortcomings shows that the investment in the public health infrastructure needs to be expanded and sustained,” said Shelley A. Hearne, executive director of the Trust for America’s Health, a nonprofit health advocacy group.

Since the terrorist attacks of Sept. 11, 2001, federal lawmakers have allocated about $3 billion in grants to the states to strengthen the nation’s public health infrastructure. Funds allocated to California have been slow in getting to the local jurisdictions to make necessary improvements, according to the RAND report.

While the federal grant money provides an opportunity to help improve the state’s public health system, the state’s continuing fiscal troubles also present an obstacle to improvement, according to the RAND report.

Other authors of the report are Jeffrey Wasserman, Michael Stoto, Sarah Myers, Roger Molander, David Mussington, Vanessa Solomon and Steven Asch.

RAND Health is the nation’s largest independent health policy research organization, with a broad research portfolio that focuses on health care quality, costs, and delivery, among other topics.

The study was conducted by the RAND Health Center for Domestic and International Health Security, which seeks to make health a key component of U.S. foreign policy, strengthen the preparedness and response of the U.S. public health and health care systems to terrorism, and prepare Americans to cope with the psychological effects of terrorism.

About RAND

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