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L.A. County Health Services Still Falter Despite U.S. Aid : Supervisors should heed warnings in UCLA report

September 28, 1997

Despite having received $536 million in federal emergency funding since 1995 to expand preventive and primary care services, Los Angeles County's Department of Health Services continues to be plagued by what a new UCLA report calls an inability to perform basic public health care functions like monitoring epidemics and offering community health and disease prevention programs.

The failure of the federal aid to ease the problems should send a clear message to the county Board of Supervisors, which will open hearings Tuesday on the UCLA report: Simply using money to patch holes in a rickety ship will never be enough to keep it from sinking, only a thorough overhaul will do.

The UCLA study points out that the county, in struggling to protect its emergency care operations, has given short shrift to its preventive public health programs. The point is undebatable, for L.A. County's appropriations for such programs have declined 24% since 1992.

The supervisors must be careful to ensure that any new dollars they allocate to public health programs are tied to the swift implementation of reforms. The most critically needed of these reforms is the granting of more authority to the department's district health officers, or DHOs. While DHOs are technically responsible for identifying and meeting health needs in their communities, the UCLA study says they lack the information, authority, training and budgets to do so. Thus most public health decisions are made at Department of Health Services headquarters, which is increasingly unable to keep track of the county's burgeoning, ethnically diverse population. So it should not be surprising that public health problems have been escalating since 1988, when a measles epidemic struck hundreds of children, killing 40, largely because the county lacked a good system for immunizing preschool children.

The most effective public health innovations in the United States in recent years have spun not out of lumbering, centralized bureaucracies but rather from empowered community-based public health officers sensitive to specific health needs. One partial model for change is San Diego County. Its system is far from perfect, for it extends services only to those who meet overly restrictive "medical severity" tests. But the county has won deserved recognition for economically providing important public health services by freeing community-based outpatient clinics from the kind of governmental red tape that prevents many Los Angeles health leaders from exploiting a variety of private and public funding sources.

Unlike the county's emergency medical services, which are often glamorized on television, its public health programs operate in relative obscurity. As the director of the UCLA study, Dr. Lester Breslow, put it, "Public health is responsible for a lot of things that don't happen, and it can be difficult to arouse people's concern about things that don't happen."

When they begin discussing the study this week, the supervisors should remember Breslow's words.

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