Health Department White Paper

By David Landau

One of the most important issues facing Delaware County today is the decline of public health. Unlike neighboring Montgomery, Chester, and Bucks counties, we have only an `Office of Intercommunity Health' which is limited to "implementing a health coordination program."

Delaware County is currently the largest county in Pennsylvania without a county health department. The lack of a health department severely diminishes the county's ability to implement preventative practices that lead to a higher quality of life. Furthermore, our superb private medical care providers are unable to procure certain state grant money for public health services because the state requires a county health department as a partner. Creating a county health department will allow Delaware County to maintain a mission of preventing illness and injury through preventative medicine and education in partnership with the private sector.

The Issues:

Delaware County falls short in virtually all aspects of public health. Our current office of inter-community health of just four people is undersized, understaffed, and unable to meet the public health needs of our county. As a result, we are forced to rely on nonprofit organizations, the charity of the private sector, and the underfunded health inspection efforts of our cash-strapped municipal government. The result has been insufficient promotion of preventative measures, strict inspection standards, community awareness, and health education for Delaware County citizens.

This insufficiency is apparent from Delaware County's historical medical trends. The goals set forth by the Federal Healthy People 2000 and Healthy People 2010 (HP2010) programs in many of the 28 major areas of indicators health serve as sobering reminder that Delaware County is not doing enough to promote health and well-being. Some of the major HP2010 areas in which important indicators of health fall below the expected goals are Access to Health Care, Maternal and Child Health, Responsible Sexual Behavior, Cardiovascular Health Improvement, Early Detection of Cancer, and Wellness/Fitness.

Particularly alarming trends emerge in the areas of Maternal, Infant and Child Care and Wellness/Fitness. In the area of Maternal, Infant, and Child Care, low birth weights in Delaware County have increased over the past five years. In the area of Wellness/Fitness, the number of Adults who have visited a physician in accordance with an accepted periodicity schedule has declined from 94.5% in 2004 to 83.4% in 2006. The number of children who visited a physician in accordance with an accepted plan dropped from 98.7% in 2004 to 91.1% in 2006. Also in the area of Wellness/Fitness, the percentage of children who are obese has risen from 11% in 1988-1994 to 24.5% in 2006.

Our neighboring counties have long had county health departments to support the mission of keeping their citizens healthy. Delaware County's lack of a health department is contributing to a decline of some indicators of health in key areas, raising the level of risk. We need to implement a change in order to preserve the health and well-being of the citizens of Delaware County through preventative medicine and education.

The Plan:

We need to create a County Health Department. Our County Health Department would have four major areas of responsibility: Public Health and Illness Prevention, Educational Programs, Food and Water Inspection, and Health Coordination Services.

I. Public Health and Illness Prevention

1. Immunization and Communicable Disease Prevention

Over the past five years, the rate of vaccination in children aged 19-35 months has actually fallen. After failing to meet the Healthy People 2000 target of 90%, we are currently failing to reach the HP2010 target of 90% as well with a reported rate of 77.3%. A Health Department coordinated vaccination and immunization program such as the programs available in Montgomery, Bucks and Chester counties would increase our rate of vaccination and become our first line of preventative care.

Out of the last 10 cases of measles to occur in Pennsylvania, nine have been in Delaware County. This kind of communicable disease transmission can be prevented by strong immunization campaigns at both an adult and pediatric level. Our peer counties also feature education programs about disease communication which serve as a preventative measure to halt the spread of disease. Delaware County is clearly in need of similar programs.

2. Chronic Disease Prevention

Statistics show that the rates of death by cancer in Delaware County exceed the Pennsylvania average of 200.8 per 100,000 people by 6.3 cases. This statistic includes higher than average rates of death by lung cancer (PA: 54 per 100,000 Delaware County: 58.5), breast cancer (PA: 27.6, Delaware County: 29.3), and colorectal cancer (PA: 21.4, Delaware County: 23.3). Studies consistently show that the single most significant factor in treating cancer is early detection. Our peer counties have cancer screening programs to help diagnose cancer as early as possible. A health department could create partnerships with some of the private cancer specialists in Delaware County in order to serve the public.

Chronic disease prevention also means preventing cardiovascular disease. Delaware County's rate of death by Stroke has risen over the past 10 years while the Pennsylvania average has fallen. Our current death by Stroke rate is at 61.8 cases per 100,000 people while the PA average is 54.6 cases by 100,000 people. Obesity and unhealthy weight rates remain alarmingly high (63.9% of all adults in Delaware County), as do the rates of adult and adolescent smokers (20.6% and 23% respectively). A county health department in partnership with the private sector could offer cholesterol screening to citizens as well as providing nutrition and exercise information and a smoking cessation program.

3. Women's Health

The 29.3 deaths per 100,000 people due to breast cancer in Delaware County remains higher than the Pennsylvania average of 27.3 cases per 100,000 and above theHP2010 target of 22.3 per 100,000. This is particularly alarming given that Delaware County has the third-highest rate of breast cancer in Pennsylvania. The percentage of women who have had a breast exam by a professional has remained stagnant in Delaware County over the past 6 years, as has the number of women who have had a mammogram. Our neighboring counties offer breast exam and mammogram services to aid in early cancer detection. Delaware County must do the same, particularly focusing on at-risk Latino and Asian populations who fall below the average in having had a breast exam or mammogram.

Cervical cancer remains an issue for the women of Delaware County as well. The percentage of women that have had preventative testing for cervical cancer in Delaware County has remained stagnant at about 81%, which not only falls below the HP2010 target of 90% but falls below the Healthy People 2000 target at 85%. We are now behind in reaching these targets. A county Health Department could supplement the cervical cancer screening services of the private sector to prevent the rise of this deadly but easily preventable and detectable cancer.

4. Maternal and Child Healthcare

The percentage of women who receive adequate prenatal care in Delaware County is not only alarmingly low at 54% in 2004 but has fallen dramatically since 1998, when the percentage was 60%. We now have the largest gap (13 points) in the past 6 years between the PA average of mothers who receive adequate prenatal care (67%) and the average of Delaware County mothers who receive adequate prenatal care at 54%. While rates of prenatal care have declined there has been a concurrent rise in the rates of infants with a low or very low birth weight of below 5.5 lbs, from 7.6% in 2001 to 9.4% from 2002-2004. Our average now falls above the PA average of 8.8% and the national average of 8.1%. There has also been a concurrent rise in the infant death rate per 1,000 births from 6.1 in 2001 to 7.9 in 2004. The rates for all three measures of maternal and child healthcare are all significantly higher in minority populations- in 2004, the infant death rate per 1,000 births was 6.0 for Caucasians and 14.9 for non-Caucasians.

The County Health Departments in our neighboring counties allow for the procurement of Title V grant money from the Federal Maternal and Child Health Bureau to provide home visits by medical professionals to expecting and recent mothers. These services are best provided through partnerships with the private sector, but the grant money is unavailable to the county or to private healthcare providers with public healthcare programs such as Crozer Keystone Health Systems in Delaware County without a county Health Department as a partner.

A county health department would allow for the procurement of grant monies that would provide pre-natal healthcare and educational resources to expecting mothers. This is one of the most vital areas of need in Delaware County. While a number of private medical care providers have the personnel, expertise and equipment necessary to make a critically needed contribution, they are unable to secure funds without a County Health Department to act as a partner.

5. STD Testing and Treatment

While the rates of newly discovered cases of AIDs and HIV have fallen over the past ten years in Delaware County, this trend is mostly attributable to national awareness campaigns sponsored by large nonprofit organizations and the Federal government. The number of deaths due to HIV and AIDS in Delaware County however remain appreciably above the Pennsylvania average. Furthermore, rates of some other sexually transmitted diseases have skyrocketed. The number of Chlamydia cases per 100,000 people has risen from 148.6 in 1997 to 234.8 in 2004. The rate of Gonorrhea infection remains substantially higher than the HP2010 target of 19 cases per 100,000 people.

STDs are costly to treat and easily preventable. Any approach to STD treatment and reduction must begin with preventative measures. While prevention begins with education about the hazards of risky sexual behavior, it continues with treatment. Treatment of STDs can be considered a preventative measure as well, as those with STDs have demonstrated sexual activeness and engagement and are thus likely to transmit disease if left untreated.

A Delaware County Health Department could offer free HIV/AIDS testing in order to promote awareness and lower the risk of transmission. A comprehensive approach would mean partnering with non-profits, school systems and Health Systems with public outreach programs to provide education and treatment.

II. Educational Programs

Despite its considerable resources, Delaware County lags far behind not only neighboring counties but also the Pennsylvania average for Educational and Community-Based Programs. The generally accepted measure of these programs is the percentage of public Elementary, Junior High and Senior High schools with a nurse to student ration of at least 1:750. While the average Pennsylvania county achieved this in 54% of schools, Delaware County's rate was 29.4%- the 8th lowest in the state.

Educational programs serve as a primary preventative practice, featuring low cost solutions to the high cost of illness. Nutrition and physical activity education have been proven to lower obesity rates, leading to lower rates of cardiovascular illness. Responsible Sexual Activity educational programs for adults are likewise proven to reduce the instance of sexually transmitted diseases and related illness. In almost every example educational programs are proven to produce results through promoting awareness. Our peer counties all offer at least basic educational programs, whether through partnership with the private sector or through direct provision. Delaware County relies on public health initiatives by private sector medical practices, leaving gaping holes in any effort to provide comprehensive educational assistance.

A Delaware County health department in partnership with the private sector would offer educational programs available for free to any organization that requested the information. Such programs would potentially include:

-Fire Safety -Water Safety -Nutrition
-Injury Prevention -Sun Stroke Prevention -Healthy Cooking Practices
-STD Prevention -Family Planning -Child Safety
-Senior Safety -Child Car Seat Checks

III. Food and Water Inspection

We must be able to trust that the restaurants at which we eat are safe and that the water we drink is clean. Our current system allows for separate community health standards in each municipality. Inspection is required by a municipal health officer, often an overworked and undertrained multi-municipal employee. Oftentimes cash-strapped municipalities do not have the resources to hire well trained or experienced health officers.

If there is no community health officer, inspection is left to the State Department of Agriculture. Statistics show that when the Department of Agriculture is responsible for inspection, establishments and wells are likely to be inspected once every two years. When county or well-trained municipal health officials are responsible, eateries and water providers/wells are inspected at an average rate of 1.6 to 1.8 times a year- almost twice a year.

A county health department would allow for proper training and oversight of health inspectors. Proper training and oversight would decrease food and water borne illness like Salmonella poisoning, of which Delaware County's species incidence rate is 14.4 cases reported per 100,000 people, which is above the Pennsylvania average. Our current system places far too much responsibility on municipalities, who are left to fend for themselves without the resources necessary to do so. The county should take the lead in assisting the municipalities' inspection efforts and in developing inter-community plans for food and water safety.

IV. County Health Coordination

1. Emergency Preparedness

We currently do not have a finalized Pandemic or Strategic National Stockpile (SNS) plan in place, although one is under development. A health department would bring together the medical resources of the county and allow for more effective development and implementation of a plan. It would also provide a central source for information, a vital need in the case of emergency of epidemic sickness.

2. Public-Private Coordination

A county health department would allow Delaware County to take advantage of the extensive private medical sector. It would do so by serving as a coordinator for communication between private sector services and supplementing these services by helping the private sector's public outreach initiatives procure funding from the State and federal government.

3. Emergency Responders

A county health department would continue to coordinate emergency medical response in the same manner as the current office of inter-community health, by working with the Department of Emergency Services. The Health Department would also continue to coordinate EMT and EMS classes and continuing education efforts amongst emergency personnel.