Strengthening Public Health

Chronic underfunding has created ongoing gaps that public health nurses are doing their best to fill.

By Adrienne Coles

PAM KEEN has been a public health nurse in Akron, Ohio, for 23 years. In that time, she has seen services dwindle and programs for her community pared down because there isn’t money to fund them. “When I first started working, we were able to give our clients supplies like diapers and baby wipes, but that has changed,” says Keen, who works for Summit County Public Health.  She works with a program called Bureau for Children with Medical Conditions that is run by the Ohio department of health. She is a member of the Ohio Nurses Association.

Public health departments at all levels of government have been chronically underfunded for decades, which has created ongoing gaps in services. No one knows this better than nurses like Keen. States rely on a combination of federal, state and local funds to support public health services like immunization programs, infectious disease prevention efforts, and other prevention programs. Funding for public health is discretionary in many states, which means funds are often at risk when budget cuts are necessary.

Stable and sufficient funding is crucial to ensure that communities across the country have the basic capability to keep their residents healthy. The Ebola cases diagnosed in the United States last year should have been a wake-up call about the need to increase funding for public health. Looking beyond Ebola, there are many other emerging diseases that are on the radar of public health officials—pandemic flu, Enterovirus D68, and MERS-CoV—which shows that the threat of infectious disease can arise with no warning; in addition, there was a nationwide outbreak of measles and whooping cough this winter.

Inconsistent and inadequate funding weakens the system and the ability of public health workers to respond to outbreaks. Today, health departments are doing more with less; and public health workers are forced to be more innovative to get and maintain funding for programs that serve their communities.

In written testimony for a U.S. Senate Committee on Appropriations hearing last November titled, “U.S. Government Response: Fighting Ebola and Protecting America,” AFT President Randi Weingarten noted that layoffs and attrition have reduced the number of public health employees “at a time when additional trained public health professionals are urgently needed in our communities.”

“We are now witnessing the shortsightedness of these disinvestments,” Weingarten wrote. “Underfunded state and local health departments and an under-resourced Centers for Disease Control and Prevention complicate local efforts to respond effectively to crises. This also makes it difficult for hospitals and other healthcare institutions to follow and implement CDC guidelines and ensure that nurses and health professionals have the training and equipment they need to keep themselves, their patients and their communities safe.”

Building healthier communities

A big part of the work that public health workers do is building healthier and stronger communities through prevention programs. But their work often is hampered due to a lack of funding. In Ohio, Pam Keen’s health department also is contending with cuts to nurses and other staff. “The cutbacks on the number of nurses have increased the caseload from 200 to 300,” says Keen. “I used to be able to provide more hands-on service, but now I do more of my work over the phone.”

The inability to have the necessary time with clients makes the job of being a public health nurse more difficult. In-person contact with clients is essential, says Keen. “How do you assess a child over the phone? How do you help clients better understand the needs of their child if I can’t see what’s happening in the home? I can learn a lot just from being in the home environment.”

For the time being, nurse visits are often farmed out to medical assistants or social workers. That means the clients will not get the patient education they need, says Keen. “As an RN, I can give the support, time, comfort and care that’s needed.”

The Ohio Nurses Association has worked with its members to fight for the resources they need—lobbying state lawmakers for increased public health funds and focusing on grant funding. “We have tried to show the administration that we want to be part of the cure,” says Keen.

Keen and her colleagues also make it a point to be visible in the community. “Clients understand our role in their lives, but we want the community as a whole to understand the advantages of focusing on public health. We can’t wait until there is a crisis to fix the system; we have to focus on prevention.”

Communities for public health

Last year, public health nurses in Seattle’s King County, many of whom are represented by the Washington State Nurses Association, learned that four public health clinics in the county were slated for closure in 2015 because of a budget shortfall. The nurses knew the impact that the elimination of these services would have on the community, especially on its most vulnerable populations. So the nurses began mobilizing WSNA members and engaging others in the community to save the county’s public health services through a coalition campaign they called Communities for Public Health.

The loss of the clinics would have been devastating, says WSNA member Hanna Welander. The proposed budget cuts put a range of services for King County residents in jeopardy, including clinics that provide adult and pediatric primary care services; disease prevention programs that track and respond to outbreaks of tuberculosis, whooping cough, measles and other public health threats; maternity support services; and vaccination clinics.

“Our public health nurses stave off health problems that can show up down the line by addressing health issues from the start,” says Welander. “We have been doing this work for decades. The programs we run are preventive, and they work. To see these programs being chipped away is tragic.”

As a part of their Communities for Public Health campaign, the nurses began to show up in large numbers at City Council meetings, county fairs, weekend farmers markets—wearing red T-shirts that said “Danger! These Cuts Can Kill.” The nurses educated the community about the possible clinic closures and what their absence would mean to residents who relied on the clinics’ services. The nurses also used their lunch hours to demonstrate, wearing their red T-shirts, holding signs and gathering signatures for petitions to save the clinics.

“People were stunned that these services were going to be eliminated,” says Welander.

Several weeks into the campaign, the tide began to turn.

One of the clinics slated for closure was provided additional money to keep its doors open. In turn, all of the public health workers—including managers and directors—voted to freeze their longevity and step increases for two years in exchange for a guarantee that at least one more clinic would be saved. In the end, the campaign managed to save all four facilities.

“Public health funding should never be cut; but it’s seen as expendable. It’s not,” says Welander. “I understand the importance of public health programs, so that has put the fire in my belly to try and save them.”

Welander believes the campaign worked because the community and its officials were committed to keeping the clinics open. “People saw that the programs were not about a handout” but instead offered a way “for people to help their families and themselves.”


Healthwire, Spring 2015 Download PDF (592.85 KB)
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Healthcare on the go

Access to care is a priority in public health. Thanks to a program initiated by the Cleveland Teachers Union’s school nurses, hundreds more Cleveland Metropolitan School District students in need of medical care are getting it. The nurses worked closely with the school district and MetroHealth, a hospital system in the area, to provide primary care to students at risk of not receiving care.

Students in need of care did not have access to the healthcare system, says Patricia Forrai-Gunter, CTU’s school nurse chapter chair and member of the executive board. “We chose to work with this system because 85 percent of our student population who do receive care get it from emergency rooms in the hospital system.”

Two mobile clinics have come to the rescue. The mobile clinics are equipped with two exam rooms that are used daily by MetroHealth medical professionals who travel to schools to provide care for kids during the school day. Students whose parents give consent can receive primary and preventive healthcare, including sports physicals, routine check-ups and immunizations. The program also helps students manage chronic diseases like asthma and diabetes, and offers referrals for additional services, including behavioral health. The school nurse coordinates appointments for clinic visits. “This is an amazing partnership between the educational and medical setting where the school nurse keeps the focus on a balance between a student’s health needs and education,” says Forrai-Gunter. The program is expected to expand to as many as 22 Cleveland schools in the next two years, which will give more than 5,800 students access to both primary and preventive care.