The state of Public Health: Answers from the doctor in charge

Georgia Public Health

When Public Health became a separate state agency last July, Dr. Brenda Fitzgerald had her work cut out for her as the department’s first commissioner.

Georgia lagged behind the rest of the nation on key health statistics, and Public Health had suffered from budget cuts for years. Meanwhile, the state was still feeling the after-effects from the economic recession.

Fitzgerald, an ob/gyn, has responded with several initiatives to turn around Georgia’s health. Later this week, in fact, Fitzgerald’s agency will be part of the launch of a major state initiative to fight childhood obesity.

In this wide-ranging GHN interview, recorded last week, Fitzgerald discusses Georgia’s problems – including child obesity, diabetes, infant mortality, and HIV. She talks of solutions such as reducing the number of pre-term births and of co-sleeping deaths; cites the value of data and of public/private partnerships; and answers questions on the EMS drug shortage and a proposed increase in the state tobacco tax.

Q : When the Department of Public Health was first launched as a standalone agency last July, what were your biggest challenges?

 A: Money and mission. The funding for public health is very complicated and needed to be simplified and streamlined. And the mission of public health, in my opinion, had had some drift [when public health was part of bigger state agencies]. The clarification of what our mission was and the clarification of the money to do that mission.

Q:  How did you go about fixing that?   

A:  A couple ways. One was I hired Kate Pfirman. I had not known her, but I asked around, and said I’ve got to have the best finance person I can get, and her name kept coming up.

All the grants now are under one location, which is under Kate. Before, all the hundred different grants we had used to finance the work of public health had been in . . . separate parts of the department, and not managed by one person.

And of course, we had a lot of help from the Legislature this year in supporting the change in the grant-in-aid that goes out to the various [public health] districts. . . . That funding formula had not been changed since 1970.

Q: The Legislature held those counties harmless that would lose money under the grant-in-aid formula change, correct?

A: Yes. That will be for this year, 2012, and for 2013. We needed some time to convert to the new systems. We really wanted to be very careful so that the individual counties would not be damaged by the new grant-in-aid formula.

So the Legislature gave us two years that the increases would occur, but there would be no decreases, so we could work with those counties that would be losing money, and make sure that transition is beneficial to the people living in those counties.

Q: How do you restore the state’s public health system after years of budget cuts?

A:  I certainly think the public health of the state needs to be improved. But I believe the most important priority is the mission, not the money. We have been as a department [working] on clarifying the mission of public health.

The book “Good to Great’’ [presents]  a very interesting way of approaching how a business does business. The example they give of a great company is Southwest Airlines. In the last 30 years, Southwest Airlines has posted a profit every single year. And that was all during a time when other airlines went bankrupt. . . . and there was 9/11. But every single year they did well. The reason they did well is that they identified their mission, and they had definite priorities on what they were going to work on, and how they were going to work on it. So the important thing for Public Health is to determine what its mission is, and what it’s going to do. And the money will be OK.

Q:  What are the most important things you’ve identified in Public Health’s mission?

A: I see Public Health’s mission is to protect the lives of the people of Georgia. We clearly have to use the information we have and analyze it so that the state can see and understand what its main health priorities are, so that we can make a difference.

For example, in childhood obesity, we know from national statistics that Georgia is No. 2 in the nation in the rate of childhood obesity. And we think that unhealthy weight will lead to medical problems in the future. We looked at our internal data. We had 11 years’ worth of data. There have been increased hospitalizations of kids 2 to 19 in that time period – it had gone up 338 percent.

Q: From obesity?

A:  From obesity. That is obesity-related hospitalizations. . . . We knew that meant that we had to do something now and we had to be unified in it. This is not just a future problem; this is right now. We have been working on the governor’s plan to approach childhood obesity. The launch of that will be May 23.

Q:  Looking at other data, clearly Georgia does not stack up well with other states on other health statistics. What are you doing about problems such as infant mortality?

A: Infant mortality is another big initiative. If you’re going to be effective, you’ve got to identify what you’re going to do and stick to it.

We knew that Georgia has a problem. And we identified where in the state there were increased instances of significant clusters [of infant deaths], so we can concentrate on those areas.

[She points on a map to counties in west central Georgia]. That’s a small number of actual problems, because the population is very sparse there. They have no obstetricians in that area. So the approach to that area will be different than the other areas we identified.

Q:  And elsewhere?

A: In Lowndes County, in Valdosta, what we did is look at the incidence of infant mortality and . . . found out what the causes were. The No. 1 cause across the state is premature birth – babies born too early. The second is genetic abnormalities. The third is SIDS, with a large part of that being sleeping deaths.

I visited Lowndes County and talked to the pediatricians and obstetricians there. They put into place a program that had do to with one particular group of high-risk women for the smallest babies. They instituted a home visiting program to help those mothers. In the first year, they cut the infant mortality in that population by half. It’s called BabyLuv.

So again, you get back to the data. If we identify where the biggest problems are, we can then focus in on it. We are coming up with a statewide community plan to look at infant mortality. Dr. [Mitch] Rodriguez, who is on our board and is a neonatologist, is heading up that study committee. . . . We have brought in private partners and public partners to come up with a statewide plan to address infant mortality.

Q: So it’s already under way?

A: Yes. Part of the problem of being born too early has to do with the elective deliveries, with babies that were induced too early. We are working with the Georgia Hospital Association, the March of Dimes, and the OB/GYN Society and the pediatricians and various hospitals to come up with a statewide policy – no delivery before 39 weeks unless it’s medically indicated.

Q: The hospitals are going along with that?

A: Yes. The Georgia Hospital Association is one of the lead partners in this. We have the data, so we looked at a couple of very interesting things. If you look at elective deliveries versus spontaneous deliveries, the elective deliveries before 39 weeks have higher incidence of antibiotics, higher instances of babies being on the respirator, and higher admissions to neonatal intensive care units. We also looked at the number of weeks in the uterus, and the [child’s] standardized testing in third grade. There was statistical difference in standardized testing if you were born at 37 weeks versus 39 weeks. . . . We have that data, we have the information; we just need to make sure everyone’s doing it.

Q:  Lack of prenatal care is often a matter of a lack of health insurance.

A: Absolutely. . . . Let me talk to you about Sudden Infant Death Syndrome. That’s co-sleeping. That coalition has had beginning talks, but that’s not as far along. In Georgia, every other day, we lose a healthy baby that should have lived because of a sleeping accident. Every other day. Part of it is babies being put down on their stomachs instead of their backs, part of it is co-sleeping. That is something we can do something about.

Q: Clearly Georgia doesn’t do well on diabetes, either.

A:  The reality is the incidence of diabetes that has to do with being born with your pancreas not working is small. But if you look at our statistics in Georgia, the cause of wrong eating, by the time we reach 70 in Georgia, is 50 percent of us will be diabetic or pre-diabetic. So it is a huge incidence. So for us, the No. 1 thing is the childhood obesity, because the reality is if you have childhood obesity, you’re much more likely to have diabetes. . . .

On diabetes, we think the most important place we can make an impact is those early years. For the adults who have diabetes, I think that’s going to have to do with workplace wellness. We’re piloting some work in the department looking at insulin level as a health indicator. That work is in the beginning stages. We don’t have recommendations for workplace wellness at this point, but we’re working on that.

Q: HIV is another issue in Georgia, especially in metro Atlanta. What is the department doing to address that?

A: The most important prevention, in my mind, is treatment. If a patient with HIV [remains under appropriate treatment], there’s about a 95 percent chance that person will not pass that virus on to another human being. It’s enormously important [for a pregnant woman] and for the adult population.

Since the department became established, we are working for agendas that we decrease the ADAP [AIDS Drug Assistance Program for low-income patients] waiting list for drugs In Georgia. We have changed the appropriate patients to the Pre-Existing Condition Insurance Program [a health reform provision to help uninsured people]. We can get those patients with HIV not only the drugs they need, but also other medical care at a lesser price than we could just by buying the drugs alone. We’ve made significant improvements on that.

We have applied for additional monies for the ADAP plan from the feds. We have talked to the CDC to encourage a more lenient use of the monies that are right now destined to be used for prevention. We would like to have more flexibility to use those monies for treatment.

Q: How has the CDC responded?
A: They’re talking to us. So far, nothing has changed. But again, that’s something I would like to see. That could be a state-by-state decision. Clearly we need education, so the entire population understands about HIV/AIDS. What I want most is that we completely take care of the HIV waiting list for drugs.

The other thing I’ve done is hired Dr. Melanie Thompson, a nationally renowned HIV expert, who is coming up with a statewide HIV policy. We have not had that in the past. We intend to work carefully with the HIV community. Again, public/private partnerships  –  we think that’s the way to solve problems.

Q: What are we doing on tobacco cessation?
A: We have the quit line. One thing that was interesting to me, was when the CDC put out their new ads . . . nationwide, our quit line [volume] has gone up significantly. There are some monies provided by the feds for tobacco, and we’re looking at how can we take those increased monies and apply them directly to people calling the quit line.

Q: Would you support a higher cigarette tax in Georgia?

That’s something for the Legislature to decide. What I would support is, for those people calling our quit line, to make sure we have tobacco replacement products that are available and that we have a very effective program to deal with that.

Q:  There is a shortage of EMS drugs in Georgia and elsewhere. Does that concern you?

A: I’m concerned. Here’s what I’ve done about that. One of the biggest things with the shortage has to do with generic products. Seventy percent of our generic products are produced outside of the U.S. When I found out this was a problem, I contacted the Association of State and Territorial Health Officers. I said, it seems to me what we need to do as states is to come up with a set list of drugs that are necessary for every ambulance to have. . . . There’s financial incentive for some company to produce those medications.

We’ve instituted in Georgia getting some daily feedback from our EMS people. We’re tracking the drugs that are missing. We are looking for short-term solutions, such as drugs that can be alternatives. We are following that very closely.

Q:  Where do you see our state’s public health five years from now? 

A:  I think the governor and the Legislature were wise in establishing a separate Department of Public Health. I think that has enabled us to be open for business. I see the model we’ll use is public/private partnerships. I see that as a powerful force to move the needle.

I think we’re going to move the needle in childhood obesity, and in infant mortality.  I know we’re going to move the needle in immunizations. We’re going to be measuring these things.

Q:  At some point in time, Georgia statistics will not be at the bottom?

A: That’s right. And I’m not interested in being state No. 43 or No. 50. I don’t really want to measure us by how we measure up to Texas. I want to measure us by how we are improving our statistics. . . .

What we’re going to do in Georgia, in public health, we’re going to improve childhood fitness and [childhood]  immunizations every single year. From 2010 to 2011, for our children up to 24 months, we went from 76 percent rate of immunizations to 82 percent statewide.

In immunizations, we’re working with school districts and Georgia pediatricians, and we’ll have a statewide flu project that’s coordinated.