A review of a recent economic surveillance survey by the National Association of County and City Health Officials (NACCHO) finds that despite modest improvement, local health departments in the United States are still struggling to recover from the recent recession. NACCHO administered the survey as part of the National Profile of Local Health Departments in 2012, prior to the 2013 sequester cuts.

Just under 80 percent of the 2,700 local health departments in the country responded to the survey, which included questions about budgets, staffing and program cuts. Close to half of the health departments responding to the survey reported reductions in, or elimination of, services in at least one health department program area for last year, and 27 percent reported budget cuts. Analysis of the survey results also found that local health departments lost 43,900 jobs through layoffs or attrition since 2008. While positions remained stable last year, many local health departments have been unable to fill positions that were cut in previous years.

The survey also found that certain program areas have been especially hard hit by budget cuts, including immunization (22 percent of local health departments faced cuts ); emergency preparedness (15 percent); and maternal and child health (15 percent).

“While workforce reductions and program cuts may have slowed in some areas of the country in 2012, on the whole, the budgets of our nation’s local health departments are not keeping pace with the general recovery,” said NACCHO Executive Director Robert M. Pestronk. “In fact,” added Pestronk, who previously served as the director of Genesee County health department in Michigan, “continuing annual draconian cuts associated with sequestration will further erode local health departments’ capacity to serve and respond. If keeping people healthy and safe is a priority, then we should rebuild local response capacity and health security, not keep cutting it.”

Examples of the impact budget cuts have had on health departments include:

• The Boston Public Health Commission (BPHC) was forced to limit its support of prenatal care services due to a five percent cut in federal funds for the Healthy Start Initiative. Other cuts resulted in the Health Commission losing community health worker positions that provided home visits to young families; case management for children and teens at risk of truancy; and services at school-based health centers.
• Because of statewide budget cuts to local health departments in Maryland in 2009, the state’s Frederick County Health Department eliminated a third of its nursing positions. Before those cuts that health department held three flu clinics simultaneously, but now supports one clinic at a time, which has reduced the number of residents getting vaccines and keeps the department from achieving its public health emergency preparedness goals.

NACCHO’s economic survey and analyses is supported by the Centers for Disease Control and Prevention and by the Robert Wood Johnson Foundation.

>>Read NACCHO's release on the new survey.

The Supplemental Nutrition Assistance Program (SNAP) is the federal government’s principal program for helping low-income families purchase enough food. More than 47 million Americans currently receive SNAP benefits; approximately half of the beneficiaries are children. As part of the debate over the Farm Bill—legislation that authorizes SNAP and other federal nutrition programs—Congress is considering legislation that would cut SNAP benefits and limit who qualifies for the benefits.

Yesterday, the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts, released a white paper that provides a rigorous, objective and nonpartisan analysis of the potential health impacts of the proposed changes to SNAP.

NewPublicHealth spoke with Aaron Wernham, MD, director of the Health Impact Project, along with lead researcher Marjory Givens, to learn more about the study’s findings.

NewPublicHealth: What is the goal of the health impact assessment on the potential changes to the SNAP program?

Aaron Wernham: Congress is deliberating reauthorizing the U.S. Farm Bill, and one of the parts of that is the Supplemental Nutrition Assistance Program or SNAP, which was formerly known as food stamps. This is one of the federal government’s main programs for ensuring that people who have low incomes are able to get enough to eat. We did this health impact assessment because so far the public health effects of these proposed policy changes have not really been a part of the political debate. We wanted to make sure that the best available public health evidence was brought to bear to help ensure that everyone has complete information—those affected by the change, the general public and decision-makers in Congress.

NPH: What’s the big picture on what SNAP has to do with health in the first place?

Wernham: Not having enough to eat—or being what’s called “food insecure”—is attached to a higher risk of a lot of diseases. So, adults who are food insecure have a higher risk of heart disease, high blood pressure, diabetes and some other problems. Children who are food insecure are more likely to be reported by their parents as being in poor health, are more likely to be hospitalized and also have a higher risk for a number of health related problems from asthma, to depression and anxiety. We actually have a number of studies that have looked at the health benefits of receiving SNAP and found, for example, that adults who had access to SNAP when they were children are less likely to have problems in adulthood, such as obesity, high blood pressure and heart disease.

NPH: What did the health impact assessment find?

Wernham: We looked at ways in which the House and Senate have proposed to change how eligibility for SNAP benefits is determined and how the amount of benefits is determined. Both the House and Senate have proposed changes, and we found that as many as 5.1 million people could actually lose eligibility under changes proposed by the House. Under the changes in the Senate, about 500,000 people might receive lower benefit amounts. With the House changes, as many as 1.4 million children and nearly 900,000 older adults would be among those five million people who could be affected. So, for those people, they would lose upward of an average of 35 percent of their total income and would be at higher risk for the health problems that relate to food insecurity.

Tainted Salad Mix Linked to Parasite Outbreak in Two States; 13 Other States Still Looking for Answers
State and federal health officials have narrowed in on a prepackaged salad mix as the possible source of a cyclospora outbreak that has sickened 370 people in 15 states. Both Nebraska and Iowa officials have identified the salad as the source; a total of 221 people in those states have fallen ill so far from the stomach-sickening parasite. The U.S. Food and Drug Administration (FDA) is still working to identify the cause in the 13 other states. “FDA will continue to work with its federal, state and local partners in the investigation to determine whether this conclusion applies to the increased number of cases of cyclosporiasis in other states,” the FDA said in a statement. ”Should a specific food item be identified, the FDA, the U.S. Centers for Disease Control and Prevention, state and local partners will work to track it to its source, determine why the outbreak occurred, and if contamination is still a risk, implement preventive action, which will help to keep an outbreak like this from happening again.” Read more on food safety.

New Model Shows Kids Consuming Far More Calories than Previously Realized
It takes far more calories for kids to gain weight than was previously realized, according to a new study in The Lancet Diabetes & Endocrinology. And, given the high rate of childhood obesity, this means kids are consuming far more calories than either their parents or health care providers realize. The new caloric model takes into account the energy requirements for boys and girls; the fact that kids generally have higher metabolisms than adults; the average drop in physical activity as kids age; and the energy required to maintain a bigger body size as they age. Whereas the old model said a normal-weight girl at age 5 would need to consume about 40 extra calories a day to be 22 pounds overweight by age 10, the new model shows its actually 400 extra calories. "Importantly, given the rather large calorie excesses fueling childhood obesity, this model is a rebuttal to the food industry arguments that exercise alone can be the answer," said David Katz, MD, director of the Yale Prevention Research Center and editor of the journal Childhood Obesity, who was not involved in the study. "For our kids to achieve healthy weight, control of calories in, not just calories out, will have to be part of the formula." Read more on obesity.

Sequester to Close all HUD Offices on Friday, August 2
Every office of the U.S. Department of Housing and Urban Development (HUD) will be closed on Friday, August 2 as part of the sequester which is being felt across all of government. The automatic spending cuts took effect March 1. HUD’s plan is to pair its seven required furlough days with holidays and weekends. HUD is encouraging people and businesses that work with the agency to plan around the schedule day of shutdown. Read more on budgets.

NIH: Greater Physical Activity Linked to Lower Stroke Risk
People who exercise vigorously enough to work up a sweat are at reduced risk for stroke, according to a new study in the journal Stroke. Inactivity is one of the main risk factors for stroke, along with high blood pressure, diabetes and smoking. Researchers found that inactive people were 20 percent more likely to experience a stroke or transient ischemic attack (TIA) than subjects who exercised at least four times a week. Researches utilized data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a long-term study funded by the National Institutes of Health’s National Institute of Neurological Disorders and Stroke that looks at the reasons behind the higher rates of stroke mortality among African-Americans and others in the Southeastern United States. “Our results confirm other research findings but our study has the distinct advantage of including larger numbers, especially larger numbers of women as well as blacks, in a national population sample so these provide somewhat more generalizable results than other studies,” said Virginia Howard, PhD, senior author of the study from the School of Public Health, University of Alabama at Birmingham. Read more on stroke.

Study: Calorie Guidance on Menus Doesn’t Lead to Healthier Eating
Research had already shown that providing calorie counts on restaurant menus did little to improve food selection. New research now shows that offering general daily or per-meal calorie guidelines also does little to help people make healthier eating choices, according to a study in the American Journal of Public Health. "The general inability of calorie labeling to result in an overall reduction in the number of calories consumed has already been pretty widely shown," said study lead author Julie Downs, an associate research professor of social and decision sciences in the Dietrich College of Humanities and Social Sciences at Carnegie Mellon University. "So that's nothing new. But in the face of that, there has been the growing thought that perhaps the problem is that people don't know how to use the information without some framework, some guidance." Instead, the study found that people given calorie guidance not only didn’t make overall better use of calorie labeling or consume fewer calories, but they actually consumed slightly more calories. Lona Sandon, a registered dietitian and assistant professor of clinical nutrition at the University of Texas Southwestern Medical Center at Dallas, said the findings help illustrate that “[k]nowledge is just one piece of the puzzle. We must consider people's attitudes, beliefs and values surrounding healthier eating and body weight.” Read more on nutrition.

Sequester to Close all HUD Offices on July 22
Every office of the U.S. Department of Housing and Urban Development (HUD) will be closed on Monday, July 22 as part of the sequester which is being felt across all of government. The automatic spending cuts took effect March 1. HUD’s plan is to pair its seven required furlough days with holidays and weekends. HUD is encouraging people and businesses that work with the agency to plan around the schedule day of shutdown. Read more on budgets.

A new report funded by the Robert Wood Johnson Foundation (RWJF) and produced by the University of Michigan Center of Excellence in Public Health Workforce Studies offers—for the first time ever—a comprehensive assessment of the state of nursing and nurses in state and local health departments. Enumeration and Characterization of the Public Health Nurse Workforce: Findings of the 2012 Public Health Nurse Workforce Surveys looked at—among other things—size, composition, educational background experience, retirement intention, job function and job satisfaction of nurses.

RWJF recently spoke with Paul Kuehnert, MS, RN, CPNP, team director of Public Health at RWJF, and an alumnus of the RWJF Executive Nurse Fellows program, to discuss the report.

Among the report’s findings is that while public health nurses report high levels of job satisfaction, they’re also concerned with issues such as job stability, compensation and the lack of opportunities for advancement. It also found that about 40 percent of public health departments have “a great deal of difficulty” hiring nurses.

“It should be a high priority to address gaps and take steps to strengthen the public health nursing workforce,” said Pamela G. Russo, MD, MPH, RWJF senior program officer. “Public health nurses are likely to need training to keep pace with the changes as health care reform is implemented and public health agencies focus more on population health. The size, makeup, and preparation of the public health nursing workforce greatly affect the ability of agencies to protect and improve the health of people in their jurisdictions.”

Read the report and recommendations from the project’s advisory committee.

Read “Love My Job … But Not My Salary: A Snapshot of America’s Public Health Nurses” on RWJF’s Human Capital Blog.

CDC Releases Tools to Help People Keep Cool this Summer
A new study in the U.S. Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Weekly Report shows that there were 7,233 heat-related deaths in the United States in the decade from 1999 to 2009, with an analysis of 2012 data showing the death rate is climbing. “No one should die from a heat wave, but every year on average, extreme heat causes 658 deaths in the United States—more than tornadoes, hurricanes, floods, and lightning combined,” said Robin Ikeda, MD, MPH, acting director of the National Center for Environmental Health and Agency for Toxic Substances and Disease Registry. “Taking common sense steps in extreme temperatures can prevent heat-related illnesses and deaths.” The CDC has released a series of tools to help people stay cool, hydrated and informed during the extreme that will most likely occur in much of the country over the hot summer months. They include the Extreme Heat and Your Health Website; Environmental Public Health Tracking Data; a Climate Change and Extreme Heat Events Guidebook; and Workplace Solutions Bulletin. Read more on environment.

Study: More than One-third of Designated Drivers End up Drinking
More than one-third of designated drivers end up drinking, according to a new study in the Journal of Studies on Alcohol and Drugs. The researchers spoke with approximately 1,100 bar patrons (mostly white, male, college-aged) in an unidentified college town and gave blood alcohol (BAL) tests to 165 who said they were designated drivers. About 65 percent had no alcohol in their systems; 17 percent had a BAL between 0.02 and 0.049; and 18 percent had a BAL of at least 0.05. The legal limit is 0.08. "While more of the designated drivers didn't drink than did drink, which is a good thing, you have people being selected because they're the least drunk, or the least intoxicated or they've driven drunk before," said study author Adam Barry, an assistant professor at the University of Florida. "The only real safe option is to completely abstain." Read more on alcohol.

Sequester to Close all HUD Offices on June 14
Though the schedule could still change, as it stands at the moment every office of the U.S. Department of Housing and Urban Development (HUD) will be closed on Friday, June 14 as part of the sequester which is being felt across all of government. The automatic spending cuts took effect March 1. HUD’s plan is to pair its seven required furlough days with holidays and weekends. HUD is encouraging people and businesses that work with the agency to plan around the schedule day of shutdown. Read more on budgets.

Eleven Public Health Departments First to Achieve National Accreditation Status
The Public Health Accreditation Board (PHAB) has awarded 5-year accreditation to eleven public health departments. The national program, which is jointly supported by the Robert Wood Johnson Foundation and the Centers for Disease Control and Prevention, aims to improve and protect the health of the public by advancing the quality and performance of the nation’s state, tribal, local and territorial public health departments. The newly accredited agencies are the first of hundreds currently preparing to seek national accreditation through PHAB, an independent organization that administers the national accreditation program. “With accreditation, we now have national standards that promote continuous quality improvement for public health and a mechanism for recognizing high performing public health departments,” said PHAB President and CEO Kaye Bender, PhD, RN, FAAN. “These are the first of many health departments that we look forward to being able to recognize for achieving national standards that foster efficiency and effectiveness, and promote continuous quality improvement.”Read more on accreditation.

Report: HIV Cured in Baby
Researchers from the Johns Hopkins Children’s Center will report today that a baby in rural Mississippi has been cured of HIV through aggressive use of anti-retroviral drugs following birth. The finding will be presented at the Conference on Retroviruses and Opportunistic Infections in Atlanta. The findings have not been yet been published in a peer review journal and the researchers say the findings may not apply to adults. Read more on HIV/AIDS.

Public Health and Sequestration
Several public health organizations has issued statements  on the potential impact of sequestration, across the board budget cuts to the federal budget, including the Association of State and Territorial Health Officers (ASTHO), the National Association of County and City Health Officials  (NACCHO) and the American Public Health Association (APHA). Read more on budgets.

The Transforming Public Health project supported by the Robert Wood Johnson Foundation (RWJF) and convened by RESOLVE brought together a group of local, state and national public health leaders to develop guidance for public health officials and policymakers in prioritizing critical public health functions in a changing political and funding landscape.

Recently, the Foundation hosted a webinar to discuss the Transforming Public Health project. Speakers included:

• Terry Cline, Oklahoma State Health Department
• David Fleming, Seattle-King County Health Department
• Abby Dilley, RESOLVE
• Abbey Cofsky, RWJF program officer
• Paul Kuehnert, senior program officer and director of the RWJF Public Health team

>>Read our recap of the discussion from the webinar.

But the conversation shouldn't stop there. We want to hear your thoughts on the future of public health. Below are some questions to get you started. Feel free to add your thoughts in the comments below, and help us chart the course for a new public health.

• How is your public health department adapting in the current changing landscape?
• How is your community prioritizing programs and services to take on new challenges in a time of declining resources?
• How have you engaged policy-makers and diverse partners in your community on issues critical to public health?

>>Read more: Check out these resources to get ready for the webinar and inform the discussion:

• Read the full Transforming Public Health report.
• Read a Q&A with Paul Jarris and Robert Pestronk on how the report’s findings can be implemented to help improve public health services and population health.
• Read our recap of the discussion during the webinar.

Combined federal, state and local budget cuts mean basic elements of public health preparedness are at serious risk, according to a new report from Trust for America’s Health and the Robert Wood Johnson Foundation. The ninth annual Ready or Not? Protecting the Public from Diseases, Disasters, and Bioterrorism report found that federal funds for state and local preparedness declined by 38 percent from fiscal year (FY) 2005 to 2012 (adjusted for inflation) - and additional cuts are expected under budget sequestration.

“We’re seeing a decade’s worth of progress eroding in front of our eyes,” said Jeff Levi, PhD, Executive Director of TFAH. “Preparedness had been on an upward trajectory, but now some of the most elementary capabilities—including the ability to identify and contain outbreaks, provide vaccines and medications during emergencies, and treat people during mass traumas—are experiencing cuts in every state across the country.”

NewPublicHealth caught up with Paul Jarris, MD, Executive Director of the Association of State and Territorial Health Officials, to talk about what these cuts in public health preparedness funding mean for state and local health departments and for the health and safety of Americans.

NewPublicHealth: What is the one big take away from the 2011 Ready or Not report?

Paul Jarris: The takeaway is that public health has dramatically transformed itself and is now very capable of protecting the American public in numerous different incidents, both manmade and natural. But it’s not something to be taken for granted. The budget cuts are dramatic. Since 2005 we’ve seen 38 percent cuts in federal budgets for state and local preparedness.. These continued cuts are threatening the ability of public health to protect the American people.

NPH: Why is this latest round of cuts particularly concerning?

Paul Jarris: Our concern is that the federal cuts are occurring at the same time that state and local economies are in really difficult situations. We are not only seeing the cuts in the federal preparedness dollars and other areas, but we’re also seeing layoffs, furloughs and program cutbacks at state and local levels. Between state and local governments, we’ve seen over 50,000 public health workers lose their jobs. We have seen about 17 percent of the state workforce and 22 percent of the local workforce lost in the last two years. Nurses, epidemiologists, laboratorians, preparedness people—all the people there to protect the American public—are losing jobs. That is going to dramatically affect our ability to respond at the same level and quality that we’ve been responding.

Faces of Public Health is a recurring editorial series on NewPublicHealth featuring individuals working on the front lines of public health and helping keep people healthy and safe. Today's profile is Linda Rae Murray, president of the American Public Health Association.

Graduations are taking place this month at schools of public health across the country. Last week, Linda Rae Murray, M.D., M.P.H., chief medical officer of the Cook County Health Department in Illinois, and current president of the American Public Health Association, gave the commencement speech at the Mailman School of Public Health of Columbia University. NewPublicHealth spoke to Dr. Murray about the students she met and what many are likely to find when they begin working in the field.

NPH: What were some of the key things you said in your commencement speech?

Dr. Murray: Well, I really focused on two issues. One is that public health is intimately, inextricably melded with social justice. And social justice is really the frame around which public health needs to function in our country. I think that reflects the feeling of the Mailman School of Public Health. They have developed an oath for public health workers and social justice is right there in that oath. The second thing I said is that we've had a tradition in public health of saying that if we do our job then we're invisible. I really reject that approach. We have to insist that we're not invisible. We have to be visible--we have to speak out on issues that concern the health of the public. For example--school budgets. When local government cuts of school budgets raises the class size, we need to be saying, "this is going to produce X number more cases of diabetes and X number more obese kids.” So it really means that we have to step forward in issues of labor management, school budgets, transportation--the whole range of things that really address the social determinants.

NPH: How specifically does cutting the school budget impact the health of students?

Murray: Well, we know a few things are likely to happen if we cut the school budgets. First, we know the earliest and quickest things for the cuts are recess, gym, extra-curricular activities and sports. So right away, we're decreasing exercise, for example. Secondly, we know that there's a clear relationship between people who are poorly educated in terms of lifestyle decisions that they're able to make. So, we know there's a relationship between education and health behaviors and opportunities that people with less education don’t have.

NPH: How is entering public health as a profession different now than when you entered the field?

Dr. Murray: Well, I think that right now we're in a position where governmental public health has really been cut to the bone. It's almost as though we're destroying the seed stock of our field. So, in 2010, 18,000 public health workers in local health departments experienced furloughing and 40 percent of the local health departments have had lay-offs or hiring freezes where they can't rehire people that retire. So governmental public health particularly is under attack and it is the core of public health. And when the governmental programs are cut back and governmental departments are cut back we really limit our ability to have good public health infrastructure and emergency preparedness response, and it also prevents us from speaking out. Another example I used in the speech to the Columbia students was from the H1N1 pandemic. We told people to cover their coughs, wash their hands, and stay home from work if they were sick, and most workers in this country don't have paid sick days. And what we should have been saying as public health people is, "If we want to have a modern country and we want to be able to respond to flu pandemics, we have to have legislated paid sick days"--which would help with a whole range of things--not just flu pandemics. So, it's that kind of ability to link what we do to people's lives that is so critical.

NPH: What do you think confronts a newly graduated student when they enter the professional field of public health that they need to learn from scratch?

Murray: Well, the first thing they have to learn is what we taught them in school isn't really true. That is to say, policy is not determined by evidence. So they have to learn the "hard knocks" politics of public health. I think the second thing is--and it varies from school to school as some schools are doing a much better job at this--they have to learn how to work with the community groups. You know, not the professionals who are in the community groups, the real people in the real streets. It doesn't matter if you have all the fliers that you want. I'm going to tell you--60 year old black people--it's really hard to convince them to get the flu shot. So understanding that and learning about what that means and how to talk to people--how to relate to people. And the third thing unfortunately, I think is a problem of our public health schools. They have to really learn how to work with other professionals--social services, urban planning, rural health--a wider variety of professionals than they usually get exposed to--not just public health. Many of our schools are pretty good about public health officials but you gotta learn how to work with the local surgeon; you have to learn how to work with the local park district, education, transportation and labor departments.

NPH: What were some of the questions the students asked you?

Dr. Murray: I was fortunate to be able to have a lunch time with faculty and students and we really talked about what things in public health make us most passionate and how do you stay active in other issues that matter to you when you start working? How do they stay active in issues and things that concern them, even while they have a job to go to? So we talked a lot about involving themselves in activities at their church or in their neighborhood that may be disconnected from their actual 9-5.

NPH: What was their reasoning behind that question?

Murray: First of all, they want to stay active. They felt that public health people needed to be more active because we have a lot of information--and they spend a lot of time asking questions about how things were connected. So we talked together about how public health was really the glue between all of these different sectors, that one thing that public health brought was a multi-faceted view. So we could see a connection between what the transportation department did and what the sanitation department did. So they really wanted to know how to do that, and they felt that many jobs that they would get--not just in government but outside of government--if you're working on an HIV grant for example, that grant may not allow you to do some work in other public health areas you’re interested in. But we talked about how it was possible to bring your knowledge about public health even outside the job. That there might be time periods where your job requires you to do something very specific but that doesn't mean you have to give up your passion.

NPH: What are some innovations that you've brought to APHA in the time since you became President?

Dr. Murray: The thing that I am most interested in is trying to find ways to increase our advocacy role--and especially our advocacy role at state and local levels. We're trying to experiment through some grants we've gotten and have more regional meetings and find ways to energize our membership at a state and local level.

NPH: What kinds of things would you like to see happen as a result of greater advocacy by APHA?

Dr. Murray: I think to the extent that we can actually mobilize people who are not public health professionals--the church community, school communities, etc.--to work on local projects, whether it's getting vending machines out of their schools or working on getting more farmers markets in poor communities. I know our state affiliates--we have an active group working on food access issues and it really leverages a whole range of community activists and community groups to address food nutrition and food security in an intelligent way.

NPH: So with so many students graduating into the field, what do you say to a student starting off today? What do you want them to keep first and foremost in their minds as they enter the field of Public Health in America?

Dr. Murray: The main thing I would ask them to keep in mind is, you're young in your career--don't think you're going to stay in your first job--whatever it may be. Don't be afraid to try new areas and new problems that you haven't maybe dealt with before. The second thing is, stay in touch with your colleagues. Whether it's through APHA or any of other public health organization, be active and involved in organizations that care about public health because that really keeps you fresh. It will help your career and it keeps you active.

>> Read more Faces of Public Health features here.

>> Read previous NewPublicHealth.org Q&As with newsmakers and difference makers in public health.