Viewpoint: Political Paradoxes of Public Health

Work in public health has become increasingly difficult, with mounting caseloads and dwindling resources. A paradox of the field is that when it's done effectively, public health is invisible. TB, HIV, and STD control, immunizations, clean water, and restaurant inspections together create a healthier state, yet the public is frequently unaware of our unseen work.

It made sense in 1993 for Washington State legislators-people in the know about public health's behind-the-scenes work-to provide $24.5 million annually in motor vehicle excise taxes (MVET) to support basic public health functions. But the fragile balance between public health needs and governmental functionality was shattered in 1999 by a successful initiative to slash these taxes. With a worsening economy, public health in Washington State now teeters on the brink of major downsizing. The midsize local health jurisdiction (LHJ) that serves Benton and Franklin counties faces a 41 percent cut in environmental and personal health services staff. Smaller LHJs, such as Adams and Garfield, may have to close their health departments altogether because they rely so much on state support.

These mounting challenges have led to the formation of a new statewide coalition whose goal is to obtain sufficient stable state funding for public health. Attending the initial June 17 coalition meeting were citizens and officials representing public health, cities, counties, labor unions, nurses, and environmental health, as well as local boards of health and others. They discussed the ebb and flow of public health funding, various funding mechanisms, and the coalition's purpose and principles. All agreed that new funding must have a population-based allocation, be sellable, at least keep up with inflation, and be sensitive to emerging public health issues.

Coalition members who trust traditional governmental processes hope the legislature will make the $24.5 million in MVET replacement funds permanent after all. But are these traditional times? Optimism is tempered by the looming $1.8 billion state budget shortfall. The consequences of the withdrawal of public health support are so severe that the coalition is discussing non-legislative strategies as well. If the legislature cannot provide stable public health funding during the coming session, the coalition plans to develop a statewide initiative, "One Percent for Public Health," in 2003. The initiative would educate the general public about the invisible work of public health and, at the same time, emphasize the public's choice about continuing to fund it.

Until fall elections are over, it's hard to make definite plans or know which funding mechanism might be best. Funding options the coalition is considering include new taxes on alcohol or utilities or the designation of a portion of existing state property taxes for public health. At the same time, the coalition is opposed to the legislature looting tobacco settlement funds to help balance the budget. Short-term gains would bring long-term losses. It will take vision and restraint on the part of legislators to leave those funds for their intended purpose, rather than to accept a short-term solution.

The coalition has formed four committees: messaging (creating a drumbeat for action and making it clear that a crisis is looming), coalitions, politics, and membership. (To become involved in any of these efforts, contact kathy@wspha.org.)

Perhaps the biggest paradox of all is that we are "quibbling over crumbs" while the federal government controls vast financial resources derived from income taxes. The majority of these resources are being used to support the military and interventions in other countries, while the health of Americans suffers. Can there be substantive change when the basic values and structure of our society work to curtail development of health and social services?

Public forums will soon provide opportunities to discuss the public health funding crisis. At the Washington State Public Health Association (WSPHA) Joint Conference on Health (Oct. 7-9 in Wenatchee), a joint plenary session of the State Board of Health and WSPHA will feature legislators, agency directors, policy makers, and critics who will invite attendees to participate in the funding conversation. The conference will also focus on providing nuts and bolts training on citizen advocacy. In addition, the University of Washington Health Policy Analysis Program's annual Washington Health Legislative Conference on December 11, 2002, will provide a breakout session for a similar discussion.

Author

Christopher Jones, MSW, MPH, is Region IV co-vice president of the Washington State Public Health Association. For more information about funding or the Joint Conference see www.wspha.org.