Dr. Alonzo Plough served nearly eight years as director of public health in Boston before he came to Seattle in 1995 to be director of the Seattle-King County Department of Health. In Boston he won acclaim for reducing a high infant mortality rate and for dealing with problems of drug and alcohol addiction. He also was a lecturer in public health policy and management at the Harvard University School of Public Health. His M.A. and Ph.D. are from Cornell University; his M.PH. is from Yale University School of Medicine. We sought Dr. Plough's perspectives on the practice of public health in Boston versus Seattle and his plans for Seattle-King County.
WPH:How did you get into public health as a career?
Plough: My training is in chronic disease epidemiology After I finished my work at Yale in the late seventies, I joined the faculty at Boston University For the first eight years or so I was a traditional academic, teaching public health and health administration, first at BU and then at Tufts. I gradually realized that I was increasingly action oriented. As a young academic I felt some frustration that good research did not necessarily lead to policy and program change that would influence our lives.
While at Tufts I established the New England Health and Poverty Action Center, which provided capital assistance and grant development help to health departments for minority health programs. Through this experience I began to get one foot out of the academic environment. In 1988 1 was asked to be director of public health in Boston based on the work I'd done around infant mortality at the center. Boston then had the second highest black infant mortality rate in the country, at about 25 per 1000. The health department had been taken to task by the community and funders who had invested money into perinatal intervention projects that had not worked. I learned public health management in real time on the job. We reduced black infant mortality in Boston by about 50% through grant development activities, the Healthy Start program, and other projects.
WPH: And what brought you to Seattle from Boston?
Plough: I survived my third mayoral election in fall 1994 and transitioned to the cabinet of the new mayor. I believed I probably would stay in Boston forever. Then I received a call from a recruiter for the Seattle-King County position who asked if I would be interested. And I said "highly doubtful, but send me the position description and I'll take a look at it and perhaps pass it around." The description of the department - its comprehensiveness and range of services - was fascinating. I knew of the excellence of the infectious disease programs, the HIV expertise here, homeless programs, and emergency medical services. It was a mix of programs similar to those in Boston and others I was not that familiar with, such as rural and suburban health issues. The university connections were really appealing, and it read like an exciting place.
I flew in for the interview just before Thanksgiving on a brilliantly sunny day. When we flew over the Cascades I thought "my goodness, this is really something." I was impressed by the department and by what was going on in health reform at the time. The appeal of the region, the support for public health and the Public Health Improvement Plan - those factors seemed to make this a wonderful place to do public health work, and I knew instantly that this was a great position. But after being in Boston for 18 years it took me a long time to decide whether my family should pack up and go west. But we did, and we love it here.
WPH: We suspect there must be some significant political differences between Boston and Seattle, especially in respect to running a health department. Have you found that to be true?
Plough: One difference is that there is a lot more politics in Seattle and King County a nine-member city council and a mayor, a 13-member county council and an executive, 34 suburban city mayors and their councils. But the big difference to me is that it's "all on the table," operating within the framework and principles of Civics 101 - very public oriented, very process oriented. Boston did not have as many actors, but the political environment was intenser, a little meaner, and where and when decisions were made was not always on the table. I like the change.
WPH: Is there a difference in the relationship between city, county, and state health departments here compared to the East Coast?
Plough: Counties in the East are not involved in public health delivery There are big city health departments, small local ones that primarily deal with environmental or sanitation issues, and the state agency, which in Massachusetts is largely a contractor of dollars to other departments and programs, so there is nothing analogous to Washington's rich network of county health departments. Another thing I like about this area is the way county public health professionals work in a nice partnership with the state.
WPH: Are you making any significant changes in the department's structure and provision of services?
Plough: We are restructuring to emphasize four regional divisions. Each will be run like a local health department with its own administrator. Coherent public health management in King County requires an understanding of the regional nuances, consideration of the health parameters, interventions, performance indicators, and outcomes in these distinct regions, and then integration into comprehensive regional health priorities. This new structure has allowed me to flatten the organization quite a bit and eliminate several divisions. It provides more focus and keeps me closer to the operations than was possible with the previous structure. And for a department of this size - with a $153 million annual budget and 1200 employees - it is important for the regional directors to communicate with the staff who are managing operating units.
WPH: Are any substantive issues a focus of dispute between the county and city? What about the sex industry outreach program that generated so much publicity in the media last fall?
Dr. Alonzo Plough |
Plough: The King County Council understands Seattle's need to define its policies and programs based on dollars the city allocates to the department beyond the funding from the state motor vehicle excise tax. County council members have clearly and repeatedly stated they have no desire to alter that relationship. If you remember, the sex industry grant involved a two-location intervention downtown Seattle and Pacific Highway South near Sea-Tac Airport. If the intervention had been focused only on Seattle, it's questionable whether it would have prompted the same level of council concern and media interest. I look at these issues as opportunities. The sex industry project generated a lot of press and prompted weeks of public dialogue about the importance of AIDS prevention intervention. My message throughout the controversy was that this program is an integral part of HIV prevention policy and people need to understand the link between the very high risk situation of sex industry workers to themselves and to others. |
Classic harm reduction requires you to go where the risk is, which creates an understandable confusion that your programs may have generated the risk. I find that I have to articulate repeatedly that the needle exchange program doesn't cause heroin trafficking and illegal drug use downtown. Public health professionals have an important educational role to play on these issues.
WPH: But everyone understands money. It costs $50 a year to keep someone in a needle assumption of risk, exchange program and $100,000 year to treat someone for AIDS. It's a "no brainer."
Plough: Exactly. These programs offer pathways to treatment. It's not just HIV prevention. Our needle exchange has a methadone component that gets people into treatment. A client who injects drugs also has unmet primary health care problems and other needs. We are trying to use the Seattle exchange as a window for other programs, and we need to get that side of the message out.
WPH: The Seattle-King County Health Department has been doing primary care for years. Will these programs be reduced as a consequence of health reform initiatives and programs such as the Basic Health Plan and Healthy Options? Are the politicians eyeing the funds that could be saved by getting out of primary care delivery?
Plough: We don't see any dichotomy between having a strong and vital primary care component and the core public health functions. In this department personal health services are part of the assurance function, certainly for the foreseeable future. We will have a continuing role in providing primary care. In fact, demand is increasing at some of our service sites; we must expand the physical capacity to meet it. Our core prevention services are partly funded by revenue generated through primary care services, so there would be no "savings" by eliminating this function.
We are enrolling people in the Basic Health Plan and in Healthy Options. We are in two managed care partnerships and probably will join others. Managed care involves the assumption of risk, an interesting new notion for a public entity. We need to figure out how we absorb that risk and appropriately buffer the county and city We are working with many providers to increase Basic Health Plan (BHP) enrollment, and we don't care where the patients go so long as they go to good systems of care. It's to everyone's advantage to get BHP enrollments: we have a legitimate role as a provider in certain areas in partnership with a variety of hospitals and public health centers.
WPH: The public health department might be at a disadvantage because it treats the less affluent people, those who can't work because they are sick, and that would increase risk under a capitation system. Or the health department might have an advantage because it is prevention oriented and perhaps will achieve synergies that private providers can't do or don't know how to do because they haven't had that focus.
Plough: We see the latter in the data from our two partnerships. We are quite an efficient managed care provider of services in terms of low emergency department use and low hospitalization. Adverse selection is an inherent factor, but I feel that the role of public health systems is to figure out how to deal effectively with these so-called adverse populations. The default models of providing services are adverse, not the people. If you provide home-based alternatives, case management alternatives, and prevention, the population does not have to become adverse in a financial sense.
WPH: It has been reported that you want to see public health departments put more emphasis on wellness, not just care. What are your plans?
Plough: We will start with the adolescent wellness initiative. Adolescence is an important time to intervene and try to support healthy behaviors. I am concerned that default public policy for high-risk adolescents is the criminal justice system. jail health services are the fastest growing part of my budget. That is not the public policy objective that we should have. A wellness perspective means school-integrated, school-linked programs and tobacco, alcohol, and drug prevention interventions. We are thinking about what we should be doing for even younger children to set healthy behaviors and trajectories. We don't have a "one-size-fits-all" approach to school health. We will do a lot of community work and involve peer leaders in programs. We are continuing our fantastic partnerships with the Seattle school district, and increasing partnerships with communities throughout the county.
WPH:What are your other top priorities?
Plough: We have a new homeless initiative that brings together services to deal with the multiple factors that influence the homeless population - HIV, STDS, substance abuse issues - where the criminal justice system is again another default provider of services. We will break ground on a new sobering center for homeless clients who are chronic inebriants, and we'll develop a new respite center that provides care for people who are too sick to be in a shelter but not sick enough to be in the hospital. We also will do some new models of directly observed therapy work with clients with tuberculosis. I'll be working closely with the mental health and drug and alcohol treatment community around common entry points and an integrated care continuum for that population, and try to make sure our drug and alcohol and primary care components are better integrated to deal with this population. Another priority is continuing community-based assessments of needs and of the public health issues that should drive our policies.
WPH:What is your view on the department's collaboration with the University of Washington? Is this an unusual model?
Plough: The university link is one of the key reasons that drew me here. I am pleased to join at least a dozen other members of the department who have appointments at the university. That's the kind of partnership that we need with the schools of public health and nursing and medicine. When I taught at Harvard I looked at public health practice and university-health department linkages nationwide, and this is one of the best ones I have seen. I have involved the School in some joint recruitment for health department positions.
WPH: Will the department ever create regular positions for preventive medicine residents from the university?
Plough: I want training to be a more central part of what this department does. We can integrate many students in structured practicum experiences that help us advance the services that we deliver and do so in many settings and ways. I'd like to initiate a program similar to one in Boston where we combined the preventive medicine residency with experiential work training for nurses, social work students, and others. This model brings a variety of health care professionals together and creates the team training and awareness that is needed to work on a peer basis with other disciplines. I'd love us to play a larger role in that effort.
WPH: It's hard to get public health in the press or on TV unless the topics are controversial or an emergency. Will you try to expand and diversify public communication?
Plough: If you asked the average person on the street what the health department did, no one would know, or they would think of us simply as an organization that responded to the high-risk problems or crisis intervention. We are starting a series of regionally oriented publications and newsletters to let people know what we're doing in their area and to show that we are continually providing services that support them. We also will use cable TV, radio, both the newspapers - every channel that we can to communicate about important health issues. Public health professionals are frustrated because all the good things we do don't seem to cross that news threshold. We are trying to develop relationships with reporters so they can understand new initiatives such as the adolescent wellness project. I've been meeting with editorial boards and key medical reporters to encourage them to work on longer term stories rather than just covering crisis issues, but I think the news ratio will always be tipped to the crisis side.
WPH: This question maybe impolitic, but your predecessors did not last long in your position. What's wrong with this system?
 |
Plough: I see wonderful, stable career trajectories for other health officers and directors in the state, but that has not been the history of the Seattle-King County department. I don't want to understate the difficulty of managing this department, especially considering the politics in a county this big and diverse. There should be a lot of politics because there are lots of constituents. You can get washed up on the rocks at any point. Sea-King approximates what goes on nationally where people are coming and going as elected officials change and because certain issues can just uncouple or derail the best of leadership. I'm here at a fortunate time because no one wants to replicate that history. |
Return to the Table
of Contents
Return
to Northwest Public Health