Georgia found itself in exotic company recently when federal officials evaluated readiness for public health emergencies.
Tied for sixth-worst among 56 states and territories, Georgia ranked ahead of Hawaii and the Northern Mariana Islands, for example, while trailing Guam and American Samoa.
This was just one among many measurements raising doubts about Georgia's preparedness to prevent, detect and contain most significant public health threats: outbreaks of pandemic influenza and foodborne illness, and acts of bioterrorism.
Federal agencies, nonprofit groups and the state's own documents depict a public health system that lacks sufficient money and, at times, basic competencies, an examination by The Atlanta Journal-Constitution found.
Georgia ranks 39th among the states in spending per resident on public health, despite having the nation's ninth-largest economic output. Its state public health laboratory could identify the sources of fewer than four in 10 foodborne illness outbreaks from 2004 to 2006, the 35th-lowest rate in the country.
At the same time, state health officers face lingering problems that also pose serious threats. Georgians are more likely than the residents of almost every other state to suffer from communicable and chronic diseases: AIDS, syphilis, tuberculosis and diabetes, among many others.
Georgia's fight against such problems has long taken place in the corner of a larger arena. The federal Centers for Disease Control and Prevention, the world's premier public health agency, is based in Atlanta, two miles from the state's main public health lab in Decatur. State officials grumble that the CDC poaches its top epidemiologists and lab technicians, and the proximity to the federal agency has served to highlight rather than alleviate Georgia's shortcomings.
"People tend to think of Georgia as being in the CDC's back yard," said Jeffrey Levi, executive director of the Trust for America's Health, a Washington-based nonprofit public health group. "You'd think that they'd make this a model health department."
Instead, Georgia is known among public health experts for, as Levi put it diplomatically, its "challenges."
Those challenges have come into clearer focus in recent months.
First, Georgia was the epicenter of a nationwide outbreak of salmonella poisoning that originated in a Blakely peanut processing plant. Then came what is expected to be the first wave of swine flu. And last week the state's public health division came under new management as part of an overhaul of Georgia's human services and health care agencies.
The state's new chief health officer, Dr. Rhonda Medows, said the public health division needs a sustained commitment "to become prepared and stay prepared."
Medows, who also is commissioner of the Department of Community Health, which is absorbing the public health division from the Department of Human Resources, said: "We see this as a target-rich area."
'The system is stressed'
In January, three months before the swine flu became a global threat, the U.S. Department of Health and Human Services gave the White House a report on whether states and territories were prepared for just such a pandemic.
The report covered 28 key areas, such as maintaining the food supply, distributing vaccines and keeping transportation systems running.
The 56 states and territories had an average of 9.2 "inadequate" ratings.
Georgia had 16.
The state, according to the report, is not ready to manage large numbers of fatalities caused by a pandemic. It doesn't have adequate plans to keep government agencies running and to protect public employees. It isn't even prepared to provide one of the most basic, yet critical, needs in an emergency: health care.
Medows described the report as a "benchmark" against which progress can be measured.
The federal government will continue monitoring Georgia's progress, but it can do little to force improvements. Although outbreaks often cross state lines, the responsibility for maintaining public health ultimately lies with state governments.
"We have tremendous variations [in public health systems] on a state-by-state basis," Levi said. "There are not enforceable national health standards."
For many years in Georgia, Medows said, public health drew attention only during crises. At other times, interest in preparedness waned. With no crisis at hand, she said, "it's probably human nature to put something to the side."
That attitude led to increasingly tight budgets for public health. State spending increased slightly in recent years, but only because population growth created additional costs at public health clinics and in similar programs.
Legislators have cut appropriations to several areas, especially epidemiology and lab services —- perhaps the most critical functions of the public health division during an emergency.
For example, spending on the division's epidemiology section, which aims to spot outbreaks during their early stages, will decrease by almost one-fourth this fiscal year, to a level slightly lower than in 2006. Earlier this year, lawmakers eliminated three jobs in the epidemiology section, along with three vacant positions in emergency preparedness.
Even without cuts, Georgia spends relatively little on public health: $18.33 per resident, compared to the national median of $33.71. Neighboring Alabama, for one, spends $58.46 for each resident, totaling nearly $100 million more a year than Georgia.
"Something's got to be done," said Russ Toal, president of the Georgia Public Health Association and an associate professor at Georgia State University. "The system is stressed."
Public health suffered when it was a division of the mammoth Department of Human Resources, where it competed with other sections —- child welfare and mental health, for instance —- that also were in crisis, Toal said.
With limited resources, public health planning leaned toward the theoretical.
"My sense is there is a lot of planning," Toal said. "The question is do they have the resources to make those plans operational in the event of an emergency? That's the big unknown."
Below average
Georgia opened its first public health lab in 1905, in the basement of the state Capitol.
A century later, the lab operates out of a gleaming facility on Clairmont Road in Decatur, with small satellites in Waycross and Albany. State technicians analyze more than 350,000 specimens a year.
The lab is "a key component" to the early detection of outbreaks of infectious and foodborne diseases, said Scott Becker, executive director of the Association of Public Health Laboratories. Technicians can spot patterns of disease in specimens submitted by physicians across the state, in what Becker described as a more efficient process than the field work performed by epidemiologists.
Georgia's lab, however, has lagged behind its cohorts in most other states.
From 2004 to 2006, the lab identified the pathogen causing foodborne illnesses in just 38 percent of cases, according to a study by the Trust for America's Health. The national average was 44 percent.
Nineteen other states fell below the average, the study found; 14 states had failure rates that exceeded Georgia's 62 percent.
In monitoring flu outbreaks, the lab relies on a statewide network of about 70 physicians who submit specimens from ill patients. The state does not offer specimen kits to other physicians and, to keep the lab from being overwhelmed during outbreaks, discourages them from sending in suspect cultures.
Georgia goes further than many other states in restricting submissions to its state lab. It is one of 24 that do not require private labs to send in samples associated with foodborne illnesses, such as salmonella.
"You catch more if specimens are required to come in," said Becker of the national lab organization, who generally praised Georgia's performance. "The problem is who pays for those specimens to come in."
Even without samples from private labs, Georgia reports exceptionally high rates of infections from such bacteria as salmonella and shigella. Georgia's rate of shigella infection is nearly three times the average recorded by the 10 states that participate in a CDC program to track foodborne illnesses, and Georgians are 45 percent more likely to contract salmonella poisoning than residents of the nine other states tracked through the CDC's FoodNet.
The data does not explain why Georgia's rates of both illnesses are so high, officials say.
Georgia officials say the state lab has been plagued by heavy employee turnover, including defections to the higher-paying CDC. In mid-May, the latest date for which figures were available, almost one-fifth of the lab's 150 jobs were vacant —- up from one-tenth three years earlier.
"The public health work force has been diminished," said Dr. Patrick O'Neal, the preparedness director of the public health division.
However, O'Neal said, "the people who have remained are among the most committed you'd see anywhere."
In 2006, a state audit found the lab was so stressed by cuts that it hadn't found time to study whether it could handle a surge of tests during an emergency. A lack of readiness, auditors said, "could result in increased illness or fatalities."
The public health agency promised auditors it would test the lab's capacity. But officials recently declined to release records of such reviews, citing security interests.
Problems facing Georgia's lab have become common nationwide, Becker said.
"There's a huge disconnect between what the public has come to expect from their lab systems and what policy-makers are willing or able to provide," he said. "How low can you go?"
Medows agrees that the state needs to spend more on public health and is calculating how much. Already, she has authorized the public health division to use federal money to fill 27 vacant positions. And if necessary, she said, she'll make a case for more money to Gov. Sonny Perdue, who has ordered widespread budget cuts because of declining state tax revenue.
"I don't have a target goal," Medows said. But "I'm not shy."
Just addressing a handful of chronic issues —- infant mortality, prenatal care, obesity —- would be expensive, she said.
"These are long-standing [problems], but we should not just accept them," Medows said. "It's going to take a sustained and coordinated effort to turn the trend."
From Page One
How Georgia compares
By virtually every indicator, public health is suffering in Georgia, with the rate of disease —- the number of cases per 100,000 people —- among the highest in the nation. Here is how Georgia's rates rank among the 50 states in several major diseases:
AIDS cases 8
Syphillis 4
Gonorrhea 5
Chlamydia 7
Cancer diagnoses 11
Tuberculosis 6
Low birth weight 11
Infant mortality 9
Teen birth rate 10
Preterm births 9
Diabetes diagnoses 4
Flu vaccinations
for people 65 and older 45
Pneumonia vaccinations
for people 65 and older 42
Deaths from stroke 10
Deaths from heart disease 13
Overall death rate 10
Workplace fatalities 7
Residents with health
insurance 43
State public health spending per resident
1. Hawaii $172.21
2. Vermont $145.23
3. District of Columbia $115.08
4. California $84.01
5. Idaho $78.29
Median $33.71
39. Georgia $18.33
47. Oregon $14.49
48. Mississippi $12.64
49. Wisconsin $10.51
50. Missouri $8.81
51. Nevada $3.37
Sources: Centers for Disease Control and Prevention, Trust for America's Health, Kaiser Family Foundation, Georgia Division of Public Health.
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How we got the story
This article is based on a review of reports and studies by federal agencies, including the Centers for Disease Control and Prevention; nonprofit groups that promote public health, such as the Trust for America's Health; and state offices that oversee public health policy and spending, primarily the Division of Public Health, which recently became part of the Department of Community Health.
Other information came from interviews with public health experts and advocates.
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