Here’s how Pennsylvania’s health departments currently work: A patient with active tuberculosis is in the third month of his six-month treatment in southwest Pennsylvania. Like many patients with active TB, he drives out to the local public health department clinic for directly observed therapy (DOT) treatment; a nurse checks him into the clinic, has him take his medication, and records it. If all goes well, he should be TB-free in three more months.

Here’s a scenario we hope doesn’t play out: At the end of his third month, his state health department clinic is set to close. Instead, he will need to go to the local community health center, which has never done DOT treatment nor dealt with patients with TB. When he next goes to the health center, he doesn’t know any of the nurses and the nurses in charge are just beginning to incorporate such patients into their workflow. Consequently his first few visits result in lengthy waits and a disjointed experience. When patients encounter greater barriers like longer waits, confusing instructions, and disruptions of routine, they are less likely to complete their treatment.

The prospect of a US state greatly limiting its public health system is worrisome, bringing up a number of other related concerns: Will the health centers be set up to handle an infectious patient? What happens the next time there’s an outbreak? These hypothetical questions may soon play out in Pennsylvania.

Memo to Health Department Workers

Last week, the Pennsylvania public health department sent out a memo to its workers, including to Laszlo Madaras, MCN’s Co-Chief Medical Officer and a Tuberculosis Physician Coordinator for the Pennsylvania State Health Department. The memo warned health department clinic employees throughout the state that, due to expected budget cuts, the state health department will likely close down most of its clinics, condensing the work to a few key areas of the state.

“It just seems counterintuitive to close the health departments,” offered Dr. Madaras, who oversees treatment of TB patients in the southeast corner of the vast state. He says the move is “short-sighted, and really bad for our national health and national security.”

While the state may save in financial costs, Dr. Madaras notes that a shutdown of the emergency response system designed to quickly take action for any health concern that arises -- recent outbreaks of West Nile virus, SARS, and avian flu were a few that came to his mind -- leaves the state more vulnerable to disease, and to greater financial burdens down the road.

“It will cost a whole lot to restart this system when the next crisis comes,” he noted, adding that a restart means a loss of institutional knowledge as well, which may lead a response to be less efficient, he said: “You don’t want to be doing a learning curve during a crisis.”

Where will patients currently in treatment go?

Dr. Madaras is concerned for TB patients whose treatment may be interrupted by the changes. Currently, the public health department clinics are responsible for assuring their care -- and that they don’t infect others.

At this stage, with just a memo and no policy action, but with budget cuts looming, no entity has been charged with taking on the tasks that the health department currently completes. Dr. Madaras believes that federally qualified community health centers may be expected to absorb the work, but it’s unclear if they have the infrastructure or capacity. The public health department’s TB-only clinic days -- with restricted patient days to assure that healthy patients aren’t inadvertently exposed to patients with active TB -- may be unfeasible in a health center setup, as would in-home nurse visits for DOT, if the health center isn’t provided additional funding to hire new staff to make the visits. If a patient has a highly contagious disease, the health department tracks down the dozens or hundreds of people who may have had contact with the patient and tracks their health for several weeks to assure the infection is contained. Health departments also collect and report epidemiological data. Local health centers are not currently organized or funded to take these steps.

Infrastructure, workflow, cost, and institutional knowledge concerns are just one part of the puzzle; patient trust and familiarity are another. Dr. Madaras worries that the switch will result in a drop in compliance among his TB patients. The six-month TB treatment regimen interrupts patients’ lives, with daily trips to the health department for DOT or with home visits by DOT nurses or outreach workers -- and a long list of potential side effects. These aspects of treatment can’t be changed, so the other contributing factors to whether a patient continues treatment -- convenience, a high level of trust, maintenance of routine, clear expectations -- are critical to ensure high completion rates. If patients have to travel large distances, have to rebuild trust with new clinicians, or hit other barriers, they are less likely to stick out the treatment to the end. Premature treatment interruption can reactivate the contagion and can result in multidrug-resistant TB (MDR-TB), which is also contagious and very difficult and expensive to treat.

What’s Next

For Dr. Madaras, the memo’s threat of closures may be just hypothetical at this stage, but the consequences are already being felt. With many clinicians within the health department recognizing that their jobs are threatened, some are looking for other work now. For his part, he frets about starting patients on treatment now, when he can’t assure them to completion -- but he continues with the hope that programs like MCN’s Health Network may help his patients during the transition through gaining their trust, removing some of the practical barriers like transportation or scheduling issues, and assuring the patients get the treatment they need.

“It’s all theoretical, but if the county state health department clinics start closing down, these may be the last patients I work with. If I get a new patient in July, I may say ‘I’m going to treat you for four months, and then, God be with you and good luck, and I hope you’re transferred to a community health center.”

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