Health Journal

Lawmakers push to add more public health nurses

A virulent flu that reached Maine early in the autumn of 1918 quickly overwhelmed the capacity of authorities to deal with a sudden public health emergency.

By early October, Lewiston and Auburn had shut down schools, churches, theaters, pool rooms and dance halls — indeed, almost everything except Bates College and key war industries — in a desperate bid to stop the growing epidemic.

In the half year that the pandemic raged, it struck a third of the world’s population and mowed down more than 20 million people, including thousands of Mainers, often those in the prime of life.

Spurred in part by the disaster, the state created a Division of Public Health Nursing and Child Hygiene in 1920 as a collaborative effort among the State Department of Health, the American Red Cross and the Maine Public Health Association. Its mission: to combat disease and help infants and families across the state.

Now, though, its supporters say the state’s public health nurses are on the ropes, their numbers sliced so deeply they can’t do the job properly.

If Maine doesn’t act swiftly to restore the system, they warn, the risk of a new pandemic will grow, infant mortality rates will rise and an array of preventable maladies will escalate.

“Over the past six years, without any open, public debate, the public health nursing program in Maine has been hollowed out,” Sen. Brownie Carson, D-Harpswell, said, leaving it “a shadow of what it was” as recently as 2011.

At the time, he said, it had 59 public health professionals that included 50 nurses in the field helping people. Today, he said, there are only 22 or 23 nurses left.

“Field offices have closed,” Carson said. “Distances between visits have dramatically increased, sapping direct patient visit time and forcing more travel. Referrals for public health nursing services are denied or go unanswered.”

Sen. Roger Katz, R-Augusta, said the Legislature has two choices: “We can sit idly by and watch the dismantling of our public health system or we can begin to reconstruct it at a time when it is more important than ever.”

Carson is pushing a bipartisan measure that would require a return to 2011’s staffing levels, a move opposed by Gov. Paul LePage’s administration, which has focused on alternatives that many public health experts say aren’t getting the job done.

Dr. Lani Graham, co-chairman of the Public Health Committee for the Maine Medical Association, said the state is “in the middle of a terrible opiate epidemic and find ourselves with a rising infant mortality rate, which is already higher than the national rate.”

Testifying for Carson’s bill, Graham said officials “may hear about other exciting options for cobbling together a different kind of model to address the functions of public health nursing,” ideas that might be great after a transparent and well-planned process.

Dr. Christopher Pezzullo, state health officer for the Maine Center for Disease Control and Prevention and MaineCare’s medical director, said that “changes in how health care is delivered, including rural health centers and FQHCs, telemedicine and population-based health promotion services make the 1920 model obsolete.”

He told the Committee on Health and Human Services that almost two years ago, the department restructured public health nursing to include “a broader view of public health” that would engage “the entire community in the health of infants and families.”

“This vision includes using public health nurses where a licensed nurse is the appropriate resource,” he said, but it also brought in “a network of other non-licensed supports, such as Maine Families Home Visiting and local community resources.”

Pezzullo said state experts “will utilize real data to determine what we actually need for a workforce and how we can best establish a public-private network with the capacity to serve all Maine people.”

Experimentation is one way that new things are learned, Graham said. “However, when things are not going well, it is much better to depend on the best lessons of the past,” he said.

“I was always told that when you find yourself in a hole, the first thing to do is to stop digging,” Graham said. “We are in a hole, and now is not the time to throw away one of the strongest tools of public health, a vital public health nurse workforce.”

Erin Guay, executive director of Healthy Androscoggin, who has worked in public health since 2002, said the reality is that “the public health system, including public health nursing, has consistently been weakened over the past several years.”

As a result, she told lawmakers, “we are not prepared for the next infectious disease epidemic” or health issues that keep popping up.

Dr. Diana Wilson, a pulmonologist practicing in Lewiston who works as a tuberculosis consultant for the Maine Center for Disease Control and Prevention, said one key reason tuberculosis is “quite rare” in Maine is that public health nurses “have worked hard for years to identify at-risk populations, screen for the disease, facilitate evaluation by a physician and monitor treatment in those that require it.”

Wilson told legislators she is concerned, however, because tuberculosis rates are on the rise in Maine for the first time in decades — an increase she tied to dwindling numbers of public health nurses.

The number of public health nurses has dwindled to the point where they can no longer carry out the critical work they perform in fighting a costly and dangerous disease, Wilson said.

Rebecca Boulos, executive director of the Maine Public Health Association, said the state should have 263 public health nurses but only has about 20.

“It is no wonder professionals are struggling to keep up with demand,” she said.

Public health supporters in the Legislature gripe that they keep funding positions for nurses but LePage won’t hire any so the overall numbers keep sinking.

“As a member of the Appropriations Committee, I have had a front-row seat to the slow starvation of Maine s public health infrastructure,” Katz told colleagues.

“Year after year, we have funded public health nurse positions, expressing the will of the Legislature,” he said. “Year after year, the administration ignored that will by failing to fill vacancies, slowly starving the capacity at CDC. Something has to give.”

Katz said a major crisis could hit anytime, due to an increase in infant mortality rates and drug-affected births and treatment-resistant tuberculosis “becoming more of a problem that could explode on us at any moment.”

When it does, he said, the key to getting through it is to be prepared.

“Presently, we are not prepared,” he said.

The state epidemiologist from 2010 to 2014, Dr. Stephen Sears, told the legislative panel he could “easily recall several outbreaks affecting Maine citizens that needed the public health nurses to respond to help prevent illness and minimize morbidity and mortality.”

Sears mentioned, for example, that when whooping cough cases arose in the middle and high schools in Penobscot County a few years ago, the state worked closely with educators “to interrupt this outbreak” by inoculating students quickly. Public health nurses gave the shots, he said.

Another time, an elderly individual in a long-term care facility developed tuberculosis in Aroostook County, he said, a big risk to all of its other residents. Public health nurses went in to help and soon identified three more cases of active TB. Without them, Sears said, “this outbreak very likely would have been far worse.”

Sears pointed to other potentially dire cases, from measles in summer camps to gonorrhea in Androscoggin County where public health nurses raced to the rescue.

“For a public health program to be effective,” Sears said, “there needs to be a fully-functioning surveillance system and an active and proactive system to intercede in disease prevention,” a function nurses fill.

And what about the flu?

“Fortunately, we now have flu vaccine, but the ability to deliver that vaccine in a crisis rests largely with” public health nurses, Dr. Sam Zager of Portland told legislators.


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