N.C. Flap Exposes Ugly Side of State Health Decisions
Political intrusion into public health all but inevitable
http://www.medpagetoday.com/publichealthpolicy/generalprofessionalissues/59676?xid=nl_mpt_DHE_2016-08-17&eun=g578717d0r&pos=5
The recent resignation of North Carolina’s state epidemiologist, Megan Davies, MD, who charged her superiors with “mislead[ing] the public,” made plain the often tense relationship between the professional staff in state health departments and their political appointee bosses.
Davies’ abrupt resignation was the fallout of internal debates within North Carolina’s Department of Health and Human Services (DHHS) and the Department of Environmental Quality (DEQ) over how to address increased levels of chemicals in the private wells of people living near the state’s 32 coal ash impoundments at 14 sites. Those debates were revealed in a series of sworn depositions given to attorneys from the Southern Environmental Law Center and other advocacy groups as part of a lawsuit against Duke Energy.
State toxicologist Kenneth Rudo, PhD, in his sworn deposition released Aug. 2, asserted that officials from the administration of Gov. Pat McCrory urged state health officials to sign off on a letter to well owners, telling them their water was safe to drink.
And Davies testified that State Health Director Randall Williams was concerned about the political fallout from maintaining a do-not-drink order that had been sent to well owners.
Rudo was accused of perjury by McCrory’s chief of staff Thomas Stith in an unusual late evening press conference last week. The administration has since backed off that accusation, but on Wednesday morning the two departments released a joint editorial savaging Rudo, saying he exaggerated health risks and questioning his scientific integrity. That was the last straw for Davies.
In her resignation letter, Davies said the departments had deliberately presented a “false narrative” in the editorial.
The episode (recounted in detail here) revealed an increasingly politicized atmosphere within DHHS, leaving an impression of a department where decisions may have been made to reflect political expedience, rather than protection of the public.
And accusations of political intrusion into public health are not confined to North Carolina, as states elsewhere wrestle with issues in which economic interests may collide with residents’ environmental and health concerns — such as “fracking” of deep natural gas wells, not to mention the Flint, Mich., water crisis.
Interviews with former health officials in North Carolina and other states, some of whom asked not to be quoted, suggested that the Tarheel State is not alone.
Pressure from Above
Jeffrey Engel, MD, served as North Carolina’s State Epidemiologist from 2002 to 2007 and then as State Health Director from 2009 to 2012 before he was replaced by former Gov. Bev Perdue. Now, he’s executive director of the Council of State and Territorial Epidemiologists, based in Atlanta.
He said he experienced pressure in his old jobs and has also heard from some of his members about political pressures.
“There is a lot of partisan stuff going on,” he said, citing how different states have approached threats such as Zika virus and Michigan’s response to the water crisis in Flint.
“Then there’s always the differences between a red state and a blue state in terms of their view and philosophy on the role of government,” Engel said. “It’s the issue of the nanny state. ‘Are we overreaching? What is the role of government here?'”
Engel also said elected officials can hold the risk of termination over the heads of state health officials, who are often “at will” employees who serve at the pleasure of their executive. He said resignations are rare, because many professionals are reluctant to risk their family’s security on principle.
“That’s why it took an incredible amount of courage for Megan to do what she did and she was able to do it on her terms, which is the highest principle I can think of,” he said, noting there are few positions for a high level physician executives like Davies to move to.
“This is a decision to derail her career and she had her eyes wide open about that,” he said, calling Davies an “outstanding medical epidemiologist.”
Davies, a former CDC Epidemic Intelligence Service officer and an 8-year veteran of the department who has served in multiple high-level positions and risen to national prominence, wrote of her “terrible loss” in leaving a job that “brings meaning to my life.”
Balancing Act
David Gifford, MD, MPH, formerly the state health director in Rhode Island, talked about being from one political party working under a governor from the other party.
“We had different views on things, but we never went there,” said Gifford, who held his position from 2005 to 2011. “And if we had to go there, I’d have to make a decision as to whether I could work for the governor or not.”
Gifford talked about the wide swaths of gray area that occur in science and in communicating risks, especially those posed by environmental health issues.
“There is nothing that’s risk free and there’s nothing that the public is more concerned about than infection and toxic exposure,” he said. “People have different levels of risk tolerance, how do you communicate that?”
“The fundamental reason is that the science is often not as strong as it is in communicable disease and protection,” Engel concurred. “The toxicity of some of these contaminants when you’re talking about safe drinking water is a little less certain than, say, a contaminated food supply or a child in a classroom with measles.
“No one will fight with you if you’re excluding that child from their classroom until that disease is over and no one will fight with you when you close the restaurant down when you find out that their salad bar is contaminated with Salmonella. But there’s always fuzziness on some of these toxicology issues around drinking water.”
Gifford noted many members of the public have a low tolerance for risks they don’t understand, even as they engage in more risky behaviors such as smoking or driving over the speed limit.
Both Gifford and Engel noted that environmental health risks are particularly thorny, with recommendations that change frequently as the science evolves.
“You’re always having to balance multiple positions,” Gifford said.
But Gifford bemoaned the way that these issues of public health have become so politicized, from both sides of the aisle.
“The discussion is always about who is to blame and how to prevent it from happening again and do it quickly,” he said, noting the media adds to the problem, in its search for sensational stories with easy-to-understand heroes and villains.
“It’s rarely an individual to blame and it’s never black-and-white as to how to solve the problem.”
In this environment, it’s hard to blame an governor’s administration for wanting to control messages about public health risk, “because every time something completely outside their control happens, they get blamed for it.”
The trick, he said, is striking the balance between minimizing or overstating a risk.
“If the communications are not well-crafted to appropriately communicate a balanced risk you can create more people who are afraid of a mosquito in the room,” he said.
That’s why Davies spoke up. In an interview Thursday, she said she felt that what the administration and her own department was doing was undermining public health.
“They accused public health of being unprofessional and irresponsible and I couldn’t leave that out there,” she said, worrying that this erosion of trust would undermine the public’s health in the event of an emergency such an outbreak or natural disaster.
Gifford concurred, saying that an administration that minimizes risks to public health can put its own political future in peril.
“When you start politicizing all these things, it takes away from being able to inform the public about them,” he said.
