Winter 1999

Bioterrorism:An International Problem of Local Concern

by Ralph Timperi MPH
Assistant Commissioner State Laboratory Institute

“Bioterrorism”, the threat of injury or disease from intentional releases of hazardous agents (in practice, the term Bioterrorism has been used to include chemical as well as biologic agents) by terrorists is a risk in our world today.

The events could include a range of acts such as hoaxes, exposure in a defined area such as a building or widespread exposure using a distribution system to produce mass casualties. This article primarily will discuss the issue of threats of biologic agents and the infrastructure for a response to all agents, as they are being addressed through a U.S. Centers for Disease Control and Prevention (CDC) funding initiative.

Pathogens that have been identified as a priority for the developing public health response system are anthrax, plague, tularemia, brucellosis, smallpox and botulinum toxin. These agents have been identified as a first priority because they are relatively easy to produce, cause death or disabling disease and can be released in ways to affect wide areas and many people. For example, anthrax spores can be dispersed with aerosol devices and cover a wide geographical area, or botulinum toxin can be placed in food and drinks.

The public health system must be able to rapidly respond to events, real or falsified, identify the risk or absence of risk, and communicate effectively with the public. Accomplishing these goals requires sophisticated technology, adequately trained rapid response teams for all components of the response system and most importantly a real time system for effective communication at the local level. The local health infrastructure is essential to the sound management of terrorist events.

Much of the required technology already exists to support rapid and accurate identification of these biologic agents. And many state public health laboratories (SPHL) have the capacity and competency to identify the priority agents except for smallpox, which would be handled at the U.S. Centers for Disease Control (CDC) in Atlanta, GA. Additional rapid identification methods are well along in their development by the U.S. Army and Navy research centers, which will make these tools available to SPHL. More laboratory staff will be trained in the identification of and immunized against these agents so that there is adequate surge capacity in the response system.

A communication, information and training system supporting an early warning and response network that protects the health of every community must be developed. The Massachusetts State Laboratory Institute (SLI) has the capacity to identify anthrax, plague, brucellosis, tularemia and botulinum toxin. As bioterrorism funding becomes available, more rapid methods will be added to our capabilities. SLI already has developed an Emergency Response Team that is on-call to assist first responders in evaluating risks, and transporting specimens to SLI for testing. Questions concerning this developing effort can be addressed to the Director’s Office at SLI (617-983-6201, ralph.timperi@nullstate.ma.us).

On February 22, 1999, CDC is expected to issue an RFA to State Health Officers, which will provide funding to upgrade national public health capability to counter real and falsified terrorist threats. The RFA will consist of five components that support state and local health departments.

  1. Preparedness Planning and Readiness Assessment to develop model statewide specific plans for response (Five awards averaging $140,000 each).
  2. Surveillance and Epidemiology Capacity for systems to detect, investigate and mitigate unusual outbreaks of illness that may be the result of terrorist activities (Thirty awards averaging $250,000 each).
  3. Laboratory Capacity for Biologic Agents (Twenty-four awards averaging $260,000 each).
  4. Laboratory Capacity for Chemical Agents (Four awards averaging $350,000 each)
  5. Health Alert Network/Training to assist local and state health departments to establish and maintain a network to communicate over the Internet and support all aspects of a response system, e.g., disease and prevention information, health advisories, test result information, press releases and query functions (15-25 awards ranging from $250,000 to $750,000).

It is expected that 85-95% of these funds will be used for improving local health information systems, unless a different distribution is mutually agreed. CDC will require a single response from the State Health Department, which incorporates the five components. States (and the three cities eligible to apply directly, New York, Chicago and Los Angeles) may decide to respond to any combination or all of the components.

The expected critical dates are April 30 for receipt of a response and August 15, 1999 for award of funding. The initial funding award will be for 12 months. Additional years of funding are anticipated, and supplemental funding may be received shortly after an initial award because of the timing in relation to the federal funding cycle.

If new funding becomes available in federal FY 2000 after October 1, 1999, it is possible that grant recipients would receive additional funds a few months after the initial award. Planning and coordination at a national level among CDC, SPHL, state epidemiologists, FBI and the U.S. Army and Navy research centers has been on going since last December.

In addition, statewide coordination activities are in progress. Developing the technical capacities to identify and intervene in terrorist events to prevent and minimize disease is a first step in preparedness. The critical component of effective communication will be developed through the collaboration of local and state health partners with the support of CDC funding through the Health Alert Network. However, development of such a complex system will take time. We must adopt a strategy that allows incremental growth and linking as many local agencies as possible as soon as possible.

How might this system work when fully operational? In the event of an announced threat, information would be made available to local agencies through the Health Alert Network. Disease specialists from the federal and state health agencies would support risk assessment of the exposure site. Environmental and clinical specimens would be triaged to SPHL and CDC according to the suspected agent and available capacity of the laboratories.

As soon as test information becomes available, it would be made available through the Health Alert Network. In the event of an unannounced terrorist act, the surveillance systems in hospitals and SPHL would be monitored for unusual events, e.g., detection of a rare disease or cluster of unexplained illnesses. Laboratory disease identification information will be reported daily through state surveillance programs and compiled at CDC. Investigation of suspect events would be done at a level appropriate to the potential risk. Special response teams from federal and state health agencies may respond quickly to gather epidemiologic data and specimens for analysis. Both announced and unannounced events will require close collaboration of local and state partners and the availability of a health alert network.

As serious a problem as identification and treatment of affected persons is, the screening of persons to rule out illness will be no less important. A terrorist event will cause concern and panic among a much larger number of people than are actually exposed and affected. It will be equally important quickly and accurately to identify those people, who are affected, and provide them effective treatment, those people exposed but not yet affected, and provide them preventive therapy, and those people not affected, and provide them with information to allay fear.

The occurrence of a terrorist event may be unlikely, but the consequences could be enormous. The current vision of a response system provides a feasible means to effectively guard against a disastrous outcome from such an attack. And the development of this surveillance system will improve the public health infrastructure for naturally occurring disease outbreaks as well.

The expected funding for Bioterrorism offers an unparalleled opportunity to improve the health of our communities and develop effective systems for communication among health professionals at all levels of the public health system. The current strength of the local and state public health agencies in Massachusetts will make our state competitive for all components of the upcoming CDC RFA. The collaborations already on-going will help us to be successful in seeking funding and effective in implementation of enhanced prevention systems.


The MAHB Computer Survey, which has been circulating since this fall will form an essential part of DPH’s request for funding under the Bioterrorism Monies…. We have tabulated about 100 responses, and now DPH will be seeking to fill in the blanks, and ask a couple of additional questions to meet the needs assessment requirement for federal antiterrorism funding. The DPH application deadline is April 30th, so your cooperation with this effort will be greatly appreciated. If you have not yet responded to our survey, DPH may be contacting your office by telephone. One of the goals of this project will be to provide all boards of health with the computer equipment and Internet access that plays an increasingly vital role in communications and information sharing.


WE DO MAKE A DIFFERENCE!

by Joan Barry

The Montague Board of Health office received an anonymous complaint in July, 1998, regarding the substandard conditions existing in a single family dwelling in the downtown section of Turners Falls, a village of Montague. Laurie and her mentally challenged adult son, Skip, lived in the house for six years and tolerated ongoing deplorable conditions. The building, of historical significance, long ago had been the area’s weigh station, but unfortunately, has a footprint of a meager 16 ft. x 18 ft. The interior consists of a small kitchen, bath and combination living room/bedroom.

The mother utilizes the living room space and Skip occupies the kitchen area as his bedroom. Laurie was reluctant to allow the health agent to conduct an inspection initially for fear of upsetting the landlord and the threat of eviction.

However, after gentle prodding consensus was reached. The inspection revealed numerous violations, including rotted or absent flooring. 3-4 inch gaps around and no locks on exit doors, unsafe basement stairs without a railing and broken windows allowing winter air to consume the living space. The house did not have a functioning heating system and the house foundation had a gaping hole where a set of cement stairs once served as access to a bulkhead door.

Due to the deleterious conditions, Laurie rented a room in another town each winter while remaining current with the rent in Turners Falls. Skip was restlessly restricted to the rented “seasonal room” until his mother came home from work. Laurie and Skip wish to remain in their Turners Falls home because in “good weather Skip is able to walk to the river to fish, walk to the local stores, and maintain ties with friends. To Laurie these living conditions were “normal”.

The health agent felt that it was incumbent upon her to spend the time with Laurie to point out each health and safety violation, how and why it needed to be rectified in the process of achieving compliance. The agent recognized that it would be more likely that timely compliance would be met if Laurie could change her perception and expectations of what “normal” living conditions were.

Unknown to either party, this was the beginning of a transformation of a single mother’s expectations of life. The property owner, being a chronic violator of the housing code, was scheduled immediately for a hearing. At the hearing, the Board of Health informed the landlord that the property would be targeted for receivership through the Attorney General’s Abandoned Buildings Program if the repairs were not completed within two weeks. The landlord had a history of noncompliance and the building was in tax title. The deadline was not met.

The Board of Health realized that compliance would only be met with the filing and follow through of criminal charges. However, Franklin County does not have a housing court and charges must be filed in district court. The district court has a history of not moving housing complaints beyond show cause hearings and the District Attorney’s office had been making overtures about not prosecuting Board of Health cases.

These obstacles left our enforcement capacity in a seriously restricted state at a time when the Montague Board of Health was aggressively focusing its efforts on proving the health impacts of neighborhood disinvestment. The village of Turners Falls has for some time struggled with a major crisis due to the downward spiral of property values, lackluster maintenance and economic vacuum. Many neighborhoods have been designated as blighted areas and Laurie’s section is included.

A survey conducted by the Inspector of Buildings and the Health Department found that more than 55% of the housing stock is in dire need of significant rehabilitation. The Board of Health took the initiative to develop a plan to inventory code violations and violators and curb this trend without the help of the legal system, since it has not been an available tool.

The Board set hearing dates germane to each enforcement order for Sanitary Code violations. The property owners were required to sign and commit to a schedule of repairs, a no-occupancy agreement, and/or a consent agreement crafted for each particular situation. Soon, the town reached a point where buildings were boarded up, rental units were not on the market and property owners needed to be encouraged to meet their obligations to upgrade and maintain properties if they wanted to remain landlords. The remaining properties were cited under the Attorney General’s Abandoned Housing Recovery Project.

This action resulted in an adherence to a rigorous schedule of repairs and in some instances, transfer of ownership of properties. As a result, the Board of Health was left with the most egregious recalcitrant property owners, including Laurie’s landlord, without an effective supply of enforcement tools. Therefore, the Board of Health initiated a forum with court officials, the District Attorney’s office, a Special Assistant Attorney General, the Department of Public Health, legal advice from MAHB, the town’s Inspector of Buildings and Board of Health members and agents, to discuss each others desired goals.

The upshot of this forum was a commitment from the Clerk Magistrate to expeditiously move the cases through show cause hearings and a promise from the District Attorney’s office to continue to prosecute Board of Health cases of neglect. Thursday mornings have now been reserved for sanitary code arraignments and Thursday afternoons are set aside for case hearings.

The ensuing Thursday morning, Laurie filed a Temporary Restraining Order against her landlord to provide utility services or alternative housing. The order was granted. Shortly thereafter, the landlord installed a gas heating system unfortunately without securing the necessary permits. The landlord entered into mediation with Laurie at the request of the judge.

The agreement stipulated Laurie not pay rent until the dwelling was brought up to code. Flooring has been replaced, weather-stripping and locks have been installed on the doors, a railing has been placed at the basement stairwell, and the windows have been repaired. Although the quality of the craftsmanship is subpar, the house is warm and for the first time in six years Laurie and Skip can sit home and enjoy a morning cup of coffee together without competing with outside winter elements. The house does not, as yet adequately meet the sanitary code. The Board of Health is unfortunately filing criminal charges in district court and is working with the Attorney General’s office to pursue the Receivership option.

At times we may question the effectiveness of our efforts as Board of Health representatives because compassion is instantaneous but resolution often seems to take an eternity. However, when one sees the positive impacts upon individuals with which we have worked it is a gratifying experience- Our community is the expression of the individuals residing within it. When we empower an individual we empower our community as well.

Now, Laurie has expressed increased expectations for herself and her son. She looks back and wonders how she accepted her earlier standard of living as sufficient. Laurie has a sparkle in her eye now and her son is pleased with the idea that he can live in his own home, not some stranger’s room. And this is just the beginning of the story.


DEP Commissioner Accepts New Challenge in Florida

Calling it an unexpected and exciting opportunity, Commissioner David Struhs has left the Massachusetts Department of Environmental Protection to become Secretary of Environmental Protection for the state of Florida.

His appointment was announced in January by Florida Governor Jeb Bush. “For the past three and a half years, I have held one of the best environmental jobs in America,” Struhs said. “Now, I’ve been offered an unexpected and exciting opportunity to bring some of Massachusetts’ pioneering environmental management strategies to Florida. It’s an opportunity I can’t pass up.”

“David Struhs is one of the nation’s most innovative environmental leaders, and will be an asset to Governor Bush’s administration,” said Governor Paul Cellucci. “He has made life better for Massachusetts families and proven that environmental protection can go hand in hand with a strong economy.” Struhs was appointed DEP Commissioner in May 1995. Among the many key accomplishments during his tenure were:

· Implementation of the Environmental Results Program, a first-in-the-nation new regulatory framework that replaces traditional permits with environmental performance standards;
· The successful negotiation of a comprehensive agreement for cleanup of the GE-Pittsfield facility and Housatonic River;
· Legislative approval and successful DEP implementation of the Rivers Protection Act;
· Reform of hazardous waste liability rules to spur brownfields redevelopment; and
· Leading a coalition of Northeast states to reduce the long-range transport of air pollution while encouraging the restructuring of the electric power industry.

“Our accomplishments are the result of the hard work and dedication of 1,100 talented DEP employees who strive every day to protect and preserve public health and environmental quality in Massachusetts,” added Struhs. “The fact that other states and governors look to our state as a leader in environmental protection is a credit to all of them.”

“Good-byes are often difficult, but especially so when leaving behind an experience as rich, as rewarding, as the three and a half years I have spent at DEP. As many of you have heard me say more than once, I feel incredibly fortunate to have held one of the best environmental jobs in America. And it’s a job I was genuinely looking forward to continuing in for the next few years, working closely with Secretary Bob Durand to build on the solid foundation of progress we have created on a number of fronts.

” But the unexpected and exciting opportunity that has been offered me to transfer Massachusetts’ pioneering environmental management strategies to Florida as that state’s Secretary of Environmental Protection is an opportunity I couldn’t turn down. I like to think that I have helped DEP achieve some important and lasting changes that allow us to better protect our public health and environmental quality.

“To the extent these accomplishments prove to be either important or lasting, the credit rightly goes to DEP’s dedicated and hardworking staff of environmental professionals. Building on the solid foundation of progressive environmental tradition in Massachusetts, we overhauled 30 years of command-and-control regulation by launching the Environmental Results Program. We expanded the use of the state revolving fund to address non-point source pollution.

“We successfully implemented the Rivers Protection Act to protect 9,000 miles of riverfront. Working with the Governor’s office and the legislature, we reformed traditional hazardous waste liability rules to encourage private sector investment in the cleanup and redevelopment of brownfields. Massachusetts led eight northeastern states in convincing EPA to impose tighter standards on dirty power plants throughout the eastern U.S. DEP was a key player in the negotiation of a landmark, comprehensive settlement with General Electric for cleanup of the Housatonic River and GE facilities in Pittsfield. These are just a handful of the dozens of successes we have forged together. Through it all, Governors Weld and Cellucci have provided not only unwavering political support for me and the agency, but have time and again provided critical guidance and insights at strategic points.

This has made the difference in our ability to deliver on our environmental mission. Massachusetts’ environmental future is as bright as it has ever been. Trudy Coxe helped establish an unrivaled record of accomplishment. And Bob Durand is uniquely qualified in terms of experience, ability and demeanor to lead us into the future. The fact that other states and governors look to Massachusetts as a leader is a credit to all of you. I thank you for that, and for your loyalty and dedication. I will always be grateful and wish you every success in the future”.


Mass DPH Communicable Disease Control and Boards of Health Collaborate on Information Technology Initiative/Immunization Information System

The Massachusetts Department of Public Health’s Bureau of Communicable Disease Control has begun an initiative that will enable some Boards of Health to access the Internet, participate in on-line training by DPH staff, track immunizations given at or by a Board of Health, and electronically manage vaccine distribution between the Boards of Health, providers and the Department.

The Division of Epidemiology and Immunization, of the Bureau of Communicable Disease Control, has made computers available to twenty eight Boards of Health serving some of the largest communities in Massachusetts. The computers will have software that will allow people at the Boards of Health to go “on-line” using the Internet, to get important disease and outbreak information.

Another important component of this project is the ability for Boards of Health to utilize the latest version of the Massachusetts Immunization Information System (MIIS).

The MIIS is a statewide immunization tracking system and central registry. The Boards of Health will be able to use the MIIS to track shots they administer. The MIIS automatically updates every shot record entered against the latest version of the Recommended Childhood Immunization Schedule and the accelerated or ”catch-up” schedule.

Every time a shot is added to a record, the projections for when the next dose is due using the child’s age, and today’s date, are updated for every vaccine type. The MIIS provides for a host of immunization reports and lists. Among them are the Immunizations Due Report that allows a provider to ask the MIIS to create a list of children at their site who are due now, coming due or overdue for some or all vaccines based on age ranges and other factors that the site identifies.

Using the MIIS, Boards of Health will also be able to send shot records to and get shot records from the MIIS Central Registry. Official parental consent is necessary for information to be shared by the Department with users of the information. The central immunization registry provides whole communities with accurate and timely immunization histories for children who migrate between providers, schools, and Boards of Health for receiving immunizations.

Boards of Health can help their communities and themselves by recruiting provider sites to use the MIIS. The newest version of the MIIS that will be released this Spring also includes a vaccine inventory module. Provider sites will be able to use the MIIS to note what lots they are currently using for each vaccine type, decrement those lots when they give shots, set reorder levels, and order and receive vaccine from Boards of Health and other depots.

Boards of Health using the MIIS will be able to electronically manage their vaccine distribution between those provider sites and the Massachusetts Department of Public Health. At this time, the Department is considering regulations that would mandate providers to report immunization records to the MIIS. These regulations are necessary to maximize completeness of information in the system, protect health care providers who report immunizations to the MIIS from civil and criminal liability, and establish safeguards to protect the privacy of individuals identified in the system.

We are in the process of obtaining further support from public health professionals and child advocacy groups and we will be seeking the support of the Massachusetts Association of Health Boards as well. The MIIS is provided free of charge to any site that distributes vaccine or that gives shots. For more information about the MIIS, contact Dennis Michaud, Director of Client Support, MIIS at 617-983-6838 or via e-mail at Dennis.Michaud@nullstate.ma.us


Evaluation Results from the 1998 MAHB Training and Certification Programs for Massachusetts Boards of Health

prepared by Edward Bertorelli -MAHB Community Outreach Coordinator

A total of 236 people registered for the 1998 trainings offered by the Mass.Assoc. of Health Boards. One hundred ninety five of those who registered attended, representing eighty-four communities with a population range of 725 (Heath) to 547,725 (Boston). In addition, representatives of the NASHOBA Assoc. Boards of Health (comprising 14 towns) and the Franklin County Council of Governments (comprising 21 towns) attended. One hundred nine people attended the Primary Certification program and eighty-six people attended the new Advanced Certification program.

The 195 attendees included :
34 Board of Health members; 28 Health Agents, 6 Health Directors; 7 Tobacco Control staff: 2 School of PublicHealth faculty: 4 DEP staff, 3 public health nurses; 7 Board secretaries.

1998 is the first year that MAHB offered a two-tiered Certification program – with Primary & Advanced components. The Primary Certification program is based upon the Guidebook for Mass. Boards of Health and is designed for those individuals who are board of health members and others wishing to acquire the experience and technical skills needed to perform their duties adequately.

The Advanced Certification program is designed to recognize those individuals who have already acquired the basic skills and knowledge from the Primary program, but want to focus on a more detailed exploration of topics important to boards of health and also focus on skill building. The content of the Advanced Program will change every year – in order to present new material. The number of registrants declined slightly from last year. Anecdotal evidence suggests that DEP Title 5 trainings, and a misconception about the advanced certification format contributed to the lower numbers. Several people reported that they did not realize that this program changes every year, and thus did not register for a second year.

Participants were asked to complete an evaluation grading both content and instructors. The Primary Program included the following topics: Introduction to Public Health; Legal Authority; Water Quality, Solid Waste Mgt. & Disposal; Conflict Resolution ; and Family & Community Health. Total ratings for the six topics were 272 A’s (met expectations), 72 B’s (partially met expectations), 7 C’s (expectations not met). Presenters received a total of 316 A’s, 69 B’s and 12 C’s. The Advanced Program included the following topics: Cancer Clusters; Nuisances & Noisome Trades; Enforcement Options; Conflict of Interest; Effective Hearings. Total Ratings were 242 A’s, 31B’s, and 6 C’s. Presenters received a total of 256 A’s, 17 B’s and 1 C. These totals reflect the fact that some surveys were only partially completed. Although the results were generally excellent, we are incorporating a number of constructive comments into the planning for the 1999 fall program. Anyone wishing to obtain the complete evaluation results may do so by contacting Edward Bertorelli, MAHB (508)473-9665.


Cambodian Health Program

by Julie Federman R.N.

The Amherst Health Department has completed the Cambodian Health Program funded by MAHB for the Spring of 1998. At the time we received the grant monies, major changes had occurred within the local grass roots program we planned to work with, the Cambodian American Association (CAA). The CAA office relocated to the same building as the Health Department, and a new Director took the lead and confronted numerous fiscal problems.

Due to this, the shape of our Cambodian Health Program changed. It was then decided not to hold weekly Tb clinics as a result of several factors. The site to do so within the Cambodian community no longer existed because of the relocation of the CAA office. Furthermore, as community assessment began, it became clear that Cambodians were being tested at the Health Department or by their own physicians on a consistent basis.

The larger need that was evident was for Tb education at all levels within the Cambodian community. Initially, the Public Health Nurse held discussions with Magda Ahmed, the Refugee Health Coordinator for Western Mass. DPH. State procedure for refugee Tb testing and tracking was reviewed. Out of these discussions, a resource was identified in the Lowell Cambodian community, who has worked as a Tb outreach worker for many years, providing outreach and education.

A meeting was arranged in April 1998 at DPH between the Public Health Nurse and the outreach worker Sovanary Lak. Carol Cahill, the Western Mass. Regional Tb Nurse Specialist, was consulted on Tb issues and the Cambodian community. Throughout May and June, the Public Health Nurse (PHN) held small weekly meetings with various leaders in the Cambodian community and a Cambodian outreach worker.

At these meetings, the Public Health Nurse provided education about Tb transmission, testing, symptoms, and treatment. Many misconceptions about Tb surfaced as well as the traditional beliefs of Cambodians, especially among older Cambodians. The Department’s role was explained regarding Tb prevention, testing, case management, and the availability of the PHN to Cambodian residents. Two representatives from the Cambodian American Association, one Cambodian caseworker from the Hampshire County WIC program, and the two main community leaders in the Amherst Cambodian community participated in theses meetings

They explained beliefs and practices surrounding Tb for many Cambodians. They also edited or rewrote Khmer teaching materials after translating their content for the Public Health Nurse to evaluate and revise. Older Cambodians believe that Tb is genetic. If a member of another family has Tb, they would say that family had a sickness and not want and/or allow their children to marry someone from that family. They sometimes believe that a Tb test confers immunity to Tb.

The Cambodian Health Advisory Committee held large monthly meetings.This committee was formed by the Amherst Health Department, Cambodian leaders, and service workers throughout Western Massachusetts. Education about Tb was presented at the Cambodian Temple via interpretation by the Cambodian outreach worker. The monk, two nuns, and several elder leaders participated in the discussion.

A policy was developed out of this project involving Tb testing. It became clear that education about the long term implications of a Mantoux test and completion of Tb prevention treatment was needed. Now, from the beginning of the testing and treatment process, clients are educated about many aspects of their health status. They are given several copies of their mantoux test results, a letter (for future employers’/health care providers) explaining that they have received RX for the test, the dates treatment was received, and a letter for themselves explaining that they should not be skin tested for Tb again and to advocate for themselves against needless x-rays, if they are system free in the future. From this project we learned that it was important to find people within the community to serve as gatekeepers.

We have had good success working with college age students who have spent a few years in the U.S. Having a bit of money to give them as a stipend helps. It is important that health department staff is flexible in working with cultural differences. For more information about the Cambodian Health Program, or copies of the Khmer teaching materials, please contact the author at the Amherst Health Department, 70 Boltwood Walk, Amherst, MA 01002, or by phone (413) 256-4077.


Institute for Local Public Health Update

A valuable new resource for Massachusetts boards of heath and health departments was launched on December 16, 1998, as the Massachusetts Institute for Local Public Health held its inaugural Invitational Conference. Over 100 public health leaders, academicians and representatives of interested professional associations gathered to participate in group discussions on the Institute’s mission and objectives.

We also heard from Commissioner Koh, Commissioner Struhs, Judith Kurland, DHHS Regional Director, and from a senior representative from each of the state’s four public health graduate schools. Resonating with the Institute’s singular mission… to strengthen the capacities and capabilities of local public health through collaborative education and research.. Judith Kurland reminded us that most contemporary public health issues must be resolved at the local level. She then outlined five challenges to the Institute”

  1. analyze infrastructure and organizational issues with a goal of determining what organization is best suited to do specific local public health tasks and how can the Institute help increase the capacity of that organization;
  2. provide much more training for all local public health practitioners and policy-makers,, and expand certification programs;
  3. consider how to redeploy existing resources and to avoid duplication in both practice and capacity-building;
  4. graduate schools must share their advanced, scientific knowledge with their communities; and
  5. communities should be involved in the early design phases of community-based research projects.

Each of these five points: infrastructure, training, resource sharing, school-community exchanges, and community-based research … will be included in the Institutes’s first-year action plan. What emerged from the presentations and discussions were several clear, concise common themes which will now shape the future of the Institute. These themes will serve as guideposts for the work of the member organizations coming together as the Institute. An overriding consensus stated that there is an increasing need for additional advocacy on behalf of local public health interest, that is. fostering community support for local public health endeavors is a critical need along with a validation of the roles of local boards of health. Further, it was agreed that there must be increased dialogue among all local public health stakeholders…board members, municipal officials, health officers, legislators, public health nurses and graduate school faculty. Beyond the focus on advocacy, two other consensus points emerged: first, there must be new, alternative pathways for graduate studies which would also serve to close some of the current disconnects between academics and community, and second, there must be a continuing implementation of new technologies, especially for distant learning. The Institute’s Program Planning Committee is already at work advising on the content of the second Invitational Conference, now tentatively scheduled for April 29, 1999.


Profile: Randall Swartz Ph.D.

9 years on the Winchester Board of Health
Presently Chairman

Prior town service:
Conservation Commission Education: B.S. and Ph.D. Rensselaer Polytechnic Institute

Hobbies: Camping, Whitewater Canoe Trekking, Rebuilding and driving classic British Sports and Touring Cars, Travel in US and Europe Interests: Efficiency and responsiveness in government

Favorite Books/movies
Science fiction especially Robert Heinlein, Adventure, especially: Clancy, Ludlum, …/ I particularly enjoyed “A Civil Action” because of the conflict portrayed between local public health, the environment and established commercial and political interests.

Why did you decide to serve?
In 1989 my young daughter was killed when her friend’s parents failed to supervise the children at a private pool. My wife and I were devastated. In dealing with the tragedy two factors coalesced —
1) I focused on swimming pool safety as a local issue. The Board of Health was the local agency responsible and the Board was very supportive. Based on my work with the Conservation Commision and my research interests in vaccines and therapeutics, the Board suggested that I run for election to it.

2) I view each of my children as a part of my legacy and believe each is here to add a measure of good to the society. My two sons, Mark and David are doing so through their work in their schools, community and church. I am very proud of them. At a very deep level I came to identify my own increased community service through the Board of Health as a way through which I could give to the world the “good” that Patricia could have given had she lived.

Important Community Health contributions
An outstanding food service inspection program featuring required training of licensees, four extensive inspections per licensee per year with followups on problems identified; an environmental improvement program especially successful in the husbanding of our recreational surface waters (we recently restored and reopened our local swimming pond) and an immunization and health maintenance program serving all age groups. Working through the BOH I led the Town in the construction of a modern potable water treatment plant.

What are the Board’s Most Pressing challenges?:
Frankly we have routine issues well in hand and institutionalized. However we are in a previously industrialized region with aging sewer systems and drainage systems and virtually unregulated growth to the North in the Aberjona River subbasin. We are environmentally challenged as a result.

Some years ago we passed a local “21E type Regulation” and this gives us authority to control waste sites and a place at the table with DEP and EPA but we have difficulty when actions taken by other municipallities and agencies threaten Winchester. We are currently responding to arsenic contamination in our watershed which may be linked to the Woburn Superfund site, massive sewage overflows and flooding in heavy rain storms related to development upstream, illegal connections to the sanitary sewer and an aging and inadequate regional sanitary sewer system. A recent project focus on substance abuse among teens is a serious challenge because the lives of our children are threatened. I am working very hard to help lead the community in adressing these problems.

Words of advice to other board members:
Local BOH’s are regulators and advocates for and creators of new regulations in health and environment. They also serve residents directly in areas of need. They must be both independent of misdirected political pressure and responsive to community needs and wants. On balance, I favor an elected Board because I have seen the potential for misuse of control even with a measure of independence of action. With the diverse skill set and focus of the more than 300 local health boards there is a great need for support of their activities and to assure the quality of their service. In the Local Health Coordinating Council many of us are working with DEP and DPH to address these needs. They will be met but I am convinced that they must be met by primarily elected Boards with strong regional and Commonwealth support.