By BILL MILLER

The Illinois director of public health
wants organized local health departments

Dr. James Q. Peterson

THE ROOTS of the Illinois Department of Public Health date back 100 years to July 12, 1877, when the Illinois legislature passed a law establishing the State Board of Health. That first board had a staff of three persons and a biennial budget of $6,000.

The state agency has grown to a present-day staff of 1,100 persons and an annual budget of $70 million in state and federal funds.

At the turn of the century, the department was spending $9 per 1,000 persons whereas now, the combined state and federal expenditure is $5,304 per 1,000 Illinois residents.

The Department of Public Health touches the lives of the state's citizenry every day. According to a report just released in connection with the department's centennial observance, it is involved "in the daily lives of Illinois residents who drink milk; eat in restaurants; swim in public pools; drink from public water supplies; have dental or medical x-rays; shop for groceries; get married, divorced, or have babies; shop for toys; send children to summer camp; need eyeglasses; visit Illinois recreational areas; and a myriad of other activities."

Those with special health needs are also served, such as premature babies; children needing immunization; persons contracting venereal disease; persons living in nursing homes; victims of sexual assaults; and migrant farm workers.

Gov. James Thompson named a professional to head the department — Dr. James Q. Peterson, who had been dean of the School of Public Health, University of Illinois Medical Center, Chicago, for six years. Prior to that, Dr. Peterson held a number of key posts, including several with the Office of the Surgeon General in Washington. He received his M.D. from the University of Illinois in 1938 and his M.P.H. from the University of Michigan in 1946.

Dr. Peterson is a strong believer in the development of local health departments as evidenced by his responses.

Q: As your department enters its second century of operation, what do you see as some of the major health issues facing Illinois?

A: Illinois does not have all its counties and cities covered with organized local health departments. When we look at the geography of the state, we have something less than one-half of the geography covered. I am committed to a program that will put in place a modern state law calling for the organization of local health departments in Illinois, providing for the tax base that will make it possible for minimal basic programs to be provided and making arrangements whereby counties can join together in multi-county departmental programs rather than the sorts of casual and unsatisfactory arrangements that now have to be negotiated when two counties want to join together to improve the quality of their program.

The second step in this process is the sharing of the responsibility for funding local health programs by the state. I have indicated to the governor that this is one of the highest priorities that I will bring to him in the development of our fiscal year 1979 program and budget.

Another area of great concern to me is in occupational health and industrial hygiene. There is no program in Illinois — other than those programs that are provided by the major industries where the state provides consultation, support for occupational medicine, occupational toxicology, industrial hygiene or occupational nursing programs. The smaller industries of this state are in desperate need of this supportive service.

A third area that I am concerned with is the fact that we are now living in an environment that is constantly receiving industrial chemicals and products that are being used widely in industrial programs of manufacturing and the agricultural industry of our state. We really do not have a mechanism to assure that we are monitoring that environment, knowing what is going into it, keeping track of the products that are beginning to appear, and having the epidemiological and environmental expertise — as well as the laboratory backup — to make it possible for us to anticipate problems. Illinois does not want to be faced with the horrible situation which developed in Michigan with the PCB's [polychlorinated biphenyls] and PBB's [polybrominated biphenyls] and other chemicals that got into

BILL MILLER
A veteran reporter and winner of many awards, he is associate professor and director of the Public Affairs Reporting Program at Sangamon State University in Springfield.

18/ December 1977/Illinois Issues

the environment and caused such extensive human concern and illness before they were identified and stopped. Another area that is one of great concern is that Illinois, like most other states of the nation, has allowed the levels of immunization among pre-school and school populations to fall to dangerously low levels. There is a program that is being initiated by the [U.S] Public Health Service and the Center for Disease Control, which Illinois will participate in this fall. We will aim at raising the immunization levels of these target populations from approximately 60 per cent, which we feel is representative of most of the state, to a level of no less than 90 per cent of these young folks in the pre-school and school-age population immunized against the major disease problems for which we have antigens and vaccines that can be used.

Q: What diseases are you talking about?

A: Diptheria, whooping cough, measles, rubella, polio, and tetanus.

Q: Do Illinois residents face a continuing upward spiral in health care costs or do you see anything to indicate a downward trend?

A: No, I think there will not be any downward trend. It is my firm belief, however, that it is possible for us to very significantly change the rate of inflation that now characterizes the health systems community of the state. I am also sure that it is possible for us to arrange for the care of a larger percentage of the health needs of our people in circumstances that are less expensive than the institutions upon which we have come to depend. It is my feeling we can begin to get some reduction in the rate of inflation by putting in place a rate review commission. A bill of that sort [H.B. 2339 to create the Illinois Health Finance Authority] was endorsed by the Departments of Public Health and Public Aid, and we worked with the Illinois Hospital Association and the insurance industry in an attempt to reach a consensus that could be reflected in legislation. That bill wasn't passed in this session, but we will be working on it because it will give us an opportunity to go to prospective rate

Fielding problems in public health PUBLIC HEALTH is a big area covering everything from public water supplies to X-rays. In the last year the Illinois Department of Public Health and its director faced a variety of problems — some recurring, some new. Immunization levels among school-children have dropped dramatically in the last few years, (nationally: 84 per cent in 1963 to 65 per cent in 1977) leading to an increase in cases of preventable "childhood diseases." Last winter there was a measles epidemic in Cook county. This October the IDPH identified cases of whooping cough, 84 of them in the East St. Louis area. A survey of kindergarten students is underway by the Illinois Office of Education to determine the number and location of unimmunized children. This way any pockets of unvaccinated children can be identified and the health department can begin immunization programs to prevent further outbreaks from occuring. Reported cases of Rocky Mountain spotted fever rose from 7 cases in 1976 to 33 cases in 1977. The IDPH advised hikers and vacationers to be alert for ticks and to wear protective clothing. The cause for the increase is unknown but may be linked to factors such as favorable weather conditions for ticks or an increase in the number of persons who visited wooded areas in the spring and summer months. Encephalitis is another seasonal threat to public health. It becomes a problem in late summer when mosquitoes turn from birds to humans for their food. Fourteen cases were confirmed by the IDPH this year, a decline from 1976 when 19 cases were reported. Horses and related animals may also be affected; 100 cases of equine encephalitis were suspected (47 confirmed) this summer. The incidence of this disease depends on its presence among birds and the number and type of mosquitoes present. Since 1975, when a severe outbreak occurred, IDPH has made surveys of bird and insect populations during the spring and early summer to determine the probability of encephalitis cropping up in the following months. As the radioactive cloud from China's nuclear test passed over Illinois in September, IDPH took samples of rainwater, milk, air and soil to determine the amount of contamination from the fallout. Tests showed a slight increase over normal background radiation levels in water and milk, but air and soil samples showed no increase. No danger to health was indicated in the tests. Because the cloud continues to circle the earth the tests were repeated, but on the second time around the cloud had lost most of its radioactive zap. Arsenic treated wood was ruled unsafe for use in dwelling foundations by the IDPH in October. Its use represents a health hazard from both arsenic poisoning and possible deterioration of the wood. This ruling came after complaints were made about apartment buildings for low and middle income families under construction in Peoria. Wood treated with arsenic has also been used for telephone poles for many years, but there appears to be no risk of soil contamination or other poisoning from this source. Plumbers are licensed by the IDPH, but the agency has its problems in this area. The state Supreme Court ruled in October that the Illinois Plumbing License Law was invalid and that by not defining what "an approved course of instruction" for plumbers consists of, IDPH's director "has not fulfilled his duty" (see Judicial Rulings p. 28). The amount of fluoride in drinking water is regulated by the federal Environmental Protection Agency (US EPA) but is also a concern of the state. The fluoride level is currently two times the optimum amount or approximately 2 milligrams per liter. In a joint statement the IEPA and the IDPH asked the USEPA to raise the maximum amount to four times the optimum level (4 mgs. per liter). This change would represent a substantial savings to public water suppliers since in some areas natural fluoride exceeds the federal limit and must be removed through an expensive process. An increase in the amount of fluoride would not be a danger to health. Research has shown no damage occurs until amounts 8-10 mg. per liter is present, although teeth may become stained when levels reach 5-6 mgs. per liter. An outbreak of cholera in several Mideast countries does not pose a threat to Illinois residents. Careful regulation of public water facilities, chlorination and good waste disposal systems eliminate the possibility of the disease here. The IDPH advised travelers planning to visit those areas to contact their doctor or the department for advice. Investigation by the department of reports that showed a high rate of leukemia in Aurora and arsenic poisoning in East Alton turned up no evidence to support the claims. According to a department spokesman, the statistics in Aurora were correct but had not been interpreted accurately. The arsenic cases in East Alton were linked to faulty lab

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setting rather than be caught in the situation we now are in where we can only reimburse on patient-care related costs. There is no way that one can get at any sort of rationalization of the economics of hospital and extended care and nursing home costs if you are just constantly paying for patient-related costs. On the other hand, if it is possible to go to prospective rate setting, where you negotiate on the basis of [hospital and nursing home] budgets, then it will be possible to begin to put in incentives that call for efficiencies.

The other thing is that we must move to a program that depends to a much larger extent on ambulatory care, on primary care, on family care — on noninstitutional care — of those who are ill. And a much, much greater emphasis must be placed on preventing preventable disease. It is such an expensive thing now to allow cancers to continue to be developed just because we allow folks to smoke too much, or have so many heart attacks because people will not eat proper foods and use proper diets, or we insist upon allowing people under the influence of alcohol to drive at excessive rates, so that we continue to fill our hospitals with unnecessary illness and trauma.

Q: How do you stand in relation to the controversy over whether marijuana should be legalized or decriminalized?

A: I have a personal stand. I know there is great controversy in this area. I am also, as a physician, aware of the data that is argued that marijuana is no more harmful than cigarettes or certainly of alcohol. I, however, as a physician cannot assume and be comfortable with a logic that says just because something is no more dangerous than some other noxious product that we should encourage people to use it by decriminalizing or by otherwise bringing it more into the social circumstance of acceptability. Our problem is not to increase the number of products that we can use to abuse our bodies. Our problem is to minimize the number of those products.

Q: Gov. Thompson is advocating some governmental reorganization. The Illinois Task Force on Governmental Reorganization, known as the Bonniwell Report, last fall recommended consolidating most existing agencies of the state into 14 major departments. Under the recommendations, the Public Health and Mental Health Departments would be merged and their regulatory functions split off into a separate independent state agency. How do you feel about it?

'We must move to a program that depends to a much larger extent on ambulatory care, on primary care, on family care — on noninstitutional care'

A: There are a number of recommendations in that report that I think are quite appropriate. For example, I think it would be desirable to bring together mental health and public health programs. The separation of the emotional from the physical man is, I think, not an appropriate one, and we are not seeing in local communities and agencies the sort of coordinated programming that ought to take place. Because they are being supported by two different state departments, the coordination is not effective and you get categorical programming that is inefficient. [In a joint statement issued October 21, Peterson and Dr. Robert A. Devito, director of the Department of Mental Health and Developmental Disabilities, pledged to collaborate at both the state and regional levels on programs and issues that involve the two agencies.]

However, I think the criteria that have been used by the Bonniwell people in developing this report did not identify the elements that ought to be governing in terms of those departments or the elements of health service that should be brought together. For example, they would propose taking all of the programs from Public Health that deal with regulatory authority and putting them into a Department of Regulations. That would be a terrible, terrible thing where just because we use regulations in food establishments — or in milk supply surveillance, or in licensure and certification of hospitals — those institutions would be taken off and put under a police authority. That would be a horrible thing.

On the other hand, Medicaid and Medicare, which are health care functions, should be a part of a health service agency. I think that potable water supplies — instead of being a part of the Environmental Protection Agency should be brought into health, because all the functions of service that focus on man and on man's health essentially point to the same constituency.The same agencies that are providing service at the local level — the health professions, the health institutions, the local health departments — all of these are a single constituency. The professional staff that is required to provide the service, the way in which the programs are structured, the techniques that are used, are common; and that is the set of conditions that ought to be the determinants in the decisionmaking that will take place as to the new configuration of the state government. It is a set of beliefs that I have already indicated to the Governor's office.

Q: You have just reached that magic age of 65 — back on June 30. Some say when we reach that age we should be put out to pasture. With some organizations, it is a mandatory retirement age. What are your feelings?

A: That comes pretty close to home when you put it that way. I think there are many situations when it is desirable — when people have obviously reached a point in their physical, emotional and mental capacities where they are unable to continue to function in the places in which they have been employed. In those circumstances, I think it is important that they step down. On the other hand, I don't feel that those of us who have reached advanced years ought to be denied opportunities to function in perhaps less demanding circumstances. Certainly, at my age, although I am no longer able to do many of the things that I could do as a young physician in public health and epidemiology, the years have given me some wisdom that make it possible for me to be helpful to younger members of our staff and help them to avoid errors that might otherwise in their enthusiasm appear. On the other hand, I will be the first to say that I will be more than happy on the day that a young physician, who has been well prepared in modern medicine and who has had graduate work in public health and preventive medicine, can be identified who will assume this responsibility in the department and be able to lead it to the years ahead in a way in which I am sure will be better than if I were to try and continue beyond my years as the director.

20 December 1977/ Illinois Issues