Health Millions going to salaries blare the headlines.

Mayor Thomas McDermott Jr. was stunned when he learned that nearly $1 million of a $1.25 million budget for a children’s health program is going to cover salaries.
Now, in the real world, a million dollars is a lot of money.

And I’m the first person to lament on the amount of waste in Government programs that require every tiny thing to be document in triplicate. I HATE paperwork.

But for public health, that’s how things are done (wish I knew a better way to do it).
Indeed, I am wondering is why the salaries are so low

A look at the newspaper article shows the positions mentioned are for people who do paper work. Where are the salaries for doctors, for nurses, for medicines? Why all the complaints about a “governing board” that doesn’t supervise the program, when there is no explanation of the program?

Well, I am not familiar with the local program in the article, but I am aware of Healthy Start and other similar programs.

Go to the link. This program, like many other public health programs, has many lofty goals. However, the paper work is enormous. Huge amounts of money go into training on how to do the paperwork, on collecting data and on publishing reports. The problem is that the impersonal goals are almost a barrier to those best at implementing the actual goals.

So what do they get for their money, aside from lots of dead trees to provide the paper for all the reports?

They provide grants.

A little extra money for the ones who actually do the work and to help them work more efficiently with high risk populations.

You see, healthy sophisticated people keep track of their own medical care. But other people, for various cultural and social reasons, don’t. But a private practitioner doesn’t have the money to pay people to do outreach on a regular basis (although many private clinics do outreaches especially HMO’s, these don’t always reach the people who by choice or by lack of money don’t visit doctors regularly).

So funding allows the clinic to be the nanny.

For example, if you run a private clinic, you might be paid for doing comprehensive care for x number of kids who are in the designated population.

For rural Pennsylvania, this was mainly children at risk and/or children from families who were below a designated income.In Migrant clinics, it would be the farmworkers. In Indian Health Service or Urban Indian Clinics, it would be Native Americans who were in your jurisdiction.

You will say: I have X number of high risk patients. I need Y. And you apply for a grant.

The grant doesn’t say: This grant hires Mary, or this grant buys a computer. computer.

The Grant says: This is to fund X clinic to provide comprehensive prenatal and well child care. The grant might include a list of things they will pay to you so that you can do this, such as funding a full time public health nurse and funding to buy a computer and palmpocket.

They don’t pay the nurse. They give you a grant. Then you do what the grant says to do, which is to hire the nurse and buy the computer. The nurse is in charge of getting moms to the clinic. The computer helps the nurse can keep track of the shots and appointments, and a palm pocket so she doesn’t have to write everything longhand and can keep track of telephone numbers and basic immunization schedules.
In English, the grant makes it easier for you because it gives you a new nurse to schedule people, to call them, to look things up, and to document what you did, and a computer to help her do this more efficiently.

Then, at the end of the year, you document and print out the statistics on how the health of the patients in your group improved. Maybe you say: We improved compliance with childhood immunizations from 46% to 84%.

And by establishing a teen clinic, we improved our prenatal care in teenagers from 30% to 70%.

You write this up in the government style of writing, so hopefully it is intelligible, and send it off to the organization that gave you the grant. If they are pleased, you get another grant with new “goals”.

So what does all this mean?

In practical terms, it might mean Mary’s child doesn’t miss her DPaT shot, so doesn’t come down with Whooping cough and end up in the hospital at age 8 months (hospital cost 25 000 dollars).

Prevention also means going into the community, where people are.

For adult outreach, it might mean holding a monthly Blood pressure clinic in the Baptist Church after services, or setting up a booth to check blood sugar at the local PowWow, or going once a week to the public high school to for a health clinic that provides teens with care for minor medical problems such as sore knees, acne, contraception services and prenatal care.

So Mrs. Perkins, who thought her headache was from worrying about her son, finds it is because her blood pressure is 190/120, and the nurse gives her a pamphlet about high blood pressure and urges her (and her daughter, who brought her to church) that she needs to see a doctor, and gives her a card with the clinic’s number. As a result, she never has that stroke and does not end up at a nursing home at age 62.

Or you might find John’s blood sugar is 300 at the testing booth you set up at the PowWow, and lecture him that he needs to go to the IHS clinic as soon as possible because it is not the fry bread causing his blood sugar to be high, it’s Diabetes. So he gets treatment before the complications of Diabetes set in, prolonging his life.

Or maybe the money lets the clinic nurse set up a weekly teen clinic at the high school, to treat things like acne, STD’s or sore knees, and give out prescriptions for simple medicines including contraceptives. So Johnny learns he has Chlamydia, and is lectured about safe sex and never does develop HIV, and Mary, who came in “complaining” of acne, is found on routine questioning to be 5 months pregnant but hiding it…and as a result, Mary receives both prenatal care and treatment for her drug abuse…and as a result, she has a 7 lb healthy baby boy, instead of a 2 pound premature baby that costs the county half a million dollars for three months in an Intensive care nursery and hundreds of thousands more for special education.

So yes, the program is often inefficient, full of bureaucratic nonsense, and requires hours and hours of paperwork, much of it probably wasted.

But the cost in lives and money saved makes it cheap in the long run.


Nancy Reyes is a retired physician who lives in the Philippines with her husband and large extended family. She has done public health both in the US and Africa.

Her webpage is Finest Kind Clinic and Fishmarket but her more boring medical essays are posted at HeyDocBlog.

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