Jonathan Fielding, the public's MD

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If you've got your health, the cliche goes, you've got just about everything. If you've got public health duties, you're responsible for just about everything from mosquitoes (West Nile carriers) to hygiene (wash your hands for as long as it takes to sing "Happy Birthday" twice). Dr. Jonathan Fielding heads L.A. County's Department of Public Health, which is bigger than some states' health departments. A pediatrician by training and the head of the county's health programs since 1998, Fielding is such a believer that he and his wife, Karin, turned savvy investments into a $50-million gift last year to UCLA's School of Public Health. Here he takes the temperature of the medical and political aspects of his work.

To the public, "public health" may sound outdated. Do we still need the department?

Clean water, pure foods, safe and effective drugs, substandard housing, occupational safety — those are public health triumphs from the late 19th and early 20th centuries, but we're now finding them in other forms. Water — whether it's drought or fracking or what's seeping into the aquifers. We've never had a time of more food recalls. What toxins don't we know about? People are not aware [of the risks]. It's a core public health responsibility, to let people know what we know and what we don't know.

Maybe "public health" needs a new name?

People say to me, "Oh, you must be providing a lot of indigent care." We are, but it's not the only thing we do. Maybe it could be [called] the health protector department?

C. Everett Koop was our best known U.S. surgeon general. He was high profile to say the least — he even wore the uniform.

Maybe a uniform would be helpful! Chick Koop was amazing. He was a truth-teller at a time when ideology was trumping common sense and knowledge.

What are L.A. public health achievements?

In the county, we're down to 13.1% of adults who smoke. The incredible progress in cardiovascular disease, stroke, lung cancer — a 60% decline in cardiovascular disease, a 40-plus percent difference in stroke. 2006 is the first time we got beyond 80 years life expectancy in L.A. [With restaurant grading], we've shown a 13% reduction in hospitalization for food-borne [related] illness compared to surrounding counties. We inspect multi-unit housing. We're the first public health agency in the country to have an agreement with the FBI; we have [public health] people at the Joint Regional Intelligence Center here. We're a national model for preparations for terrorism.

A West Hollywood man recently died of bacterial meningitis, making a total of four such deaths in L.A. County over five months. It's not an unusual number, but some have used the word "outbreak."

We were on it the same day and made sure people who were exposed to [the victim] had prophylactic antibiotics. There were statements made that this could be the new AIDS, that this was somehow a coverup. Unfortunately, that resonated with some in the gay community because of the terrible history of HIV. We did not have an increase in [meningitis] cases, we had no "outbreak" based on the usual criteria. The CDC has very clear [outbreak] criteria: three related cases within three months and a rate of at least 10 [cases] per 100,000. We weren't there.

We have to be careful because the words we use don't always mean the same to the public as they do to us. "Outbreak" is one. "Plague" — that's certainly another; people have this notion of the Black Death in history. Certainly "epidemic" is one.

Science can be slow, but the public wants information now. How does that affect your work?

It's a question of whether it's a public need or a public demand. Social media has positives and negatives. There's no way in real time that we can respond to misinformation because we have to verify what's actually happening.

There was a report on social media of a gonorrhea superbug. It turns out that there was a naturopathic physician who claimed this was happening. It was not true, but it got picked up quickly. A lot of people don't ever hear the correction, so they're living with the myth. All it takes is the "send" key.

New York and Mayor Michael Bloomberg have been hammered for imposing "nanny state" rules on big sodas, trans fats and the like.

We have to make sure when we're abridging individual freedom that there's a real strong reason for it. Tobacco [restrictions], for example — we've made huge progress. It makes sense, when you can empower consumers. You need to be not authoritarian but authoritative.

Public health is [altered] often by successive redefinitions of the unacceptable. Think about tobacco. I wrote an editorial about 20 years ago about banning smoking in public places. They almost didn't print it. They said it was so outrageous it would never happen. Look at it now.

What about guns as a public health issue?

It's definitely a public health issue. African American males in L.A. County live on average 18 years fewer than an Asian Pacific Islander female. Some of that is the high rate of homicide. There are estimates of 300 million guns [in the U.S.]. If you're starting from that, where do you go?

Vaccines were a 20th century breakthrough. Now some people are refusing to get themselves or their children vaccinated.

Part of the problem is that people have never seen these diseases we've almost wiped out. They've never seen a kid with measles pneumonia. Also, we've increased the number of vaccines, so people say, "You're giving too many shots to my kid." What's very harmful is this fraudulent report linking vaccine administration to autism. It was retracted. We don't know what causes autism, but the one thing we know doesn't cause autism is vaccinations.

I think [resistance to vaccinations] is going to lead to more outbreaks of diseases in these [anti-vaccination] populations. We recently had an epidemic of whooping cough, so suddenly we had huge numbers of people being immunized. I think you're going to see very few people refusing [that vaccine] now.

Even some nurses are refusing to get flu vaccinations.

It's shocking to me. I don't understand that, from the point of view of individual protection, not just protection of the patients.

L.A. now requires that condoms are used by porn productions. How is that working?

Measure B says you can get a health permit from us [if] you're doing pornography, and we've had six applications over the last few months. It's not a very high number. We're working with them and with Cal-OSHA on a training course; they have to have somebody on site who's gone through this training. Our concern is what we're not able to see. We've sent inspectors out, one [for] a complaint and the other was [random]. We haven't found any problems yet. It's not an easy thing to enforce. The chance of us being there when they're filming — even if we were, they'd start using condoms right away. We agree with the intent [of the measure]; I'm just not sure we have a perfect way. A state law would be helpful, and the enforcing authority should be Cal-OSHA.

You know the jokes about people lining up for those inspection jobs.

We have investigators who also go to the sex clubs, which we also regulate, so it's not like we've not had some experience here. It's already in their bailiwick.

The AIDS Healthcare Foundation filed a suit against the county alleging misconduct after the county said the foundation overbilled it.

I can't comment on pending litigation.

And now the foundation is behind a movement asking L.A. city voters to create a city health department to sidestep the county department.

We were asked to do an analysis [for the Board of Supervisors], but we are precluded under law from making pronouncements about that.

The county has dozens of ethnic cultures with behaviors that might not conform to health laws. The listeriosis outbreak from unpasteurized Mexican cheese in the 1980s killed more than two dozen people.

We try to be sensitive, but it's a balancing act. Sometimes we have to say, this crosses the line. We've seized a lot of foods. We seize food from illegal vending — these carts, these big trucks, people doing things that frankly aren't safe.

We're not going to let people sell sliced fruit where they don't have any water, no place to wash anything. That is not OK. We're trying to work with [them]. They could sell whole fruit.

We just put something out in Chinese about H7N9 [flu] because that's a problem in China. Our emergency preparation materials [are] in eight or nine languages. We have people who speak all these languages, who go speak to any group on public health subjects. That's the way we work with [ethnic] communities.

How do you expect Obamacare to affect your work?

It's going to achieve what we should have achieved decades ago: people not having to worry about the economic effects of not having insurance. I don't think it necessarily does the best job of controlling healthcare costs, which is a crying need.

The 18% we're spending on sickness care is crowding out so many other things: universal preschool, smaller class size, social welfare programs. It's very difficult politically, so I'm not criticizing anybody, but there is a high cost to what we're not doing that we could be doing.

Even with the county's restaurant letter grades, is it hard for you to go out to eat, wondering what's going on in the kitchen?

I did go outside today and look at the food truck parked outside to make sure they had their permit!

You can follow the Los Angeles County Department of Public Health on Facebook, Twitter and YouTube.

patt.morrison@latimes.com

Follow Patt Morrison on Twitter @pattmlatimes

 

This interview was edited and excerpted from a taped transcript. An archive of Morrison's interviews can be found at latimes.com/pattasks.

 

Copyright © 2014, Los Angeles Times
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