It was only 11 a.m. on a recent day in Montebello, and already the heat was oppressive. Shade trees are few in this careworn neighborhood of newly arrived immigrants, and fear keeps many from opening their doors to strangers.
But Lydia Cardenas has adapted to the hardships of her job. When people refuse to open their doors, she shouts her message through the keyholes.
"I'm from the health department . . . . Are there children living with you?" Cardenas calls, switching easily from English to Spanish as needed. "May I see their immunization cards?"
Cardenas represents the latest effort by public health officials in California and across the nation to accomplish what faxes and flyers, radio and television ads have failed to do--halt the worst measles epidemic in decades. In a move reminiscent of the pre-vaccine era, people are being asked to carry the lifesaving message of immunization.
In Los Angeles, Cardenas reaches out to people isolated by poverty and language, hoping to lead them back into the health-care system.
In low-income and Latino areas of Orange County, a van is going to community centers and parks to give free measles shots to children and adults.
In rural Riverside County, nurses are preparing to travel to desert horse ranches with vaccine for the families of migrant workers.
In Rochester, N.Y., staff members of hospital emergency rooms are preparing to discuss immunization with every family that takes a child in for care and to administer vaccine on the spot.
Federal, state and private money is paying for these efforts as policy makers come to grips with the epidemic's implications.
As serious as measles is, much more is at stake: Epidemiologists consider measles a sentinel disease. The outbreak, some say, signals a basic weakness in the public health-care system that, if left uncorrected, could permit the resurgence of other contagious diseases such as polio or diphtheria--diseases that vaccines almost had relegated to the history books.
Flaring in late 1987, the epidemic now extends from South America to Canada, with no end in sight, according to Dr. Walter Orenstein, director of immunization for the federal Centers for Disease Control. Every state except North Dakota reports measles. U.S. cases through June totaled nearly 14,000, contrasted with 8,663 for the same period last year. The biggest single outbreak is in Los Angeles County, with more than 4,000 cases this year.
In Orange County, the epidemic is not as large, but it is still much worse than it was last year. From January to June this year, 511 cases of measles and two deaths were reported. It reached a peak in May, when 125 cases were reported. There were 390 cases and no deaths reported last year.
Measles is suspected as the cause of 42 deaths in California, more than twice the number for 1989. Most of the victims are children under the age of 5. Both of the deaths in Orange County this year were of infants.
Many now say the measles epidemic was an inevitable result of inadequate funding of the public health system. Where once an elaborate network of community-based nurses kept tabs on such basic family health needs as immunization, today the system in the United States depends largely on parents' knowing when their children need care and how to obtain it.
And what minimal community services exist have not adapted adequately to new immigrant waves, urban growth and other social changes that have eroded traditional channels of communication.
The result is a growing number of families outside the health-care system, their children unimmunized, their infections overlooked by keepers of the nation's health statistics--ideal fuel for an epidemic.
"Everyone knows that when immunization levels drop, it is just a matter of time before you get an epidemic," said Dr. Philip A. Brunell, professor of pediatrics at UCLA and a past chairman of the American Academy of Pediatrics' "Red Book" committee on immunization and infectious disease.
Health officials concede that they have lost track of a lot of young and mostly poor families in casting their immunization net. Dr. William L. Atkinson, the head of measles surveillance for the Centers for Disease Control, said the problem is most acute in big cities.
"And once you get behind, then a few years later you've literally got thousands of vulnerable children," he said.
Recent national studies of preschool-age children show that fewer than half the urban poor are properly immunized. Even lower immunization rates have been measured in Los Angeles, especially among Latinos who have accounted for most of the cases in Southern California.
That comes as no surprise to Ann Ivey, a public health nurse in San Bernardino County since 1957 who now directs community services for the county's Department of Public Health Services.
Ivey is heartsick over the dismantling of what she believes was an effective public health system for preventing epidemics like this one. Changes in the delivery of health care over the last 25 years have depersonalized it to such a degree that many people are unable to find their way to needed services, Ivey contends. Money also has been short. She cites California's Proposition 13, which eviscerated the budget for community-based public health nurses--reducing a force of 45 nurses ministering to 800,000 county residents in 1978 to 33 mostly clinic-based nurses today, responsible for 1.4 million residents.
"We went to the people and met them when they were pregnant and followed them until their children reached kindergarten. We did not lose them the way all these people are lost today," Ivey said. "But policy makers and managers have lost sight of the fact that you have to create a human relationship with someone before you can get them to understand what they need to do on their own behalf."
San Bernardino County statistics support Ivey's contention that the close, personal attention provided by community-based public health workers helped prevent disease outbreaks. Only isolated cases of measles were recorded in the 1970s and early 1980s; this year, 1,361 San Bernardino County residents have been stricken, and 10 have died.
Ivey's views are echoed by Dr. Paul F. Wehrle, professor of pediatrics at UC Irvine and a key player in the worldwide eradication of smallpox through vaccine.
"I think it is an absolutely unmitigated disgrace that we have measles in the numbers that we do in Southern California," Wehrle said. "And it cannot be helped by pouring vaccine willy-nilly into the population. You have to know precisely where the need is. You have to know the people who are your targets."
So health officials have turned to Cardenas and others like her to hand-carry the immunization message to people's doorsteps.
"We've utilized Kiwanis Club, Lions Club, the Red Cross, boys and girls clubs, the NAACP," said Gary Euler, disease control manager for the San Bernardino County health department. "We've given vaccine at churches, at the local (minor league) baseball games. About the only thing we haven't done is drive trucks with loudspeakers mounted on top to order people in for measles shots."
In Riverside County, immunization clinics have been set up outside supermarkets. "People may not know to take their child to a health center, but they do know where to get food," explained the health department's Barbara Cole.
In Orange County, where most of the measles cases and the county's only deaths have been among Latinos, the health department is using Spanish-language radio to announce vaccination clinics.
"It is a matter of digging up old, tired methods and seeing what works," said Dr. L. Rex Ehling, health director for Orange County.
Meanwhile, in a cluttered office at a county health clinic in South-Central Los Angeles, Dr. Suzanne Westman is trying to figure out how measles got a foothold and exactly why the health-care delivery system failed to halt its spread.
Hers is a demonstration project, one of six the CDC is funding nationally to come up with effective techniques to reach families, increase immunization levels and prevent future epidemics. The emergency room effort in Rochester, N.Y., is another CDC-funded project.
Others are in Philadelphia, where the city health department is looking to see if vulnerable preschool-age youngsters can be identified by studying the immunization records of their school-age siblings; San Antonio, where the health officials are studying the effectiveness of emphasizing immunization in community- and hospital-based parental education programs; New Jersey, where a variety of programs to promote parental awareness of immunization and increase parental responsibility are being tested; Phoenix, where the county health department is emphasizing to its staff the importance of immunization, and integrating immunization services with other department programs such as family planning.
But changing the way health care is delivered takes time and money. An epidemic consumes the former, and county health departments are very short of the latter. Looming over the measles picture in Los Angeles County is a proposal to close virtually all of the public health clinics, plus pediatric services at two major hospitals serving the poor, because of a projected $3.6-billion shortfall in the California budget.
"If what is proposed comes to pass, it is going to be a disaster," said Dr. Steven Waterman, chief of acute communicable disease control for Los Angeles County. "We immunize (at the clinics) a third of the children in Los Angeles County."
At the same time, the county last year spent $3.5 million on the hospital care of critically ill measles victims, an expenditure that Ivey and others cite to illustrate the foolish economy of cutting preventive public health services.
California's lawmakers have met the epidemic with $7.8 million in special measles appropriations, most of which has been spent, according to Dr. Loring Dales, immunization chief for the state Department of Health Services.
Congress, meanwhile, has given the CDC an extra $12 million to help the states, money that Dales expects to receive a share of this fall.
Help is also coming from the private sector. Centinela Hospital Medical Center in Inglewood plans free immunization clinics at community sites between Aug. 18 and Sept. 23, using characters from the popular "Teenage Mutant Ninja Turtles" television program to attract participation.
MEASLES EPIDEMIC NATIONWIDE
Listed below are the annual nationwide figures for measles cases and deaths, 1960-89.
Year Cases Deaths 1960 441,703 380 1961 423,919 434 1962 481,530 408 1963 385,186 364 1964 458,083 421 1965 261,904 276 1966 204,136 261 1967 62,705 81 1968 22,231 24 1969 25,826 41 1970 47,351 89 1971 75,290 90 1972 32,275 24 1973 26,690 23 1974 22,094 20 1975 24,374 20 1976 41,126 12 1977 57,345 15 1978 26,871 11 1979 13,597 6 1980 13,506 11 1981 3,124 2 1982 1,714 2 1983 1,497 4 1984 2,587 1 1985 2,822 4 1986 6,282 2 1987 3,655 2 1988 3,396 2 1989 17,850 41
MEASLES IN ORANGE COUNTY 1987: Deaths: 0 Cases: 12 1988: Deaths: 0 Cases: 109 1989: Deaths: 0 Cases: 389 1990*: Deaths: 2 Cases: 504 *As of June 1990
Source: Orange County Health Dept.