Los Angeles Times Interview : Shirley Fannin

Los Angeles County may be in the grip of a continuing epidemic of tuberculosis. Then again, it may not. Nobody knows for sure, according to the county’s director of communicable disease control, Dr. Shirley L. Fannin. The problem is not that TB isn’t treatable. In fact, it’s curable--if detected early enough and people conclude their required treatment. But, because of cutbacks and disorganization, Fannin says, she has lost track of the infected population.

Fannin is hyperkinetic and, after 21 years on the job, her whirlwind-energy level seems to demonstrate the intensity of her commitment. She is 60 years old, unmarried and board-certified in pediatrics. Educated in her native Illinois, she came to Los Angeles in 1969 to work with Dr. Benjamin Kagen at Cedars-Sinai Medical Center as part of her fellowship in infectious disease at UCLA.

To control outbreaks and prevent epidemics, Fannin administers a complex system of tracking more than 60 diseases that can be passed between human beings, or from animals to humans. It’s this system, she fears, that is now breaking down.

In the past 25 years, she explains, the county’s population has grown from 6 million to 9 million and diversified beyond all expectations. But, while public-health needs have increased correspondingly, resources have not been expanded to meet them. In fact, they’ve been cut dramatically, especially during the financial crisis that almost bankrupted the county government in 1995.

A jurisdiction that once boasted more than 50 public-health doctors in 25 separate districts now has only nine. Thirty-nine public-health clinics were similarly cut to nine--meaning one public-health clinic for every 1 million people. Eventually, some of this load may be picked up by public-private partnerships and private institutions. But, for now, Fannin says there is no longer a system that allows her to do her job.

Disease control starts with constructing a profile by locating, counting and analyzing the occurrence of those 60 different ailments. When patterns emerge, appropriate action can then be taken to ward off health crises of major proportions. But Fannin says her staff is so busy gathering data and responding to health emergencies, it has no time to analyze and report what’s going on.

A grim example that may bode ill for the future is the timing of the 1995 county health profile. Staff shortages held it up until last month. So it’s just come out--but it’s already out of date by more than a year. And Fannin still doesn’t know if the TB epidemic is getting better or worse.

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Question: What’s your biggest worry?

Answer: What concerns me most is that, with a decreasing number of places to report and a decreasing number of people having community contacts, you lose your surveillance system and you lose your edge. Our tuberculosis epidemic is a good example.

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Q: What exactly is an “epidemic,” and when did ours begin?

A: “Epidemic” means more than the expected number of new cases. Starting in 1989, new tuberculosis cases grew by leaps and bounds more than expected, up to a peak of about 2,200 a year in 1992. Then, in 1993, the rate started dropping by 7% to 12% a year, and last year we had a much larger drop in that case number--40% between January and April.

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Q: Why isn’t that good news?

A: I’d love to believe we are bringing our epidemic under control, but control happens gradually, so I’m very concerned about such a precipitous drop. It may be due to the major decline in the number of patients coming to our clinics. That could mean there are undiagnosed cases out in the community. And a TB case that’s undiagnosed and untreated is contagious.

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Q: After diagnosis, how difficult is the treatment process?

A: When people are contagious, they have to be isolated and stay home until they’re declared noncontagious. TB requires treatment by at least three to five drugs--depending on the resistance of the organism--and it takes from nine to 18 months to cure TB when its nonresistant. That’s a very long time for some people to take their drugs faithfully and stay home.

Not all patients comply, and they can’t just be allowed to run about the community while they are contagious. They don’t need an acute-care hospital for $1,500 a day, but they do need food, shelter and clothing while confined. We haven’t had TB sanitoriums for many years, so there’s no place to put them until they’re under control or noncontagious.

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Q: Could there even be an increase you’re not aware of?

A: That’s my major concern. If diagnosis and treatment are delayed, we can’t use drugs to make people noncontagious, so we’ll have more cases.

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Q: With the 1995 report not even out yet, does anybody know the status of health in Los Angeles County?

A: The Board of Supervisors should be asking that question, but we never even get to it. We talk about the budget and the money we spend, but we don’t ask what should be of interest to the citizens: How many people have chronic diseases? Why? Where are they?

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Q: How does a good surveillance system operate in times of crisis?

A: There was a cholera epidemic aboard an airliner that took off from Argentina and landed in Los Angeles on Friday, Feb. 14, 1992. On Saturday of that same weekend, there was a fire at the Health Department building. It was a three-day weekend, so we didn’t work Monday; when we came back to work Tuesday, all my communicable-disease investigators had been moved to a warehouse in Commerce, without any phones. In the meantime, three private emergency rooms--not county facilities, but private ones--had called and reported suspect cholera cases. By Wednesday, we had collected enough information to figure out they’d all been on that plane, and we went public.

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Q: To try and track down the passengers?

A: With state help and federal help, since a lot had gone on to other places. Anyway, we considered that performance a model of surveillance and response under the worst conditions in the whole world, at the same time we were surrounded by an administrative nightmare.

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Q: Since you did that in 1992, should we then feel confident that you could do it again in 1997?

A: No, I don’t think so. You know, right now, we do not have a clear organization that could predictably mount that kind of effort. We’re not organized in such a way that we could probably get the resources to do that in a short period of time.

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Q: Would the private emergency rooms report the way they did before?

A: Well, I hope so--except there are a lot of changes occurring out there. We have to establish new reporting sources in the new health-care environment as we shift to HMO’s. Private offices are closing, doctors are retiring, and somebody has to take their place and do the reporting. That’s not something that happens overnight; it’s a long-term process. We’re not sure what the impact will be on cooperation or reporting. We do not feel very comfortable. We’ll just have to see.

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Q: You mean, wait for a crisis?

A: We have reduced funding. We have a dysfunctional organization. The only way to know if this system is in place is if there’s a crisis.

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Q: Why do you think there has been this decline in the funding for public health?

A: If you’re not in a crisis, you’re on the back burner. Right now, we have a big problem delivering direct patient care. People think that’s the same as public health, but nothing could be farther from the truth. Public health is supposed to be about saying, “What do we have to do? What action does the community have to take to protect itself?” You don’t do that by treating people in clinics. You have to measure the health status of the community, and the only way to do that is to count.

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Q: Why aren’t we doing it?

A: It costs money. People have a hard time with the concept “Is it worth it?” because they have no sense of what it’s like if you don’t control something. Take rabies, for example. It’s been under control in humans for a long time, but it’s not eradicated. It’s still incurable. If you get it, you die; it’s that simple. The only way you can do anything is to prevent it, so we invested in rabies control. But, now we have people saying, “We haven’t had any human cases of rabies for a while, so it’s not important anymore.”

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Q: What are the consequences?

A: On the East Coast, it’s a horror show: a resurgence of raccoon rabies that’s spreading like wildfire--even as far as the Midwest. They’ve got domestic-animal rabies, raccoon rabies and they spend huge amounts of money just keeping on top of it. Well, in Los Angeles, we’re a step better than that, but how long is it going to be? We have damaged our surveillance system for rabies by eliminating a major part of it, so I’m not even confident we could pick up a case early. We’re not sampling the population of animals that we used to sample.

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Q: Has L.A. County historically been an important source of public-health data?

A: Los Angeles County is unique because of its size and complexity. We have a favorite saying around here: “If two things happen in the world, one of them is likely to be in Los Angeles.” We have 9 million people under a single health jurisdiction, which gives us a unique opportunity to discover rare conditions that don’t turn up very often in smaller places.

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Q: What’s an example?

A: In the early ‘80s, we got phone calls from three different doctors over several months. Altogether, they had five patients with similar problems: previously healthy gay males with a devastating immune deficiency. The state had not heard of anything similar, so we called the Centers for Disease Control in Atlanta, and we hit pay dirt. New York and San Francisco were having strange cases that sounded very much like ours. Basically, they already had started putting it together, so it was what I call “prepared ground.” Our call enhanced their suspicion that something new was going on, and it led to the definition of a new disease called AIDS. That was a very nice demonstration of the value of surveillance and epidemiological investigation on this huge population center.

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Q: Which depended on those doctors calling in.

A: Yes, and allowing their results to be reported. In New York and San Francisco, they had more cases, but the doctors wanted to publish in the New England Journal of Medicine, which wouldn’t accept material that had already been reported anywhere else. Here, we tried to build a culture by training our medical community about the importance of their observations and their reports of those observations to the general good of the community.

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Q: It sounds as if we’ve devolved away from that.

A: We’re just not sampling the population. We don’t see enough people to really say we have an idea of how much illness is occurring.

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Q: Could there be an outbreak of communicable diseases among a large number of people without our having adequate resources to deal with them?

A: Yes. And, you know, these things don’t go away. We’ve only eliminated one single disease in history, and that’s smallpox. We’ve not eliminated the other diseases, we’ve just brought them under fairly good control. When you quit making the control effort, you can expect the diseases to resurge. It may take as many as 10 years for some diseases to make a comeback, but they will comeback.

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Q: Are there examples in other places?

A: Look at the former Soviet Union. They had a good system of immunization and health care, but they became politically unstable in the late 1980s. Now they are having tens of thousands of cases of diptheria, a disease we had under control by the 1940s in most of the developed world. Well, we obviously didn’t eliminate the bacterium that causes diptheria, we just had a highly immunized population where only sporadic cases were occurring. It’s a bit scary to see what happens when you stop taking care of business.

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Q: But we may be losing control because of cuts in resources. What can people do?

A: They have to take more responsibility for their own health. We can devise new ways of looking for disease, and we can improve our surveillance system, but sheer numbers have to be looked at. We’ve had a massive increase in population, we’ve decreased our resources already, and we’re still in financial trouble. People need to watch their own health more closely, go to the doctor when they have symptoms and get screened. There are very few people out there to exhort them any more, and they are going to have to do these things for themselves. Citizens really do need to educate themselves, especially to make sure they immunize themselves to protect against diseases that aren’t going away.